A Case of Complex Regional Pain Syndrome

ABSTRACT

A Case of complex regional pain syndrome is presented from the perspectives of pain specialists from the Czech Republic. Clinical presentation, goals of therapy, epidural analgesia, radiofrequency ablation, and nerve block, opioids and spinal cord stimulation are discussed. Commentaries on this case are provided by pain specialists from Israel and Sweden.

KEYWORDS. :

• complex regional pain syndrome
• CRPS
• opioids
• spinal cord stimulation
• epidural
• radiofrequency ablation
• diagnosis

PERSPECTIVE FROM SWEDEN

Professor Stephen Butler Department of Anaesthesia and Intensive Care, Uppsala University Hospital, Sweden

This case illustrates a not so infrequent problem, although the cause of injury is somewhat unusual. First the diagnosis. The International Association for the Study of Pain (ISAP) criteria¹ are

• The presence of an initiating noxious event, or a cause of immobilization.

• Continuing pain, allodynia, or hyperalgesia where pain is disproportionate to the event.

• Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of the pain.

• Exclude conditions that would otherwise account for the degree of pain and dysfunction.

The criteria are not fulfilled and I would diagnose this as a neuropathic and nociceptive pain problem, but the treatments should be the same as for CRPS. Why might this case not be type 2 CRPS? Firstly, for the first IASP criterion, the inciting event and ongoing evidence for pathology can explain the pain. Secondly, for the fourth criterion, the same reasoning suggests that the signs and symptoms are compatible with the injury and pathology described. The case report also mentions radiographic findings as a possible criterion but these are nonspecific findings associated with disuse. The first goal of treatment for CRPS is pain relief.

There is little indication for standard antiinflammatory drugs except where there is evidence of acute, nociceptive pain. Opioids are not too helpful but should be tried. Drugs for neuropathic pain are first line. Invasive therapies, from sympathetic, plexus, or peripheral nerve blocks to epidural analgesia to neurostimulation have been tried with some success. The next and most important stage is active remobilization, which is what resolves the symptoms.

The emphasis in the case report is on pain relief with very little importance given to remobilization and no program for this is described.