Lower Extremity Complex Regional Pain Research Articles

Sphenopalatine Ganglion Block With Lidocaine Drops Relieves Lower Extremity Complex Regional Pain Syndrome: A Case Report

BACKGROUND: Lower extremity complex regional pain syndrome (CRPS) is a debilitating, neuropathic pain disorder that may develop into a refractory, chronic condition, which currently has no gold-standard treatment. We would like to share the first report of a transnasal sphenopalatine ganglion block with lidocaine that effectively relieved the pain of a patient suffering from lower extremity CRPS. CASE REPORT: A 48-year-old man with CRPS suffered from pain that was resistant to analgesic medications, spinal blocks, and a spinal cord stimulator. A sphenopalatine ganglion block was administered to the patient via long, hollow cotton-tip applicators with lidocaine drops. After just one block, for the first time in 10 years, he was 100% pain free for 5 days. CONCLUSIONS: This case report demonstrates that the lidocaine sphenopalatine ganglion block could be a simple, safe, inexpensive, and noninvasive treatment option for those affected by lower extremity CRPS. KEY WORDS: Sphenopalatine ganglion block, lidocaine, chronic pain, complex regional pain syndrome

Prediction of the Efficacy of Lumbar Sympathetic Block in Patients with Lower Extremity Complex Regional Pain Syndrome Type 1 Based on the Sympathetic Skin Response.

Complex regional pain syndrome type 1 (CRPS-1) is prevalent after trauma, with intractable pain being the most prominent clinical symptom. The impact of sympathetic block on CRPS is unclear. The goal of this study was to explore the characteristics that predict successful symptom relief with lumbar sympathetic block (LSB) in patients with lower extremity CRPS-1. The study was designed as a prospective cohort study. Ninety-eight patients diagnosed with lower extremity CRPS-1 between March 2021 and March 2022 were enrolled as participants. All of the patients received two LSB treatments within a month. Sympthetic skin response (SSR) and numeric rating scale (NRS) were recorded before and after LSB treatment. The procedure was judged as a clinically positive response if the patients a 50% or greater reduction in NRS scores. Patients were divided into positive response and negative response groups after LSB treatment: LSB (+) and LSB (-), and the different characteristics and examination findings of the two groups of patients were compared. Furthermore, a multivariable logistic regression model was utilized to evaluate the predictors of successful symptom relief following LSB treatment. A total of 43.9% (43/98) of patients experienced successful symptom relief, while 56.1% (55/98) had unsuccessful symptom relief. After LSB treatment of all subjects, the overall NRS score decreased, the SSR amplitude increased, and the SSR latency shortened in the affected extremity (P < 0.05). There was a significant difference in the change in SSR amplitude between the LSB (-) and LSB (+) groups (P = 0.000). A 12-month disease duration had an OR (odds ratio) of 4.477 (P = 0.009), and a 510-µV baseline SSR amplitude of the affected extremity had an OR of 7.508 (P = 0.000) in the multivariable analysis that included these explanatory variables. Patients with lower extremity CRPS-1 can experience significant pain relief after LSB treatment. The predictors of successful symptom relief after LSB treatment were a baseline SSR amplitude of the affected extremity < 510µV and a disease duration < 12months. The study was registered in the Chinese Clinical Trial Registry (ID: ChiCTR2000037755, date of registration: September 4, 2020).

The Tourniquet Ischemia Test Effectively Predicts the Efficacy of Lumbar Sympathetic Block in Patients with Lower Extremity Complex Regional Pain Syndrome Type 1.

