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Complex Regional Pain Syndromes Differential

Diagnoses
Author: Anthony H Wheeler, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA more...

Updated: Apr 3, 2012

Diagnostic Considerations
Differential Diagnosis Overview

The risk of overdiagnosing CRPS must be taken into account. A detailed history and physical examination, as
well as the aforementioned specifications, including testing, are necessary to differentiate CRPS from other
neuropathic and pain syndromes.

Neuropathy (eg, diabetic polyneuropathy) may also present with spontaneous pain, skin color changes, and
motor deficit that are distinguished from CRPS by the patient’s history and their symmetrical distribution.
Furthermore, all kinds of inflammatory, rheumatological, and infectious conditions might induce intense unilateral
skin warming. Unilateral arterial or venous occlusive diseases can cause unilateral pain and vascular
abnormalities, and therefore must be excluded when diagnosing CRPS. The repetitive artificial occlusion of blood
supply to one limb can be seen in psychiatric, factitious disorders when individuals induce secondary structural
changes in the blood vessels and cause abnormalities in perfusion that mimic the symptoms and signs of CRPS.

Posttraumatic neuralgia

Many patients with posttraumatic neuropathy have pain but not the full clinical profile of CRPS type II. In these
cases, pain is located largely within the territory of the injured nerve, which contrasts with patients with CRPS
type II. Although patients with neuropathy often describe the pain as burning, they exhibit a less complex clinical
picture than patients with CRPS type II and do not show marked swelling or the progressive spread of symptoms.

The principal symptoms for posttraumatic neuropathy are spontaneous burning pain, hyperalgesia, and
mechanical allodynia. These sensory symptoms are confined to the territory of the affected peripheral nerve,
although the allodynia may extend beyond the nerve territory's border by some centimeters. Both spontaneous
and evoked pain is felt superficially, not deep inside the extremity, and the intensity of both is independent of the
position of the extremity.

Patients with posttraumatic neuropathy usually obtain relief with sympatholytic procedures, although much less
often than patients with CRPS. Following the IASP classification, it is possible to choose the term posttraumatic
neuralgia for this type of neuropathic pain (pain within the territory of the lesioned nerve). However, the new
definition of CRPS type II also includes the statement that symptoms can be limited to the territory of a single
peripheral nerve. Therefore, the term CRPS type II could be applied to these localized posttraumatic
neuropathies, even though they are different syndromes with different underlying mechanisms, which highlights
the problems with this definition of CRPS II.

Diagnostic considerations

CNS

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Complex Regional Pain Syndromes Differential Diagnoses http://emedicine.medscape.com/article/1145318-differential

Brain (stroke, neoplasm, encephalitis)

Spinal cord (trauma, transverse myelitis, either structural or tumor-related syringomyelia)
Tabies dorsalis
Multiple sclerosis
Poliomyelitis
Radiculopathy
Structural (eg, due to structural impingement of a diskal, osteophyte-, or tumor-related nature)
Metabolic (eg, diabetes, vasculitis infectious)
Neoplastic
Plexopathy
Infectious
Autoimmune/idiopathic
Tumor (primary or secondary neoplasm), especially Pancoast syndrome
Trauma (macro or cumulative)
Entrapment (thoracic outlet syndrome)
Neuropathy
Focal
Diabetes
Inflammatory or infectious (Lyme), sarcoid
Posttraumatic
Entrapment (eg, carpal tunnel, cubital tunnel)
Toxic
Neoplastic (neuroma)
Multifocal (mononeuritis multiplex)
Diabetes
Vasculitis
Infectious
Toxic
Bilateral or diffuse
Diabetes
Alcohol
Nutritional
Guillain Barre syndrome or chronic inflammatory demyelinating polyneuropathy
Porphyria
Vascular disorders
Raynaud phenomena
Peripheral atherosclerotic disease
Arterial insufficiency
Phlebothrombosis
Monomelic amyotrophy
Psychological
Hysteria
Somatoform disorder, including malingering
Movement disorders
Metabolic or systemic (eg, renal failure, amyloidosis)
Autoimmune or rheumatological disorder
Infectious (eg, viral, fungal, Lyme) Iatrogenic (eg, prescribed medication)
Demyelinating (CIDP, paresis or sensory deficiency due to multiple sclerosis)
Toxic exposure (eg, vinca alkaloids, heavy metals)

Contributor Information and Disclosures

Author
Anthony H Wheeler, MD Pain and Orthopedic Neurology, Charlotte, North Carolina

Anthony H Wheeler, MD is a member of the following medical societies: American Academy of Neurology,
American Academy of Pain Medicine, North American Spine Society, and North Carolina Medical Society

Disclosure: Allergan, Inc. Salary Speaking and teaching; Gralise None Consulting

Specialty Editor Board

Jorge E Mendizabal, MD Consulting Staff, Corpus Christi Neurology

Jorge E Mendizabal, MD is a member of the following medical societies: American Academy of Neurology,

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Complex Regional Pain Syndromes Differential Diagnoses http://emedicine.medscape.com/article/1145318-differential

American Headache Society, National Stroke Association, and Stroke Council of the American Heart Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Glenn Lopate, MD Associate Professor, Department of Neurology, Division of Neuromuscular Diseases,

Washington University School of Medicine; Director of Neurology Clinic, St Louis ConnectCare; Consulting Staff,
Department of Neurology, Barnes-Jewish Hospital

Glenn Lopate, MD is a member of the following medical societies: American Academy of Neurology, American
Association of Neuromuscular and Electrodiagnostic Medicine, and Phi Beta Kappa

Disclosure: Baxter Grant/research funds Other; Amgen Grant/research funds None

Chief Editor
Stephen A Berman, MD, PhD, MBA Professor of Neurology, University of Central Florida College of Medicine

Stephen A Berman, MD, PhD, MBA is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Neurology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

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