Abstract
The hypothesis is explored that CRPS I (the "new" RSD) persists due to undiagnosed injured joint afferents, and/or cutaneous neuromas, and/or nerve compressions, and is, therefore, a misdiagnosed form of CRPS II (the "new" causalgia). An IRB-approved, retrospective chart review on a series of 100 consecutive patients with "RSD" identified 40 upper and 30 lower extremity patients for surgery based upon their history, physical examination, neurosensory testing, and nerve blocks. Based upon decreased pain medication usage and recovery of function, outcome in the upper extremity, at a mean of 27.9 months follow-up (range of 9 to 81 months), gave results that were excellent in 40% (16 of 40 patients), good in 40% (16 of 40 patients) and failure 20% (8 of 40 patients). In the lower extremity, at a mean of 23.0 months follow-up (range of 9 to 69 months) the results were excellent in 47% (14 of 30 patients), good in 33% (10 of 30 patients) and failure 20% (6 of 30 patients). It is concluded that most patients referred with a diagnosis of CRPS I have continuing pain input from injured joint or cutaneous afferents, and/or nerve compressions, and, therefore, similar to a patient with CRPS II, they can be treated successfully with an appropriate peripheral nerve surgical strategy.
Highlights
For the patient given the traditional diagnosis of "Reflex Sympathetic Dystrophy" (RSD) who fails to recover from sympathetic blocks, anti-inflammatory medication and physical therapy, current treatment options largely consign the patient to a Pain Management center for life.[1,2]
Painful dorsal column input can arise from neuromas of cutaneous nerves, which can be determined by nerve block of the appropriate nerve, taking care not to place the anesthetic where two nerves will be blocked simultaneously
If the principles described in the past to treat painful cutaneous neuromas in the upper extremity can be applied successfully in the lower extremity, patients with Complex Regional Pain Syndrome I" (CRPS I) after ankle injury, who have persistent superficial peroneal and sural neuromas related to lateral ankle stabilization or fracture fixation, should receive a nerve block of these nerves, and be considered potential surgical candidates
Summary
For the patient given the traditional diagnosis of "Reflex Sympathetic Dystrophy" (RSD) who fails to recover from sympathetic blocks, anti-inflammatory medication and physical therapy, current treatment options largely consign the patient to a Pain Management center for life.[1,2] Changing the diagnosis to the more "appropriate", current term, "Complex Regional Pain Syndrome I" (CRPS I),[3] does not change this treatment plan.[1,2] Other than sympathectomy or an implanted spinal cord or peripheral nerve stimulator, surgery is rarely recommended.[1,2,4,5,6] For the lower extremity, "RSD of the knee", [7,8,9,10,11] and CRPS I of the foot[12] have been characterized, but, again, without a suggestion that surgical intervention on the peripheral nerve itself might be appropriate.[13]. With the hypothesis that chronic pain input to the dorsal spinal columns can be the source of CRPS II, misdiagnosed as CRPS I, and with the hypothesis that injured joint and/or cutaneous afferents as well as chronic nerve compression can be the source of these painful dorsal column inputs, an approach was taken to re-evaluate patients with CRPS I of the upper or lower extremity. The results of this approach are reported
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