BackgroundNeuropathic pain is the most common clinical sign of complex regional pain syndrome (CRPS). Currently, lumbar sympathetic block (LSB) is commonly utilized in lower extremity CRPS that has failed to respond to medication therapy and physical therapy, but its effectiveness is unknown. The tourniquet ischemia test (IT) can distinguish between two types of CRPS: IT-positive CRPS and IT-negative CRPS.ObjectiveThe aim of the study was to investigate whether LSB improves pain scores in patients with lower extremity CRPS-1 and to screen factors to predict its efficacy.Study DesignProspective clinical observational study.SettingPain management center.SubjectsForty-three patients diagnosed with lower extremity CRPS-1 using the Budapest criteria were included as participants.MethodsForty-three CRPS-1 patients were treated with LSB therapy, and all of them underwent a tourniquet ischemia test (IT) before undergoing LSB therapy. LSB therapy was performed using a combination of ultrasonography and fluoroscopy. Then, numeric rating scale (NRS) scores and the symptom relief rates of patients were evaluated at 1, 4, and 12 weeks. Finally, peripheral blood inflammatory cytokine samples were collected before and after the LSB treatment.ResultsAt 4 weeks after the treatment, the total effective symptom relief rate of LSB on CRPS-1 was 25.6% (11/43), with 52.6% (10/19) of IT(+) patients and 4.2% (1/24) of IT(-) patients. There was a significant difference between the IT(-) and IT(+) groups (P = 0.001). The multivariate binary logistic regression analysis revealed that the response to the tourniquet IT was the only significant independent predictor of sympathetic block success (p = 0.007).ConclusionTourniquet IT is a simple, safe and effective test to distinguish patients with lower extremity CRPS-1. The response to the tourniquet IT is a reliable predictor of LSB effectiveness in lower extremity CRPS-1 patients.

Perineural Adductor Canal Catheter Placement for Prevention of Complex Regional Pain Syndrome-I Exacerbation After Knee Arthroscopy: A Case Report

Arthroscopic knee surgery is a common trigger for lower extremity complex regional pain syndrome (CRPS). Few studies assess nerve block catheters for CRPS treatment; they do not appear to be studies of regional anesthesia to treat CRPS that occurs after knee surgery. We present a case of CRPS-I triggered by knee surgery on multiple prior occasions but finally prevented by perineural adductor canal catheter placement. The literature presents only moderate evidence supporting interventions such as intravenous regional anesthesia and sympathetic blockade; continuous nerve blockade may be an effective treatment of CRPS-I and in particular postoperative CRPS-I.

This Month in Anesthesiology

This Month in Anesthesiology

Effect of Patient Characteristics on Clinical Outcomes More Than 12 Months Following Dorsal Root Ganglion Stimulation Implantation: A Retrospective Review

IntroductionDorsal root ganglion (DRG) stimulation is an effective treatment option for lower extremity complex regional pain syndrome and other focal pain conditions. However, the patient characteristics that may predict long-term outcomes have not been defined. Materials and MethodsThis was a retrospective observational study that included 93 patients who were implanted with a DRG stimulator at a single private practice institution. A variety of demographic data was collected. Follow-up results were reviewed from multiple time points more than 12 months. Patients were classified as either “responder” or “nonresponder” status using two different thresholds, “greater than or equal to 50% pain relief” and “greater than or equal to 80% pain relief.”Results: A history of prior chronic opioid use was associated with significantly lower rates of responder status based on both a 50% pain relief threshold and 80% pain relief threshold at the one week to one month, three months, and 12-months visits. ConclusionsThis single-center retrospective study found patients prescribed chronic opioids at the time of DRG stimulator implantation had a higher likelihood of less than 50% pain relief and 80% pain relief at one month, three months, and 12 months follow-up visits.

Kompleks Bölgesel Ağrı Sendromu Olan ve Olmayan Hastalarda Cilt İletkenlik Monitörü Kullanılarak Sempatik Aktivitenin Karşılaştırılması

Aim: Sympathetic system dysfunction has been described among the theories involved in the pathophysiology of complex regional pain syndrome. Objective measurement of the sympathetic activity of the affected extremity in patients with complex regional pain syndrome has not been compared to normal subjects in the literature. The skin conductance monitor is a non-invasive monitor that can objectively measure sympathetic skin activity of the extremity. In this study, we aimed to compare the differences in sympathetic activity of extremities in subjects with and without complex regional pain syndrome by using a skin conductance monitor. Material and Methods: Sympathetic skin responses were evaluated in 63 subjects, including 25 measurements on the affected extremities in 13 patients with lower extremity complex regional pain syndrome type 1 and 50 measurements in 50 normal subjects in the control group. Among the skin conductance indices, the "peaks per second (0.02)" index was used as the main sympathetic skin response index. Descriptive criteria and the mean values of sympathetic skin response measurements were compared. Results: When sympathetic skin responses were compared with a skin conductance monitor using the "peaks per second (0.02)" index, no statistically significant difference was found between the complex regional pain syndrome and control groups in terms of sympathetic activity in the extremities (p=0.837). Conclusion: In this study, skin sympathetic nerve activity in the affected limb of patients with complex regional pain syndrome was similar to normal subjects. Further studies are required to assess the changes in sympathetic activity in complex regional pain syndrome.

