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Complex regional pain syndrome (CRPS)

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... Pain Management: A Comprehensive Review; and (2) Gerald M. Aronoff, M.D., ... tissues * Musculoskeletal disorders Postural defects Myofascial syndromes III. – PowerPoint PPT presentation

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Title: Complex regional pain syndrome (CRPS)


1
Complex regional pain syndrome (CRPS)
  • Syed M. Nasir, M.D.
  • Assistant Professor
  • The University of Texas Medical School at Houston
  • Department of Anesthesiology

2
What is Reflex Sympathetic Dystrophy (RSD)?
  • Reflex sympathetic dystrophy (RSD), or complex
    regional pain syndrome-CRPS I, applies to a
    variety of seemingly unrelated disorders having
    similar clinical features and manifesting the
    same fundamental disturbed physiology. The term
    reflex indicates a response to a primary exciting
    stimulus that is traumatic, medical, infectious,
    or vascular the term sympathetic indicates the

3
What is Reflex Sympathetic Dystrophy (RSD)?
(cont.)
  • neurologic pathway subserving the development and
    maintenance of these syndromes and the term
    dystrophy indicates that, if untreated, these
    syndromes uniformly result in trophic changes as
    a result of the persistent sympathetic
    stimulation.

4
What is Causalgia?
  • Causalgia, which means burning pain, is a
    historical term describing a reflex sympathetic
    dystrophy that follows partial or, rarely,
    complete injury to a peripheral nerve trunk.1 It
    is also called complex regional pain
    syndrome-CRPS II. It is characterized by
    constant, spontaneous, severe, burning pain and
    is usually associated with hypoesthesia (decrease
    sense of touch or sensation or partial loss of
    sensitivity to sensory

5
What is Causalgia? (cont.)
  • stimuli) and hyperesthesia (abnormal increase in
    sensitivity to stimuli of senses), hyperpanthia
    (exaggerated pain sensation to nociceptive
    stimuli), and allodynia, along with vasomotor and
    sudomotor (sweat glands) disturbances that, if
    persistent, result in trophic changes
    (interruption of nerve supply). RSD need not be
    initiated by damage to a major peripheral nerve
    trunk.

6
Mechanism
7
Causes of RSD
  • I. Trauma
  • Accident injury
  • Sprain, dislocations, fracture (usually of the
    hands, feet, or wrists)
  • Minor cuts or pricks, lacerations, contusions
  • Crush injury of fingers, hands, or wrists
    traumatic amputation of fingers
  • Burns

8
Causes of RSD (cont.)
  • Surgical
  • Procedures on the extremities
  • Excision of small tumors, ganglia wrist
  • Forceful manipulation, tight casts
  • Surgical scars
  • Damage to small peripheral nerves with a needle
    (e.g., during its insertion for infusion,
    transfusion, injection therapy, or analgesic
    block)
  • Injections or irritants

9
Causes of RSD (cont.)
  • II. Diseases
  • Visceral diseases (e.g., myocardial infarction)
  • Neurologic diseases
  • Cerebral vascular accidents (posthemiplegic
    dystrophy), tumors, syringomyelia, and others
  • Spinal cord poliomyelitis, combined
    degeneration, tumors, syringomyelia, and others

10
Causes of RSD (cont.)
  • Spinal nerves or their roots herpes zoster,
    radiculitis
  • Brachial plexus
  • Infiltrating carcinoma from the breast, apex of
    the lung (upper extremity), or pelvis (lower
    extremity)
  • Glomus tumor (benign tumor that differentiates to
    become modified smooth muscle cells called glomus
    cell)

11
Causes of RSD (cont.)
  • Infections
  • Extremity skin and other soft tissues
  • Periarticular
  • Vascular
  • Generalized periarthritis nodosa, diffuse
    arteritis, arteriosclerosis
  • Peripheral thrombophlebitis, tissues

