Presentation on theme: "Complex Regional Pain Syndrome Dr. Dawood Nasir. Definition CRPS: Complex regional Pain Syndrome, a neuropathic pain syndrome associated with sympathetic."— Presentation transcript:
Complex Regional Pain Syndrome Dr. Dawood Nasir
Definition CRPS: Complex regional Pain Syndrome, a neuropathic pain syndrome associated with sympathetic nervous system dysfunction CRPS1: Previously known as Reflex sympathetic dystrophy, is a syndrome occurring after minor trauma CRPS 11: Causalgia, usually occurs after major nerve injury
Complex Regional Pain Syndrome
Pathophysiology Peripheral & Central Mechanism Proposed mech include -Sensitization of small diameter polymodal C & A delta afferent fibers -Sensitization of central wide dynamic range neurons -Altered activity of low threshold A beta fibers
Question Complex regional pain syndrome type 11 (Causalgia) is differentiated from complex regional pain synd type 1 by knowledge of A.Etiology B.Chronicity C.Affected body region D.Type of symptoms E.Rapidity of onset
Answer (A) Complex regional pain syndrome type 1 is a clinical syndrome of continuous burning pain usually occurring after an injury or surgery. Pts present with variable sensory, motor, autonomic, & trophic changes. Complex regional pain syndrome type 11 exhibits the same features as complex regional pain syndrome type 1, but the etiology is damage to a major nerve.
Diagnostic criteria At least 4 of the following must be present to diagnose CRPS Examination findings: 1.Temperature / Color change. 2.Edema 3.Trophic skin, hair, nail growth abnormalities. 4.Impaired motor function. 5.Hyperpathia / Allodynia 6.Sudomotor changes
Diagnostic criteria-cont- Diagnostic test results -Three phase bone scan that is abnormal in pattern characteristic. - This test is not needed if 4 or more of examination findings are present.
Stages of Complex regional type 1 CRPS 1 is divided into 3 stages 1. Acute 2.Dystrophic 3.Atrophic
Acute phase Pain: Localized, Severe, Burning Extremity : Warm, swollen, nail growth Skin: Dry & red, growth of hairs X-ray: Normal Mech.: Could be due to increase blood supply
Dystrophic Phase Pain: Diffuse, throbbing Extremity: Cold, Cyanotic, edematous, muscle wasting. Skin: Sweaty, thinning or loss of hairs X-ray: Reveals osteoporosis Mech.: Could be due to vasoconstriction
Atrophic Phase Pain: Less severe, may involve other extremities Extremity: Severe muscle atrophy, contractures Skin: Glossy & atrophic X-ray: Reveals severe osteoporosis, & ankylosis of joints. Mech.: Could be due to disuse atrophy
Physical Exam Allodynia: Perception of non noxious stimulus as painful Hyperesthesia: Increased response to mild stimulus Skin discoloration/mottling Dry glossy extremity Sweating Edema Abnormal temperature Weakness, tremor, Hyperkeratosis, Brittle nail
Question Allodynia is defined as A.Spontaneous pain in an area or region that is anesthetic B.Pain initiated or caused by a primary lesion or dysfunction in the nervous system. C.An unpleasant abnormal sensation, whether spontaneous or provoked D.An increased response to a stimulus that is normally painful E.Pain caused by a stimulus that does not normally provoke pain.
Answer (E). The IASP has defined several pain terms. Anesthesia dolorosa: refers to spontaneous pain in an area or region that is anesthetic. Neuropathic pain: is caused by dysfuction in NS. Dysthesia :is unpleasant abnormal sensation. Hyperalgesia :is increased response to painful stimulus. Allodynia: is pain caused by a stimulus that does not normally provoke pain.
Tests Imaging -Osteoporosis or fine demineralization on xray -Increased periarticular uptake in delayed bone scintigraphy
Question Which of the following choices is not consistent with a limb affected by complex regional pain syndrome? A.Osteoporosis. B.Allodynia. C.Dermatomal distribution of pain D.Atrophy of the involved extremity. E.Hyperesthesia.
Medications First line -Anticonvulsants 1.Gabapentin up to 900 mgs PO q8 hrs. 2.Pregabalin up to 300 mg PO q 12 hrs -Tricyclic antidepressants: 1.Amitriptiline up to 150 mgs PO qhs 2.Nortriptylene: upto 150 mgs PO qhs 3.Desipramine: upto 150 mgs PO qhs - NSAIDs: If no complications
Second Line Other anticonvulsants -Oxcarbazepine upto 600 mg PO q12 hrs -Lamotrigine upto 150 mgs PO qhs Short & long acting opioids (Controversial) Alpha adrenergic blocking agents Corticosteroids(Short term only) Biphosphonates Topical therapies
Interventional Regional anesthetic approaches Sympathetic blockade (local with or without steroids) Peripheral nerve blockade IV regional analgesia (reserpine, guanethidine, bretylium) Chemical sympathetic neurolysis Radiofrequency sympathetic rhizotomy Epidural clonidine Spinal cord stimulation
Rehabilitation Avoid immobilization Desensitization Mobilization Edema control Isometric/Isotonic strengthing Stress loading/range of motion Aerobic conditioning TENS
Mental Test/Behavioral Psychometric testing -Counseling -Behavioral modification -Relaxation therapy -Group therapy -Self-hypnosis Psychotherapy Medical management of depression
Technique for Stellate ganglion Block Pt. supine, head midline, mouth slightly open 2 finger breadth or 2 cm. above clavicular head, trachea, sternocleidomastoid ms, & carotid sheath palpated at level of cricoid cartilage 2 fingers press down at lat. Edge of transverse process of C6, pushing the contents of carotid sheath laterally A in. 23 or 25 gauge B bevel needle is inserted lat to trachea after skin inf. With local anesth. Transverse of C6 encountered between 2 fingers withdraw needle 2 mm & inj 8-10 ml local
Stellate Ganglion Block
Question Stellate ganglion lies in closest proximity to A.Common carotid artery. B.Internal carotid artery. C.Vertebral artery. D.Axillary artery. E.Aorta.
Signs of successful block Horners synd. Ipsilateral nasal congestion Flushing of conjunctiva & skin Temperature increase in the ipsilateral arm & hand
Side effects & complications Lump sensation in throat Hoarseness & dysphagia due to recurrent n block Hematoma, osteitis Brachial Plexus block Phrenic nerve block Epidural & subarachnoid block Pneumothorax Vertebral art. Inj. Causing loss of consciousness Cardioaccelarator nerve block with hypotension
Follow up Prognosis Some resolve with minimal management Most respond to initial conservative measure Early aggressive treatment in those with rapid temporal changes has best results if initiated within 12 weeks of onset Prognosis poor if pain becomes chronic with marked disability, thus emphasizing multidisciplinary approach.