1. Therapy of CRPS I in children by spinal cord stimulation (a case presentation) Michael Kretzschmar, MD, DSc Consultant in Anesthesiology and Pain Management, Head of Department of Anesthesia, Intensive Care and Special Pain Management, Klinikum Altenburger Land GmbH, Altenburg, Germany Introduction: Complex regional pain syndrome type I (CRPS I) is often a devastating neuropathic condition that has been recognized with increasing frequency in the lower extremities. Patients with CRPS I, who are not diagnosed and treated in time, may worsen to such a degree that the individual may never return to a satisfactory and productive life. Before the use of spinal cord stimulation (SCS), patients who failed to respond to conservative therapy were left to live with continued and debilitating pain. CRPS I is rare but not uncommon in children, particularly in adolescent girls. There is usually in history of minor, local trauma and there are no signs of persistent tissue injury 1, 2. Case report: A 12 year old girl presents with CRPS I of the right ankle joint after a distortion injury. Initial conservative treatment with non-steroidal anti- inflammatory drugs, prednisolone, calcitonin and minimal-invasive therapy (continuous sciatic nerve block) showed no satisfactory improvement, so the decision for neuromodulative therapy was made. A lumbar-epidural temporary electrode (octrode) was placed, followed by 7 days trial stimulation. Within 5 days the child was pain free and the local symptoms were resolving. On grounds of the positive response to the temporary treatment the decision to convert into a permanent therapy system was made. On discharge the girl was pain free and already mobilizing. After 9 month of therapy a re-admission was necessary as the pulse generator was depleted and the trial of omitting neuromodulation resulted in a re-occurrence of the original symptoms. Under the assumption that the neuromodulation treatment would be required for a prolonged period a rechargeable pulse generator was implanted and within a very short time the girl was pain free again. January 2009 April 2010 August 2010 DateHeightFrequencyPulse widthLead configuration PerceptionTolerance 29.01.2009171 cm80 Hz390 µs00000-++2,0 mA7,8 mA 21.04.2010174 cm80 Hz375 µs000+-+003,3 mA11,4 mA 26.08.2010178 cm80 Hz375 µs0+-+00005,6 mA25,4 mA Discussion and Conclusion: As there is only very little data available on neuromodulation in children, the case presentation shows that the treatment algorithm in adults 3 can also be applied in pediatric cases of CRPS I. SCS in a relatively minimal-invasive method that in adults has proven to be effective for treatment of CRPS I. In conformation to Olsson et al. 4 it can be recommended for treatment of severely paediatric cases. Special attention has to be paid to differences in therapy response in children and the requirements to the leads as growth in children still continuous. Results (fig. 4, table 1): After further 6 and 10 month the resetting of the sites of stimulation was required due to remarkable growth spurts in the child. Literature: 1 Low AK et al. Pediatric Complex Regional Pain Syndrome. J Pediatr Orthop 2007; 27: 567- 572 2 Stanton-Hicks M. Plasticity of complex regional pain syndrome (CRPS) in children. Pain Med 2010 ;11: 1216-1223 3 Binder A, Schattschneider J, Baron R. Complex Regional Pain Syndrome Type I (Reflex Sympathetic Dystrophy). In: Waldmann SD. Pain Management. Saunders Elsevier, Philadephia 2007, pp 283-301 4 Olsson GL, Meyerson BA, Linderoth B. Spinal cord stimulation in adolescents with complex regional pain syndrome type I (CRPS-I). Eur J Pain 2008; 12: 53-59 Fig.1 Clinical situation before starting SCS-Treatment (27th Janury 2009): atrophy of ankle, calf and knee. Fig.2 Three-phase bone scintigraphy: characteristic increased unilateral periarticular tracer uptake. Fig. 3 A.p. fluoroscopic view showing SCS lead in the epidural space at the cephalic aspect of the 12th thoracic vertebra. Acknowledgement: I wish to thank Dr Andreas Gerhardt, Gera, and Dr Bernd Bansche, Altenburg, for pleasant collaboration. The author is grateful to Mrs. Elke Lieckfeldt, St. Jude Medical Inc., for skillful technical assistance during SCS programming. Correspondence: PD Dr. M. Kretzschmar, Klinikum Altenburger Land GmbH, Klinik für Anästhesie, Intensiv- und Schmerztherapie, Am Waldessaum 10. D-04600 Altenburg