BRIEF DISCUSSION

COMPLEX REGIONAL PAIN
SYNDROME
25-08-2009

 

MODERATORS: - Professor & HOD B J Kamath
Dr Deepak M Naik
PRESENTER: - Dr Praveen Babu K H
Department of Orthopaedics
Kasturba Medical College,
Mangalore

Introduction
Complex regional pain syndrome (CRPS) is a
chronic progressive disease characterized
by severe pain, swelling and changes in the
skin.
 The exact cause of this syndrome is
currently unknown.

Synonyms  Reflex Sympathetic dystropy  Sudeck’s osteodystrophy  Algo dystrophy  Causalgia after nerve injury  Pour four du petit syndrome  Sympathetic paralysis .

Synonyms Cont…  Leriche posttraumatic pain syndrome  Sympathic maintaince pain syndrome  Transient osteoperosis  Acute atrophy of bone  Shoulder-hand syndrome .

Florida S W Mitchell . Evans ‘reflex sympathetic dystrophy’. a special consensus workshop held in Orlando.History and Nomenclature  Ambroise in the 17th century  1864 S W Mitchell during the American Civil War  1900 Sudeck described regional demineralization  1946.  1993.

8 years  Mean age at time of injury 37.7 years  Mean duration of symptoms before pain center evaluation = 30 months  2.3 to 3 times more frequent in females than males  Usually involves a single limb in the early stage .Epidemiology  Age – common in younger adults  Mean 41.

does not have demonstrable nerve lesions.Classification The International Association for the Study of Pain  Type I. also known as causalgia.  .  Type II. has evidence of obvious nerve damage.

no precipitant can be identified .Etiology Triggered        In by a variety of events Minor trauma ranks as the leading provocative event Ischemic heart disease and myocardial infarction Cervical spine or spinal cord disorders Cerebral lesions Infections Surgery Repetitive motion disorder or cumulative trauma approximately 10% of patients.

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 Asymmetry or instability of temperature or color.  Asymmetry or instability of sweating. hair.  Hyperalgesia  Swelling. .  Trophic changes of skin.  Burning pain. nails.Clinical Features History  Symptoms develop following injury  Single extremity.

 Hair Loss.Clinical Features cont… On examination  Hyperalgesia or allodynia.  Edema  Vasomotor changes  Sudomotor changes  Trophic changes  Shiny Skin.  Abnormal Nail Growth.  Impaired motor function .

swelling and dysfunction are localized  Symptoms are mild  Allodynia is generally absent  Hyperesthesia  Limb is relatively immobile and sensitive  Last up to 3 months.Stage I (Acute stage) Characterized by mild Symptoms  Begins within days or weeks  Sharp.  . burning pain.

Stage II CRPS (Dystrophic) Increasing dysfunction  Chronicity of the symptoms. cold & edematous  The skin becomes mottled.  Increasing joint stiffness  Myofascial contractures  Can last 3 to 12 months.  Pain & sensitivity persists  Moist .  .

Stage III CRPS (atrophic) Most severe stage  Severe aching and throbbing pain  Functionally useless  Chronic autonomic dysfunction  Dystrophic changes  Halted growth  Regional osteoporosis  Symptoms are unresponsive  Considered permanent  .

Differential Diagnosis Diabetic and small-fiber peripheral neuropathies  Entrapment neuropathies  Thoracic outlet syndrome  Vascular insufficiency  Deep vein thrombosis  Cellulitis  Lymphedema  Erythromelalgia  Discogenic disease  .

bone scan may be normal  X-ray may show osteoporosis  Modified Sympathetic Blockade Testing  . MRI.Investigations Thermography may be helpful  CT.

Treatment Physical therapy  Pharmacologic management  Bisphosphonate  Baclofen  Adrenergic active drugs  Systemic steroids  Other therapies  .

Treatment Cont…  Invasive treatments Ganglion blocks Intravenous regional blocks Epidural clonidine Regional sympathetic nerve block .

Treatment Cont… Dorsal column spinal cord stimulation Sympathectomy Tender point injections Nerve stimulation .