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Complex Regional Pain Syndrome

Dr. H. Metwally BScAPh, MBChB, MDA, FFARCSI, MRCA, MSc Pain Management

Diana Princess of Wales Hospital

Pain Medicine, Anaesthesia and Critical Care Lincs Pain Clinic


What is CRPS?  A chronic painful

progressive disease  Characterized by severe pain, swelling and changes in the skin (colour, temp hair and nails).  There is no cure. Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Is it one type?

ď Ž The International Association for the Study of

Pain has divided CRPS into two types based on the presence of nerve lesion following the injury.

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


CRPS Type I  Formerly known as:  Reflex sympathetic   

dystrophy (RSD), Sudeck's atrophy Reflex neurovascular dystrophy (RND) Algoneurodystrophy It does not have demonstrable nerve lesions. Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


CRPS Type II ď Ž Formerly known

as causalgia ď Ž It has evidence of obvious nerve damage.

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


CRPS  The cause: unknown.  Precipitating factors  Injury  Surgery  There are documented cases that have no demonstrable injury to the original site.  These problem was certainly major by the

importance of the vasomotor and sudomotor symptoms, but stemmed from minor neurological lesions. Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


 History  Pathophysiology  Susceptibility

 Contributing factors  Genetic theory

(hidden slides)

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Symptoms  Usually manifest near the site of an injury,

either major or minor.  The most common symptoms overall are      

Burning, electrical sensations, shooting pain May also experience muscle spasms Local swelling Abnormally increased sweating Changes in skin temperature and color Softening and thinning of bones Joint tenderness or stiffness, restricted or painful movement. Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Symptoms  The pain is continuous  May be heightened by emotional or physical

stress  Moving or touching the limb is often intolerable.  The symptoms of CRPS vary in severity and duration.

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Diagnosis, The IASP criteria for CRPS  CRPS types I and II share the common diagnostic

criteria 

Spontaneous pain or allodynia is not limited to the territory of a single peripheral nerve, and is disproportionate to the inciting event. There is a history of oedema, skin blood flow abnormality, or abnormal sweating in the region of the pain since the inciting event. No other conditions can account for the degree of pain and dysfunction.

 The two types differ only in the nature of the inciting

event.  

Type I CRPS develops following an initiating noxious event that may or may not have been traumatic Type II CRPS (causalgia) develops after a nerve injury. Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Thermography  Measuring blood flow by

determining the variations in heat emitted from the body.  An altered blood supply to the painful area, appearing as a different shade (abnormally pale or violet) than the surrounding areas of the corresponding part on the other side of the body.  A difference of 1.0°C between two symmetrical body parts is considered significant  The affected limb may be warmer or cooler than the unaffected limb Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Sweat testing  Abnormal sweating can be

detected by several tests.  A powder that changes color when exposed to sweat can be applied to the limbs; however, this method does not allow for quantification of sweating.  Two quantitative tests that may be used are the resting sweat output test and the quantitative sudomotor axon reflex test.  These quantitative sweat tests have been shown to correlate with clinical signs of CRPS.

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Radiography  Patchy osteoporosis, which may be due to

disuse of the affected extremity, can be detected through X-ray imagery as early as two weeks after the onset of CRPS.  A bone scan of the affected limb may detect these changes even sooner.  Bone densitometry can also be used to detect changes in bone mineral density. It can also be used to monitor the results of treatment, as bone densitometry parameters improve with treatment. Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Electrodiagnostic testing Electromyography Known

as Nerve conduction study Detect the nerve injury that characterizes type II CRPS. The symptoms of type II CRPS extend beyond the distribution of the affected peripheral nerve (In contrast to peripheral mononeuropathy)

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Management

ď ŽPrevention ď ŽTreatment

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Prevention  Treat post traumatic pain and inflammation without

dealy.  Vitamin C has been shown to reduce the prevalence of complex regional pain syndrome after wrist fractures. A daily dose of 500 mg for fifty days is recommended  These studies are difficult to interpret because the incidence of CRPS in those who took the Vitamin C in this study are similar to the incidence without taking anything in other studies

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Treatment ď Ž The general strategy in CRPS treatment is

often multi-disciplinary, with the use of different types of medications combined with distinct physical therapies.

