Clinical Update
By Dr P. Max Majedi, Pain Medicine Specialist, SCGH Pain Management Department
Complex regional pain syndrome CASE REPORT
She eventually underwent trial dorsal root ganglion (DRG) stimulation with stimulation of C6, 7, 8 and T1. The trial went for four weeks with 100% improvement in pain, complete reversal of the skin changes and full return of function.
This patient first presented with a painful right thumb (dominant hand) with dystrophic and hyper pigmented skin changes. This was after a minor work-related accident with a small cut to the thumb. Soon after the cut she developed severe pain, swelling, redness and loss of function. It was treated conservatively. However, it rapidly worsened and started to get hyper-pigmented, with rapid loss of function and hypersensitivity to the dominant right hand. On presentation, she was being investigated for a potential infection of the thumb with reviews and skin samples by a dermatologist and numerous steroid and antibiotic treatments but to no avail.
She was eventually implanted with a full device and is currently using it effectively. Discussion
Q Fig1: Before DRG stimulation
The choice of this technology was based on science of DRG stimulation, which in some respects may offer neuropathic and nociceptive modulation. Although such intensive input is not required for the majority of patients, in selected scenarios, this approach is advantageous to ensure a collaborative model of care that is 100% patient-centred.
Her GP attempted to treat her with the standard analgesia and anti-neuropathic medication, all of which caused significant side effects. He was doing ring blocks and cleaning of the hypertrophic tissue sometimes on a weekly basis. She was initially assessed medically and then by the multidisciplinary team including hand therapist, physiotherapist and clinical psychologist. She was treated with numerous trials of pharmacotherapy including lignocaine infusion with no results. By this stage there was talk of amputation by her treating surgeon given the aggressiveness of her condition. The workers’ compensation interaction had become adversarial and there was little support to fund ongoing therapy. She had several attempts at stellate ganglion blocks with some improvement. Eventually the decision was made to do a direct brachial plexus block with addition of steroids and clonidine to the local anaesthetic. This gave the best results, as confirmed by her, the wound nurse and the hand therapist. However the results where short-lasting.
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42 | MARCH 2016
This case demonstrates a very complex pain situation requiring input from multiple disciplines within the one team without any commercial conflict of interest. As a team there were direct lines of communication and frank discussion about the issues. This allowed timely decision making all the way to the highend treatment such as spinal cord stimulation.
Q Fig2: Two weeks after DRG Stimulation
Then the medical treatment added pulsed rhizotomy to the brachial plexus, with pain control resulting for about four weeks. This continued for approximately one year, as her workers comp case was still ongoing with additional stressors and a number of other psychosocial confounders. Eventually, the decision was made for trial of a spinal cord stimulator once the workers’ compensation case was finalised.
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It also demonstrated some of the shortcomings of our current workers compensation system where some medical conditions are simply not treated adequately and aggressively enough, predominantly due to disease classification and absence of understanding of the socio-psycho-biological nature of persistent pain. Complex regional pain syndrome, in its most overt form, responds poorly to psychosocial stressors that invariably are part of the compensation-based medicine system, when the pain generator cannot be identified by scans and tests. In the case of this patient, her response is very clear and confirmed by several medical practitioners and allied health practitioners. Author competing interests: no relevant disclosures.
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MEDICAL FORUM