Management of Bilateral Complex Regional Pain Syndrome in a Pediatric Patient

To describe the physical therapy management of a pediatric patient with bilateral lower extremity complex regional pain syndrome (CRPS). The participant was a 13-year-old adolescent girl who was admitted to an inpatient rehabilitation unit with bilateral lower extremity CRPS-I. Examination included assessment of lower extremity active range of motion, transfers, mobility, and completion of the Functional Independence Measure for Children (WeeFIM). Intervention consisted of gradual desensitization techniques, progressive weight bearing and mobility, functional transfer training, progressive strengthening, and cardiovascular exercises-all conducted using a modified pain exposure therapy approach. WeeFIM scores increased to modified independence or independent in all areas. The severity of the patient's CRPS necessitated a progressive and function-based approach to physical therapy management. Motivation, a pain exposure-based approach, and a multidisciplinary team approach appeared to affect the participant's recovery of function and reintegration into school and leisure activities.

Acute Cardiovascular Toxicity of Low-Dose Intrathecal Ziconotide

Dear Editor, Ziconotide, marketed in the United States as Prialt® (Jazz Pharmaceuticals, Dublin, Ireland), is the first in a new class of non-opioid pain medication targeting N-type voltage-gated calcium channels (VGCCs) approved after a series of landmark clinical trials in the 1990s ⇓. Due to its limited bioavailability in the central nervous system (CNS), it is primarily administered via chronically implanted intrathecal (i.t.) pump. Ziconotide has a number of dose-limiting side effects, typically neurological or psychiatric symptoms. Here, we report a case where a remarkably short, low-dose exposure to i.t. ziconotide produced severe cardiovascular and neurological impairment reversing over the course of 24 hours. Patient SK, a 42-year-old man, had a 3.5-year history of lower extremity complex regional pain syndrome type I when he presented for an i.t. ziconotide trial, having failed standard opioid analgesics, antineuropathics, epidural injections, lumbar sympathetic blocks, and a spinal cord stimulator trial. His medical history was significant for severe obesity (body mass index = 39.5), hypertension, major depressive disorder, and obstructive sleep apnea. He had sustained moderate trauma to his left foot from a falling object in a store, followed by progressive allodynia, hyperesthesia, and hyperalgesia, originating in the left foot and ultimately affecting his entire left side including …

Lower extremity complex regional pain syndrome type II after a craniotomy: case report

Complex regional pain syndrome (CRPS) is a collection of signs and symptoms that most often include regional pain, edema, changes in skin temperature, increased skin sensitivity, and weakness that usually affects the extremities. It almost always exclusively affects the surgical site. A 52 year old woman presented with lower extremity CRPS due to positioning after a craniotomy.

Lower Extremity Complex Regional Pain Syndrome: Long-term Outcome after Surgical Treatment of Peripheral Pain Generators

We undertook a retrospective study to evaluate the hypothesis that complex regional pain syndrome (CRPS) I, known as the “new” reflex sympathetic dystrophy, persists because of undiagnosed injured joint afferents, cutaneous neuromas, or nerve compressions, and is, therefore, a misdiagnosed form of CRPS II, which is known as the “new” causalgia. We used a research protocol, with institutional review board approval, to review medical records for the purpose of identifying 30 patients with lower extremity reflex sympathetic dystrophy, based on their history, physical examination, neurosensory testing, and response to peripheral nerve blocks, who were treated surgically at the level of the peripheral nerve. In this report, we describe long-term outcomes in 13 of these patients who were followed up for a minimum of 24 months (mean, 47.8 months; range, 25-90 months). Based primarily on the results of physical examination and the response to peripheral nerve blocks, surgery included a combination of joint denervation, neuroma resection plus muscle implantation, and neurolysis. Outcomes were measured in terms of decreased pain medication usage and recovery of function, and the results were excellent in 7 (55%), good in 4 (30%), and poor (failure) in 2 (15%) of the patients. Based on these results, we concluded that most patients referred with a diagnosis of CRPS I have continuing pain input from injured joint or cutaneous afferents, and chronic nerve compression, which is indistinguishable from CRPS II, and amenable to successful treatment by means of an appropriate peripheral nerve surgical strategy.