12
Causes of RSD (cont.)
  • Musculoskeletal disorders
  • Postural defects
  • Myofascial syndromes
  • III. Idiopathic

13
Sympathetically Maintained Pain
14
Mechanism of Generation of RSD
  • REFLEX SYMPATHETIC DYSTROPHY
  • (ALGODYSTROPHY)
  • Trauma with
  • Nerve lesion
  • Abnormal state of
  • afferent neurones
  • Distorted information
  • Processing in spinal cord
  • Dysregulation of
  • sympathetic activity
  • (vasomotor, sudomotor)

Pain
Trophic changes
15
Clinical Presentation
  • Trauma secondary to accidental injury is probably
    the most common cause. Peculiar to sympathetic
    dystrophy is the lack of correlation among
    severity of injury, incidence, and subsequent
    severity of the resultant syndrome.
  • In the majority of cases, the precipitating
    injury may be so minor and to the patient so
    insignificant that he or she may forget the
    incident questioned by the physician.

16
Signs and Symptoms
  • RSD is manifested by pain, hyperesthesia,
    vasomotor and sudomotor disturbances, and
    increased muscular tone, followed by weakness,
    atrophy, and trophic changes involving the skin,
    and its appendages, muscles, bones, and joints.
  • However, common to all cases of sympathetic
    dystrophy is the fact that the pain and physical
    signs do not conform to known patterns of nerve

17
Signs and Symptoms (cont.)
  • distribution, either segmental (dermatomes,
    myotomes, and sclerotomes) or peripheral.
    Moreover, they have a tendency to spread
    proximally to involve the contralateral and
    ipsilateral extremity. Once RSD has become
    established, the entire syndrome will continue
    even after the causal mechanism has healed or
    disappeared. An important characteristic common
    to all of the sympathetic dystrophies is the fact
    that the symptoms

18
Signs and Symptoms (cont.)
  • can be abolished by sympathetic block at an
    appropriate level if carried out before the
    point at which the syndrome becomes irreversible,
    repetitive interruption of the involved
    sympathetic pathways can result in resolution of
    the entire syndrome.

19
Course
  • Sympathetic dystrophy has three phases, and the
    presenting signs and symptoms will vary somewhat
    depending on the stage at the time the patient is
    first seen.
  • Acute (hyperemic) stage
  • During this stage, the syndrome can be
    completely reversed by sympathetic blockade.

20
Course (cont.)
  • Dystrophic (ischemic) stage
  • If the acute stage is untreated, it can be
    expected to progress to the second, or
    dystrophic, stage. During this stage,
    sympathetic blocks may still be effective in
    reversing the process, although the response to
    blockade may be short-lived and less pronounced.
    A larger series of blocks or prolonged
    sympathetic blockade may be necessary to afford
    permanent relief.

21
Course (cont.)
  • Atrophic stage
  • The third stage is characterized by marked
    trophic changes that eventually became
    irreversible. At this point many of the trophic
    changes produced by the syndrome become
    irreversible, and although interruption of
    sympathetic pathways by blocks may still provide
    temporary relief, repetitive sympathetic blocks
    alone are no longer effective in terminating the
    process permanently. An

22
Course (cont.)
  • aggressive approach including physical therapy,
  • psychologic counseling, and sympathetic and
    somatic nerve blockade is needed to reverse the
    process as much as possible.

23
Stages and Characteristics of RSD
Stage Stage Stage
Characteristic I Acute II Dystrophic III Atrophic
Pain Burning/neuralgia Burning/throbbing Burning/throbbing
Dysthesia
Function Minimal impairment Restricted Severely restricted
Autonomic dysfunction Increased blood flow NI or decreased flow Decreased blood flow
Temperature Increased Decreased Decreased
Discoloration Erythematous Mottled/dusky Cyanotic
Sudomotor dysfunction Minimal
Edema
Trophic changes 0
3-phase bone scan Increased activity, all images Normal uptake, all phases except increased static phase Decreased activity, all phases except NI static
Osteoporosis _
24
Diagnosis
  • A diagnosis of RSD may be obvious if
  • there is a history of recent or remote trauma,
    infection, or disease
  • there is persistent, spontaneous pain that is
    burning, aching, or throbbing in character
  • there are vasomotor or sudomotor disturbances
    and
  • there are obvious trophic changes

