Complex Regional Pain Syndrome: Diagnostic and Treatment Conundrum

Abstract

A 54-year-old man presented with a 12-week history of right lower extremity radicular pain with symptoms and signs of complex regional pain syndrome (CRPS). He reported a recent medical history of transient ischemic attack followed by cerebrovascular accident for which he underwent carotid endarterectomy. Following carotid endarterectomy, the patient was left with minimal residual speech and memory deficits, but concomitant presentation of right lower extremity radicular pain in the postoperative period was the reason for seeking pain relief. Right lumbar radiculopathy was suspected at the time of presentation to the pain clinic, and magnetic resonance imaging revealed bilateral moderate to severe lumbar foraminal stenosis, worse on the right side. Parasagittal lumbar epidural steroid injection, and aggressive multimodal pain management strategy was started resulting in significant improvement in pain scores, functionality and stress levels, albeit for a short period. Patient continued to obtain incomplete resolution of symptoms with conventional treatment. He underwent spinal cord stimulation at an early stage but only derived moderate benefit. The presented case is unusual because of overlapping etiologies that influenced our treatment plans. In this article, we will discuss the evidence for each of the questions raised by practitioners while treating aforementioned patient with CRPS. J Med Cases. 2016;7(1):33-42 doi: http://dx.doi.org/10.14740/jmc2378w