Complex regional pain syndrome in a patient with spinal cord injury: management with pulsed radiofrequency lumbar sympatholysis

Short communication. To report a case with bilateral lower extremity complex regional pain syndrome (CRPS) in a patient with paraplegia occurring following spinal disc herniation surgery, who was treated successfully with pulse radiofrequency (PRF) lumbar sympatholysis. Departments of Physical Medicine and Rehabilitation, Algology Department of Anaesthesiology and Nuclear Medicine, Medical Faculty of Ege University, Izmir, Turkey. A 55-year-old woman had neuropathic pain in her lower extremities after T12-L1 disc herniation surgery. The pain decreased to a tolerable level with conservative treatment and her condition remained stable for the following 6 months; then she developed swelling, redness and severe burning pain in both feet. Physical examination showed edema and redness in the feet. On the basis of clinical findings and Tc-99m methylene diphosphonate (MDP) three-phase bone scintigraphy, she was diagnosed to have CRPS. The patient underwent a diagnostic sympathetic ganglion blockade with bupivacaine, which resulted in a marked decrease in the pain and edema of the feet. Consequently, PRF lumbar sympatholysis was performed with a successful outcome in pain, edema and color changes in the feet. When treatment of CRPS fails with conventional modalities, PRF sympatholysis may be used for control of pain and other symptoms in such patients.

(797): Fluidotherapy, an adjunct treatment for complex regional pain syndrome: Two case studies

Fluidotherapy is a dry whirlpool utilizing convection heat with particles of corn husks. This treatment is believed to increase collagen tissue extensibility, and facilitate increased range of motion, circulation and desensitization. For these reasons we utilized fluidotherapy as adjunct treatment for 2 patients with lower extremity complex regional pain syndrome (CRPS). Both patients had failed previous treatment without fluidotherapy including: spinal cord stimulators, epidural steroid injections, nerve blocks and tunneled epidural catheters. Patient 1 was a 15-year-old female with 4-month duration CRPS. On admission to the Chronic Pain Rehabilitation Program, pain was 7/10, and she was wheelchair dependent. Patient 2 was a 29-year-old male with 2-year duration CRPS. On admission to the Chronic Pain Rehabilitation Program, pain was 7/10, and he was unable to tolerate room air temperature that he perceived as extremely cold. Patient 1 received a team approach treatment that included almost daily fluidotherapy. She quickly acclimated to the fluidotherapy with transmucosal fentanyl during treatment. Following 16 days of treatment, she exhibited decreased pain/edema, increased range of motion, was fully ambulatory, and her pain was 2/10. Oral opioids were discontinued, and shortly after discharge, the epidural catheter with fentanyl was removed. Patient 2 elected to discontinue team treatment through the Chronic Pain Rehabilitation Program after 9 days. He did continue with occupational therapy, including fluidotherapy and daily living skills training. He initially used a blanket or heater for his ankle and foot regularly. He had applied for disability, and was off his feet 22 hours a day. By the end of treatment, he was playing basketball, was able to tolerate outdoor winter temperatures, his pain was 4/10, and he was referred to a work hardening program. We believe that fluidotherapy shows promise, should be considered as an adjunct treatment for CRPS, and that further investigation is warranted.

Simultaneous upper and lower extremity complex regional pain syndrome type I in tetraplegia