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Drugs  Variety of drugs including:  Antidepressants  anti-inflammatories such as corticosteroids and COX-inhibitors       

such as piroxicam Vasodilators GABA analogs such as gabapentin and pregabalin Alpha- or beta-adrenergic-blocking compounds The entire pharmacy of opioids. Bisphosphonates: treat osteoporosis in cancer patients (Pamidronate) Ketamine????? Although many different drugs are used, there is not much supportive evidence for most of them. This doesn't necessarily reflect evidence that they don't work, just a lack of evidence that they do. Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


ď Ž How to use each of these drug groups?

(Leave it for the discussion)

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Pamidronate in complex regional pain syndrome type I ď Ž 30-60 mg as a single dose IVI over one hour ď Ž Good response so far

Pain Med. 2004 Sep;5(3):276-80. Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Bier’s Block  Guanethidine (Ismelin) (30 mg for U.L or 40

mg for L.L): antihypertensive drug that reduces the release of catecholamines  Bretylium: (100 mg) antiarrhythmic agent. It

blocks the release of noradrenaline from nerve terminals 

+ Clonidine 75mcg +Ketorolac 40 mg + Prolocaine 40 mls (U.L) or 60 mls (L.L) Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Ketamine  Ketamine is the only potent

NMDA-blocking drug currently available for clinical use

 Ketamine is being used as

an experimental and controversial treatment for CRPS.  May have more than one mechanism of action  Can be taken oral or infusion Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Local anaesthetic  Blocks, Regional injections or Topical  Often the first step in treatment  Repeated as needed  Early intervention with non-invasive

management may be preferred to repeated nerve blockade.  The use of topical lidocaine patches has been shown to be useful

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Spinal cord stimulators Directly stimulating the spinal cord Place electrodes either in the epidural or directly over nerves located outside the central nervous system A systematic review concluded: Spinal cord stimulation appears to be an effective therapy in the management of patients with CRPS type I (Level A evidence) and type II (Level D evidence) Moreover, there is evidence to demonstrate that SCS is a cost-effective treatment for CRPS type I. Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Implantable drug pumps Implantable drug pumps may also be used to deliver pain medication directly to the cerebrospinal fluid which allows powerful opioids to be used in a much smaller dose than when taken orally Other treatments with encouraging published results (e.g., neural stimulators) are not used often enough." Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Sympathectomy  Surgical, chemical, or

radiofrequency  Interruption of the affected portion of the sympathetic nervous system  Can be used as a last resort in patients with impending tissue loss, edema, recurrent infection, or ischemic necrosis  There is little evidence that these permanent interventions alter the pain symptoms of the affected patients. Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Chemical Sympathectomy  Non destructive:

Local anesthetic  Botulinum toxinType A in addition to Local anesthetic  Clonidine  Destructive:  Alcohol 100%  Phenol 

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Physical and occupational therapy  Primarily by desensitizing the affected

body part  Restoring motion  Improving function.  Some people at certain stages of the disease are incapable of participating in physical therapy due to touch intolerance  Graded

Motor Imagery  Mirror Therapy Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Physical and occupational therapy  Mirror box therapy

 Tactile discrimination training

 Graded exposure to fearful activities

 EEG Biofeedback Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Prognosis of CRPS ď Ž Good progress can be made in treating

CRPS if treatment is begun early, ideally within 3 months of the first symptoms. ď Ž If treatment is delayed, >> spread to the entire limb >> changes in bone, nerve and muscle may become irreversible.

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Prognosis of CRPS ď Ž Is not always good. ď Ž The limb, or limbs, can experience

muscle atrophy, loss of use and functionally useless >> require amputation.

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Conclusion

CRPS will not "burn itself out" but, if treated early, it is likely to go into remission.

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic


Thank You

Assiut Anaesthesia Conference 2012 Dr. Metwally, Diana, Princess of Wales Hospital Lincs Pain Clinic

Complex regional pain syndrome Assiut 2012  

Complex regional pain syndrome Assiut 2012

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