Background & Aims

Complex Regional Pain Syndrome (CRPS) is a rare pain condition characterized by extreme pain and sensitivity disproportionate to a preceding injury. Diagnosed by the Budapest Criteria, CRPS encompasses a variety of clinical changes including motor, autonomic and trophic changes which can often lead to disability and significant psychological distress. The complex pathophysiology of CRPS remains a challenge in developing treatments to successfully combat this impairing condition. Treatment options for CRPS range from medications, physical therapy, interventional procedures, and operative intervention. Earlier treatment leads to more favorable outcomes, but frequent revaluation after each intervention may change the course of treatment. Furthermore, identification and treatment of underlying conditions such as peripheral nerve compression, if present, may improve functional outcomes.

Methods

A review of the literature found few high-quality studies evaluating the efficacy of early, aggressive treatment for patients with CRPS. This case report highlights the importance of pursuing more intensive interventions, communication with surgical services and ruling out alternative treatments early if a patient fails to progress to prevent chronic, disabling pain.

Results

Here we present a case of a 38-year-old male with a history of a gunshot wound to the right thigh who presented with chronic right lower extremity pain. Patient reported associated symptoms of swelling, hypersensitivity, allodynia, discoloration, and right thigh atrophy and was diagnosed with CRPS.
This patient was treated with neuropathic medications, lumbar sympathetic blocks paired with graded motor imagery with minimal long-term benefit. Based on the transient response to injections, he underwent a Dorsal Root Ganglion Stimulator trial and later implant with significant improvement in function, allodynia, swelling, color change, and pain. Despite improvements, he continued to have residual severe pain on the dorsum of his foot with a positive Tinne’ls sign at the fibular head. With careful discussion with our surgical colleagues, he underwent a decompression of the right common peroneal nerve with significant improvement in pain and discomfort, and functional restoration.

Conclusions

Given the complex nature of this syndrome, it is unlikely that targeting a specific mechanism will be effective. There is still no consensus to determine the optimal treatment for CRPS. Patients who are not symptomatically improving, despite regular analgesia, neuropathic agents and physiotherapy, should be considered early for interventions such as sympathetic blocks, dorsal root stimulation and potential operative interventions. There is often great hesitancy to operate on patients with CRPS given the risk of making the CRPS worse. We have found that pre and postoperative blocks or even implantation of spinal cord stimulators may reduce the sympathetically mediated symptoms to allow patients to undergo successful surgery. The future of CRPS treatment may lie in early intensive combination therapy and studies investigating this will be necessary. The importance of communication with surgical and non surgical services is key to the ultimate success for these patients.

References

1.de Mos, M., Huygen, F. J. P. M., van der Hoeven-Borgman, M., Dieleman, J. P., Ch Stricker, B. H., & Sturkenboom, M. C. J. M. (2009). Outcome of the complex regional pain syndrome. The Clinical Journal of Pain, 25(7), 590–597. https://doi.org/10.1097/AJP.0b013e3181a11623

2. Dellon, A., Andonian, E., & Rosson, G. (2014). CRPS of the upper or lower extremity: surgical treatment outcomes. Journal of Brachial Plexus and Peripheral Nerve Injury, 04(01), e7–e12. https://doi.org/10.1186/1749-7221-4-1

3. Ghaly, L., Bargnes, V., Rahman, S., Tawfik, G.-A., Bergese, S., & Caldwell, W. (2023). Interventional Treatment of Complex Regional Pain Syndrome. Biomedicines, 11(8), 2263. https://doi.org/10.3390/biomedicines11082263

4. Lee, J., & Nandi, P. (2011). Early aggressive treatment improves prognosis in complex regional pain syndrome. The Practitioner, 255(1736), 23–26, 3. https://pubmed.ncbi.nlm.nih.gov/21370711/

5. Limerick, G., Christo, D. K., Tram, J., Roya Moheimani, Manor, J., Chakravarthy, K., Karri, J., & Christo, P. J. (2023). Complex Regional Pain Syndrome: Evidence-Based Advances in Concepts and Treatments. https://doi.org/10.1007/s11916-023-01130-5

Presenting Author

Hiba Zafar

Poster Authors

Hiba Zafar

M.D.

Washington University of St. Louis

Lead Author

E-mail

Topics

  • Specific Pain Conditions/Pain in Specific Populations: Complex Regional Pain Syndrome (CRPS)