Complex regional pain syndrome type I after myocardial infarction treated with spinal cord stimulation

OBJECTIVE: A rare case of Complex Regional Pain Syndrome (CRPS) type I after myocardial infarction (MI) and significant comorbid illness with few treatment options for pain control was successfully managed with the placement of a spinal cord stimulator (SCS). CASE REPORT: A 44-year-old man presented with left upper extremity burning pain after MI. His past medical history included insulin-dependent diabetes mellitus, oxygen-dependent idiopathic pulmonary fibrosis, and recent coronary revascularization surgery. His pain was presumed to be related to his MI and a clinical diagnosis of CRPS type I (or reflex sympathetic dystrophy) was made. Facing limited medical and less invasive options for his pain relief, he underwent a spinal cord stimulation trial with excellent response. He had more than 70% pain relief from the spinal cord stimulation at the last follow-up, 2 years later. CONCLUSION: CRPS type I after MI can be difficult to treat because of other comorbid illnesses. SCS can be a safe and effective mode of therapy for patients facing limited treatment options.     

Complex regional pain syndrome type I: efficacy of stellate ganglion blockade

Background  

This study was performed to evaluate the treatment of complex regional pain syndrome (CRPS) type I with stellate ganglion blockade.     

Complex regional pain syndrome

As suggested by this article, considerable advances in clinical management and research have taken place during the past 20 years. Although mechanisms underlying the pain syndrome CRPS I and CRPS II remain far from one's understanding, glimpses of the pathophysiology are beginning to take shape. There is now strong evidence that these syndromes exemplify a complex neurologic disease involving the brain at several integrated levels. The changes that occur in CRPS I patients involve somatosensory, sympathetic, and somatomotor systems. The diagnostic criteria have helped to focus on aspects of these foregoing systems and whereas there is no specific laboratory test for CRPS, enough is now known about the pathophysiology to use the following tests: quantitative sensory testing (QST), autonomic testing that include quantitative sudomotor axon reflex test (QSART) for sweating abnormalities, the cold pressor test in conjunction with thermographic imaging to observe the vasoconstrictor response, and laser Doppler flowmetry to monitor background vasomotor control. Recognition of a motor disorder requires accurate documentation and may be a component of the diagnostic criteria in the future. Until a better understanding of mechanistic overtones that would help to put in place mechanism-based therapeutic strategies, current management is built around a rehabilitation model. For this to be successful, as described in the foregoing pages, different non-interventional and interventional modalities are applied in a time-restricted manner to facilitate those modalities that favor progress in the treatment algorithm. As has been described, it is important when using physiotherapeutic maneuvers to minimize joint movement in the affected region to reduce the mechanorecpetor barrage and its increase in perceived pain to encourage and maintain a patient's compliance with their rehabilitation. Finally, of greater significance is the understanding that sympatholysis per se is not a "diagnostic" test for CRPS, but rather a useful procedure that may facilitate treatment for pain that is sympathetically maintained.     

Complex regional pain syndrome

Br J Anaesth 2001; 87: 99–106     

Complex regional pain syndrome

Despite its recommendation by the International Association for the Study of Pain, the term 'complex regional pain syndrome' has not been widely adopted. Most authors still prefer the term 'reflex sympathetic dystrophy'. The diagnostic criteria recommended by the International Association for the Study of Pain have been criticized as lacking specificity, and refined criteria have been proposed. The pathophysiology of the complex regional pain syndrome remains elusive, but most recent work favours a central mechanism both for the sensory features and the autonomic features. Peripheral mechanisms include tissue acidosis. Some investigators, however, view the condition as psycho-neurogenic. Although recommended by some, laboratory tests add little to diagnostic confidence. Certain prophylactic measures have been recommended for patients undergoing surgery, and for the treatment of fractures of the radius. Treatment is still based largely on traditional wisdom. Some new treatments have been promoted on the basis of uncontrolled studies. Controlled studies have indicated possible roles for bisphosphonates and spinal cord stimulation.     

Complex regional pain syndrome

Opinion statement Complex regional pain syndrome (CRPS) is a heterogeneous disorder that falls in the spectrum of neuropathic pain disorders. It is maintained by abnormalities throughout the neuraxis (the peripheral, autonomic, and central nervous systems). The pathophysiology of CRPS is not fully known. There are no scientifically well-established treatments. The diagnostic criteria for CRPS at this time are purely clinical, and the use of diagnostic tests has not been demonstrated. The most appropriate management of CRPS uses a multidisciplinary approach, with the inclusion of medical and psychologic intervention, and physical and occupational therapy. The key is gradual, persistent, functional improvement. The rational use of pain therapies must be grounded in a thorough knowledge of the neurobiology of pain, its endogenous modulation, and the clinical presentation. Potential peripheral pathophysiologic targets (and possible treatments) include increased spontaneous firing and responsiveness of peripheral afferent fibers mediated by inflammatory and other algogenic substances (somatosensory blocks, corticosteroids), altered levels of expression and functioning of multiple ion channels (local anesthetics, calcium channel blockers, anticonvulsants), abnormal interneuronal communication, and increased peripheral expression of adrenergic receptors and sympathetic excitation (sympathetic blocks, alpha-adrenergic antagonists, alpha-2 agonists). CRPS is also perpetuated by central mechanisms, with pathophysiologic targets (and possible treatments) including reorientation of dorsal horn terminals (desensitization techniques), functional reduction in inhibitory interneuron activity (tricyclic antidepressants, gabapentin, opioids), central sensitization and increased central excitability (gabapentin, topiramate, spinal cord stimulation, somatosensory blocks), impaired descending nociceptive inhibition (tricyclic antidepressants, opioids), and adaptive changes in the cortical centers underlying the sensory-discriminative and affective-motivational dimensions of pain (psychologic, physical, and occupational therapies). The treatment choices should be aimed at remodulating, normalizing, disrupting, or preventing the progression of abnormalities in pain processing. Sympathetic nerve blocks should be performed at least once to assess if sympathetically maintained pain is present. To the extent that peripheral somatosensory nerve blocks can diminish nociceptive input to the central nervous system, these techniques may help reduce the nociceptive sensitization of spinal neurons. Pain relief, however it is achieved and however temporary it is, is intended to facilitate participation in functional therapies to normalize use and to improve motion, strength, and dexterity. Psychologic therapies, such as biofeedback and cognitive-behavioral techniques targeting pain, stress, and mood disorders, are valuable adjunctive treatments for pain control and can facilitate functional improvement.     

