Reversal of Complex Regional Pain Syndrome Type 2 and the Subsequent Management of Complex Regional Pain Syndrome Type 1 Occurring after Corrective Surgery for Residual Ulnar Claw

Abstract

Dear Editor, Complex regional pain syndrome type 1 (CRPS-1) that has previously resolved can recur after repeat surgery at the same anatomic site [1]. No existing treatment reverses CRPS-2 or a recurrent CRPS-1 [2–7]. We report the reversal of initial CRPS-2 as well as the subsequent CRPS-1 after surgery for residual ulnar claw with a multi-modality treatment regimen (MMTR) developed by us [8]. A lady of 39 years presented with 3 months of CRPS-2 following surgery for humerus fracture. Electromyography confirmed radial and ulnar nerve involvement. The Disability of Arm, Shoulder and Hand (DASH) score was 90.2 [9]. Ultrasonography (USG) showed hyperechogenicity in CRPS-2-affected muscles (Figure ⇓). She was treated with MMTR comprising medications (daily nortriptyline 35 mg, pregabalin 150 mg, tramadol 100 mg, and diclofenac as needed), continuous brachial plexus block (CBPB) for 4–5 weeks, dry needling (DN) of muscles of CRPS extremity, and physical therapy (PT). Figure 1 (A) Muscles of the normal left upper extremity showing a well-defined distinction between hypoechoic muscle fascicles enveloped by hyperechoic fascia characteristic of a normal muscle. (B) Muscles of CRPS-2-affected right limb flexor carpi radialis (FCR), flexor digitorum superficialis (FDS), flexor digitorum profundus (FDP) show reduction in size and hyperechogenicity indicating fibrosis, whereas pronator teres (PT) is showing normal echogenecity; extensor digitorum (ED), supinator (S), biceps, and brachialis show hyperechogenecity, loss of outline, and reduction in size. (C) FCR, FDS, and FDP showing increase in size and appearance of new muscle fibers replacing fibrosis; ED showing new muscle fibers replacing fibrosis; biceps and brachialis showing new muscle fibers, appearance of outline, and increase in size. A-A, B-B, C-C, D-D are calipers put to measure the thickness of muscles; BI = biceps; BR = brachialis; CRPS = complex regional pain syndrome; EXT or E = extensors; …