Clinical case report. To present the first case of incomplete tetraplegic spinal cord injury (SCI) in which complex regional pain syndrome (CRPS) type I was present in all four of the patient's extremities. Ankara Physical Medicine and Rehabilitation Education and Research Hospital, Ankara, Turkey. A 49-year-old man with incomplete tetraplegia (American Spinal Injury Association (ASIA) C) was admitted to our clinic for rehabilitation. According to the patient's history, pain and edema began in his right foot 1(1/2) months after his injury. After 10 days later the same symptoms appeared in his left foot as well. In the third week after pain and edema appeared in the right foot, these were also observed in both hands, markedly in the left. Three-phase bone scan images supported a diagnosis of stage 3 CRPS type I in all four extremities. After the diagnosis was made, passive range of motion (PROM) exercises were started. Transcutaneous electrical nerve stimulation and whirlpool sessions were used for pain and edema control. Drug therapy included Calcitonin, Naproxen sodium and Amitriptyline. After 6 weeks of treatment, the patient's visual analog scale pain score had decreased to 38 mm from an initial score of 85 mm at the onset of the treatment, and PROM of wrists/hands, fingers and ankles had become full and painless. We conclude that CRPS type I might be more common in SCI than is usually suspected, and that tetraplegic patients should be carefully evaluated for the presence of CRPS type I in upper and lower extremities.

Impairment level SumScore for lower extremity Complex Regional Pain Syndrome type I

Objectives : To construct a single indicator on impairment level for lower extremity Complex Regional Pain syndrome type I (CRPS I). Design : The Impairment level SumScore (ISS) for upper extremity CRPS I was adapted to be used for lower extremity evaluation. Medline literature search and research findings were used to adapt the upper extremity version of the ISS, with emphasis on reliability, responsiveness and validity of measurement instruments. Where needed, additional patient data was gathered to evaluate these aspects for different measurement instruments. Setting : An outpatient clinic of a university hospital in the Netherlands. Participants : Two groups consisting of 17 and 26 healthy volunteers, and two groups of respectively 40 and 18 lower extremity CRPS I patients according to Veldman's criteria. Main outcome measures : VAS and McGill pain scores, water displacement volumeter values, and physicians' and patients' assessment of CRPS I severity. Results : A combination of measurements, incorporating pain (VAS and McGill), temperature (infrared thermometer), volume (water displacement volumeter) and active range of motion (universal goniometer), was converted in a single score ranging from 5 to 50. The reliability, as well as the responsiveness was adequate. Conclusions : The lower extremity ISS permits evaluation of the most prominent symptoms in CRPS I, and can be used to monitor changes in CRPS I.

Complex Regional Pain Syndrome I: Management through the Use of Vertebral and Sympathetic Trunk Mobilization

The purpose of this study was to describe the clinical differential diagnostic process and effective management of an individual presenting with lower-extremity complex regional pain syndrome I (CRPS I). A 50-year-old female 8-weeks status post ORIF right tibia/fibula presented with a warm, red, edematous, hyperhidrotic right lower extremity. She also exhibited hyperalgesia, allodynia, and a positive slump test on the right. The patient satisfied clinical diagnostic criteria for a diagnosis of CRPS I. The subject was treated for 10 sessions over a 3-month period using progressive desensitization, weight-bearing activities, thoracolumbar mobilizations, and a neural mobilization technique referred to as slump long sitting with sympathetic emphasis (SLSSE). An analysis of outcome measures at the time of discharge and at a one-year follow-up demonstrated a significant improvement in both pain and function. Effective management was achieved by addressing both the patient's proximal and distal impairments including thoracolumbar segmental lesions and positive neurodynamic tests. It is speculated that the influence of neural mobilizations to the ipsilateral sympathetic ganglia directly affected the pathophysiology associated with autonomic dysregulation and pain in this subject. This case report provides initial evidence that the SLSSE may be an effective neural mobilization technique in reducing the magnitude of symptoms and improving function in patients with CRPS.

Measuring perceived activity limitations in lower extremity Complex Regional Pain Syndrome type 1 (CRPS I): test-retest reliability of two questionnaires.

To assess the test-retest reliability of two questionnaires for measuring activity limitations in patients with Complex Regional Pain Syndrome type 1 (CRPS I) of the lower extremity. Patients filled out the Walking Stairs Questionnaire and the Questionnaire Rising and Sitting Down twice during a one-week period. Outpatient pain clinic of a university hospital. Twenty-one outpatients with CRPS I of the lower extremity. The Walking Stairs Questionnaire and the Questionnaire Rising and Sitting Down were reliable in terms of test-retest reliability as expressed by Spearman's r (range 0.79-0.90 and 0.85-0.89 respectively) and the ICC (range 0.78-0.84 and 0.84-0.87 respectively). Both questionnaires form a reliable tool for measuring activity limitations of patients with CRPS I of a lower extremity.