25
Diagnosis (cont.)
PUTATIVE DIAGNOSTIC CRITERIA FOR RSD
Clinical symptoms and signs Burning pain Hyperpathia/allodynia Temperature/color changes Edema Hair/nail growth changes
Laboratory results Thermography/thermometry Bone x-ray Quantitative sweat test Response to sympathetic blockage
Interpretation based on number of criteria present gt6, probable RSD 3-5, possible RSD lt3, unlikely RSD
26
Diagnosis (cont.)
  • A score of 0 is assigned if the criteria is
    absent, ½ if it is equivocal, and 1 if it is
    present. These scores are tabulated, and the
    following categories are arbitrarily determined

Interpretation based on these Criteria Interpretation based on these Criteria
0 to 2 ½ RSD absent
3 to 4 ½ Possible RSD
5 to 9 Probable RSD
27
Current Treatment
  • Because the pathophysiology of RSD is
    predominantly a hyperactivity of the regional
    sympathetic nervous system, pain management in
    such patients should focus on interrupting the
    activity of the sympathetic nervous system. This
    interruption can be produced by different
    modalities classified as pharmacologic, nerve
    blocks, surgical or chemical sympathectomy,
    physical therapy, and psychology.

28
Treatment of RSD
Treatment of RSD Treatment of RSD
Antidepressants Bier block
Sedative-hypnotics Sympathetic blocking agents
Anxiolytics Vasodilators
Anticonvulsants Neurolytics
Muscle relaxants Nerve block
Narcotic analgesics Surgical sympathectomy
Nonnarcotic analgesics Chemical sympathectomy
Nonsteroidal antiinflammatory agents Physical therapy
Corticosteroids Transcutaneous electrical nerve stimulation (TENS)
Local anesthetics Psychology
29
Reflex Sympathetic DystrophyReview Questions
  • Questions from P. Prithvi Raj, M.D., Pain
    Management A Comprehensive Review

30
1. In reflex sympathetic dystrophy there is
  • A. Correlation between pain and known
    dermatomal distribution
  • B. Abnormality in EMG studies
  • C. Abnormality in peripheral angiograms
  • D. Abnormality in triple-phase bone scan

31
1. In reflex sympathetic dystrophy there is
  • D. Abnormality in triple-phase bone scan

32
2. When considering psychotherapy for
longstanding reflex sympathetic dystrophy
patients, one should not plan for
  • A. Management of depression
  • B. Psychologic factors that affect compliance
    with treatment
  • C. Teaching of effective coping strategies
  • D. Learning new skills at work

33
2. When considering psychotherapy for
longstanding reflex sympathetic dystrophy
patients, one should not plan for
  • D. Learning new skills at work

34
3. One of the reasons for failure of surgical
sympathectomy has been
  1. Reinnervation from contralateral sympathetic
    chain
  2. Permanent destruction of the cut sympathetic
    chain
  3. Inability of myelinated A fibers to take over the
    function of sympathetic fibers
  4. Increased vascularity of the region effected by
    sympathectomy

35
3. One of the reasons for failure of surgical
sympathectomy has been
  • A. Reinnervation from contralateral sympathetic
    chain

36
4. Appropriate medications for chronic reflex
sympathetic dystrophy are all of the following
EXCEPT
  1. Tricyclic antidepressants
  2. Anticonvulsants
  3. Narcotics
  4. Calcium channel blockers

37
4. Appropriate medications for chronic reflex
sympathetic dystrophy are all of the following
EXCEPT
  • C. Narcotics

38
5. Several clinical measurements and
investigations are available for the diagnosis of
reflex sympathetic dystrophy. These tests
include the following EXCEPT
  1. Temperature measurements
  2. Triple-phase bone scan
  3. Q-START test
  4. MRI

39
5. Several clinical measurements and
investigations are available for the diagnosis of
reflex sympathetic dystrophy. These tests
include the following EXCEPT
  • D. MRI
  • This presentation material was referenced from
    (1) P. Prithvi Raj, M.D., Pain Management A
    Comprehensive Review and (2) Gerald M. Aronoff,
    M.D., Evaluation and Treatment of Chronic Pain,
    Third Edition
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