Complex regional pain syndrome

Complex regional pain syndrome (CRPS) is a challenging pain condition for doctors and patients, with a natural history characterized by chronicity and relapses that can result in significant disability. CRPS is difficult to diagnose and treat, and requires close follow-up to ensure that progress is being made. Early diagnosis and treatment are required to prevent a long-standing or permanent disability. Clinical features such as spontaneous pain, edema, hyperalgesia, temperature or sudomotor changes, motor function abnormality, and autonomic changes are the hallmark of this disease. The treatment of CRPS remains controversial, and includes medications, physical therapy, regional anesthesia, and neuromodulation.     

Complex regional pain syndrome

Opinion statement  Complex regional pain syndrome (CRPS) is a heterogeneous disorder that falls in the spectrum of neuropathic pain disorders. It is maintained by abnormalities throughout the neuraxis (the peripheral, autonomic, and central nervous systems). The pathophysiology of CRPS is not fully known. There are no scientifically well-established treatments. The diagnostic criteria for CRPS at this time are purely clinical, and the use of diagnostic tests has not been demonstrated. The most appropriate management of CRPS uses a multidisciplinary approach, with the inclusion of medical and psychologic intervention, and physical and occupational therapy. The key is gradual, persistent, functional improvement. The rational use of pain therapies must be grounded in a thorough knowledge of the neurobiology of pain, its endogenous modulation, and the clinical presentation. Potential peripheral pathophysiologic targets (and possible treatments) include increased spontaneous firing and responsiveness of peripheral afferent fibers mediated by inflammatory and other algogenic substances (somatosensory blocks, corticosteroids), altered levels of expression and functioning of multiple ion channels (local anesthetics, calcium channel blockers, anticonvulsants), abnormal interneuronal communication, and increased peripheral expression of adrenergic receptors and sympathetic excitation (sympathetic blocks, alpha-adrenergic antagonists, alpha-2 agonists). CRPS is also perpetuated by central mechanisms, with pathophysiologic targets (and possible treatments) including reorientation of dorsal horn terminals (desensitization techniques), functional reduction in inhibitory interneuron activity (tricyclic antidepressants, gabapentin, opioids), central sensitization and increased central excitability (gabapentin, topiramate, spinal cord stimulation, somatosensory blocks), impaired descending nociceptive inhibition (tricyclic antidepressants, opioids), and adaptive changes in the cortical centers underlying the sensory-discriminative and affective-motivational dimensions of pain (psychologic, physical, and occupational therapies). The treatment choices should be aimed at remodulating, normalizing, disrupting, or preventing the progression of abnormalities in pain processing. Sympathetic nerve blocks should be performed at least once to assess if sympathetically maintained pain is present. To the extent that peripheral somatosensory nerve blocks can diminish nociceptive input to the central nervous system, these techniques may help reduce the nociceptive sensitization of spinal neurons. Pain relief, however it is achieved and however temporary it is, is intended to facilitate participation in functional therapies to normalize use and to improve motion, strength, and dexterity. Psychologic therapies, such as biofeedback and cognitive-behavioral techniques targeting pain, stress, and mood disorders, are valuable adjunctive treatments for pain control and can facilitate functional improvement.     

腹股沟疝修补术后复杂性区域疼痛综合征

疼痛是临床实践中最常见的问题之一,在外科领域更为普遍.但是有些疼痛的发病机制比较复杂,治疗困难,临床称为复杂性区域疼痛综合征(complex regional pain syndrome,CRPS).腹股沟疝手术后疼痛的发生率也不低,严重影响患者的生活质量,得到学术界的高度重视,是临床处理的一个难点.     

Complex regional pain syndrome type 2 after radial artery catheterization: a case report

Complex regional pain syndrome has multiple causes. The clinical picture includes pain that can be debilitating, along with vascular and motor abnormalities, changes in sweating, delayed recovery, eating disorders, and occasionally psychological changes. Treatment is complex and should be started early if symptoms are to be reversed. We report the case of a man who developed complex regional pain syndrome type 2 in his left arm after surgery with extracorporeal circulation to repair an interatrial septal defect. The clinical picture was believed to have been triggered by catheterization of the radial artery.