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complex_regional_pain_syndrome_assiut_2012
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Complex Regional Pain
Syndrome
Dr. H. MetwallyBScAPh, MBChB, MDA, FFARCSI, MRCA, MSc Pain Management
Diana Princess of Wales Hospital
Pain Medicine, Anaesthesia and Critical CareLincs Pain Clinic
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
What is CRPS?
A chronic painful progressive disease
Characterized by severe pain, swelling and changes in the skin (colour, temp hair and nails).
There is no cure.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Is it one type?
The International Association for the Study of
Pain has divided CRPS into two types based
on the presence of nerve lesion following the
injury.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
CRPS Type I
Formerly known as:
Reflex sympathetic
dystrophy (RSD),
Sudeck's atrophy
Reflex neurovascular
dystrophy (RND)
Algoneurodystrophy
It does not have
demonstrable nerve
lesions.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
CRPS Type II
Formerly known
as causalgia
It has evidence
of obvious
nerve damage.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
CRPS
The cause: unknown.
Precipitating factors
Injury
Surgery
There are documented cases that have no demonstrable injury to the original site.
These problem was certainly major by the importance of the vasomotor and sudomotor symptoms, but stemmed from minor neurological lesions.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
History
Pathophysiology
Susceptibility
Contributing factors
Genetic theory
(hidden slides)
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Symptoms
Usually manifest near the site of an injury, either major or minor.
The most common symptoms overall are Burning, electrical sensations, shooting pain
May also experience muscle spasms
Local swelling
Abnormally increased sweating
Changes in skin temperature and color
Softening and thinning of bones
Joint tenderness or stiffness, restricted or painful movement.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Symptoms
The pain is continuous
May be heightened by emotional or physical
stress
Moving or touching the limb is often
intolerable.
The symptoms of CRPS vary in severity and
duration.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Diagnosis, The IASP criteria for CRPS
CRPS types I and II share the common diagnostic criteria Spontaneous pain or allodynia is not limited to the
territory of a single peripheral nerve, and is disproportionate to the inciting event.
There is a history of oedema, skin blood flow abnormality, or abnormal sweating in the region of the pain since the inciting event.
No other conditions can account for the degree of pain and dysfunction.
The two types differ only in the nature of the inciting event. Type I CRPS develops following an initiating noxious
event that may or may not have been traumatic
Type II CRPS (causalgia) develops after a nerve injury.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Thermography
Measuring blood flow by determining the variations in heat emitted from the body.
An altered blood supply to the painful area, appearing as a different shade (abnormally pale or violet) than the surrounding areas of the corresponding part on the other side of the body.
A difference of 1.0°C between two symmetrical body parts is considered significant
The affected limb may be warmer or cooler than the unaffected limb
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Sweat testing
Abnormal sweating can be
detected by several tests.
A powder that changes color
when exposed to sweat can be
applied to the limbs; however,
this method does not allow for
quantification of sweating.
Two quantitative tests that may
be used are the resting sweat
output test and the quantitative
sudomotor axon reflex test.
These quantitative sweat tests
have been shown to correlate
with clinical signs of CRPS.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Radiography
Patchy osteoporosis, which may be due to disuse of the affected extremity, can be detected through X-ray imagery as early as two weeks after the onset of CRPS.
A bone scan of the affected limb may detect these changes even sooner.
Bone densitometry can also be used to detect changes in bone mineral density. It can also be used to monitor the results of treatment, as bone densitometry parameters improve with treatment.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Electrodiagnostic testingElectromyography
Known as Nerve
conduction study
Detect the nerve injury
that characterizes type
II CRPS.
The symptoms of type
II CRPS extend beyond
the distribution of the
affected peripheral
nerve (In contrast to
peripheral
mononeuropathy)
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Management
Prevention
Treatment
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Prevention
Treat post traumatic pain and inflammation without
dealy.
