Abstract
Venipuncture, the most frequently performed invasive medical procedure, is usually benign. Generally it produces only transitory mild discomfort. Venipuncture-induced neuropathic pain is hard to recognize at an early stage. Medical literature reviews show that there is not adequate medical knowledge about this important subject. The inciting incident in complex regional pain syndrome (CRPS) can often seem far too trivial to result in a condition with such severe pathophysiologic effects. The practicing physician has little information available to enable early recognition of the condition, initiation of multidisciplinary treatment modalities, and proper referral to pain specialists. We encountered a unique case of venipuncture-induced complex regional pain syndrome (CRPS). The patient is a 52-year-old school teacher with no significant past medical history, who presented initially to the Center of Pain Medicine with left upper extremity pain. The pain started while phlebotomy was performed in the patient's left antecubital area for routine blood check. The patient's pain did not improve with multiple medications, physical therapy, or several nerve blocks. The patient demonstrated all the signs and symptoms of chronic neuropathic pain of CRPS in the upper extremity with minimal response to the continuous pain management. We decided to proceed with cervical spinal cord nerve stimulation along with continuing other modalities. The patient responded to this combination. During the follow-up, we noticed that the patient's pain course was complicated by extension of the CRPS to her lower extremity. We will describe the course of treatment for the patient in this paper. In this paper we will discuss the electrical neuromodulation as an important modality in addition to the multidisciplinary pain management for a patient with venipuncture-induced chronic neuropathic pain.
Highlights
Venipuncture, the most frequently performed invasive medical procedure, is usually benign, producing only transitory mild discomfort
Several case series and individual patient reports document nerve injuries consequent to the procedure. While such injuries are reportedly rare (1 : 21,000– 1 : 26,700) some can be severe with permanent residua, the most disturbing being chronic neuropathic pain, complex regional pain syndrome type 2 (CRPS-II), or causalgia
Complex regional pain syndrome (CRPS) is an enigmatic clinical condition characterized by various combinations of sensory, autonomic, and motor dysfunction
Summary
Venipuncture, the most frequently performed invasive medical procedure, is usually benign, producing only transitory mild discomfort. Several case series and individual patient reports document nerve injuries consequent to the procedure While such injuries are reportedly rare (1 : 21,000– 1 : 26,700) some can be severe with permanent residua, the most disturbing being chronic neuropathic pain, complex regional pain syndrome type 2 (CRPS-II), or causalgia. Original International Association for the Study of Pain (Orlando) diagnostic criteria for complex regional pain syndrome include (1) the presence of an initiating noxious event or a cause of immobilization, (2) continuing pain, allodynia, or hyperalgesia with which the pain is disproportionate to any inciting event, (3) evidence of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain at some point in time, and (4) diagnosis that is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction. In a Japanese study, between 2004 and 2008, venipunctures were performed with 133 cases of resultant persistent pain and 19 cases of neuropathic pain [5]
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