Vitamin C has been shown to reduce the prevalence
of complex regional pain syndrome after wrist
fractures. A daily dose of 500 mg for fifty days is
recommended
These studies are difficult to interpret because the
incidence of CRPS in those who took the Vitamin C
in this study are similar to the incidence without
taking anything in other studies
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Treatment
The general strategy in CRPS treatment is
often multi-disciplinary, with the use of
different types of medications combined with
distinct physical therapies.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Drugs
Variety of drugs including:
Antidepressants
anti-inflammatories such as corticosteroids and COX-inhibitorssuch as piroxicam
Vasodilators
GABA analogs such as gabapentin and pregabalin
Alpha- or beta-adrenergic-blocking compounds
The entire pharmacy of opioids.
Bisphosphonates: treat osteoporosis in cancer patients (Pamidronate)
Ketamine?????
Although many different drugs are used, there is not much supportive evidence for most of them. This doesn't necessarily reflect evidence that they don't work, just a lack of evidence that they do.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
How to use each of these drug groups?
(Leave it for the discussion)
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Pamidronate in complex regional
pain syndrome type I
30-60 mg as a single dose IVI over one hour
Good response so far
. 80-276):3(5Sep;2004 Pain Med.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Bier’s Block
Guanethidine (Ismelin) (30 mg for U.L or 40 mg for L.L): antihypertensive drug that reduces the release of catecholamines
Bretylium: (100 mg) antiarrhythmic agent. It blocks the release of noradrenaline from nerve terminals
+ Clonidine 75mcg +Ketorolac 40 mg + Prolocaine 40 mls (U.L) or 60 mls (L.L)
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Ketamine
Ketamine is the only potent
NMDA-blocking drug currently
available for clinical use
Ketamine is being used as
an experimental and
controversial treatment for
CRPS.
May have more than one
mechanism of action
Can be taken oral or
infusion
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Local anaesthetic
Blocks, Regional injections or Topical
Often the first step in treatment
Repeated as needed
Early intervention with non-invasive management may be preferred to repeated nerve blockade.
The use of topical lidocaine patches has been shown to be useful
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Spinal cord stimulators
Directly stimulating the spinal cord
Place electrodes either in the epidural or directly over nerves located outside the central nervous system
A systematic review concluded: Spinal cord stimulation appears to be an effective therapy in the management of patients with CRPS type I (Level A evidence) and type II (Level D evidence)
Moreover, there is evidence
to demonstrate that SCS is
a cost-effective treatment
for CRPS type I.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Implantable drug pumpsImplantable drug
pumps may also be
used to deliver pain
medication directly to
the cerebrospinal fluid
which allows powerful
opioids to be used in a
much smaller dose
than when taken orally
Other treatments with
encouraging published
results (e.g., neural
stimulators) are not
used often enough."
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Sympathectomy
Surgical, chemical, or radiofrequency
Interruption of the affected portion of the sympathetic nervous system
Can be used as a last resort in patients with impending tissue loss, edema, recurrent infection, or ischemic necrosis
There is little evidence that these permanent interventions alter the pain symptoms of the affected patients.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Chemical Sympathectomy
Non destructive:
Local anesthetic
Botulinum toxinType A in addition to Local anesthetic
Clonidine
Destructive:
Alcohol 100%
Phenol
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Physical and occupational therapy
Primarily by desensitizing the affected body part
Restoring motion
Improving function.
Some people at certain stages of the disease are incapable of participating in physical therapy due to touch intoleranceGraded Motor Imagery
Mirror Therapy
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Physical and occupational
therapy Mirror box therapy
Tactile discrimination training
Graded exposure to fearful activities
EEG Biofeedback
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Prognosis of CRPS
Good progress can be made in treating
CRPS if treatment is begun early,
ideally within 3 months of the first
symptoms.
If treatment is delayed, >> spread to the
entire limb >> changes in bone, nerve
and muscle may become irreversible.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Prognosis of CRPS
Is not always good.
The limb, or limbs, can experience
muscle atrophy, loss of use and
functionally useless >> require
amputation.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Conclusion
CRPS will not "burn itself out" but, if
treated early, it is likely to go into
remission.
Assiut Anaesthesia Conference 2012 Dr.
Metwally, Diana, Princess of Wales Hospital
Lincs Pain Clinic
Thank You