Lower Limb Complex Regional Pain Research Articles

Clinical results of lumbar sympathetic blocks in lower limb complex regional pain syndrome using infrared thermography as a support tool.

To describe the clinical outcomes for a group of complex regional pain syndrome patients using infrared thermography as an intraprocedural support tool when undertaking fluoroscopy-guided lumbar sympathetic blocks. 27 patients with lower limb complex regional pain syndrome accompanied by severe pain and persistent functional impairment. A series of three fluoroscopic-guided lumbar sympathetic blocks with local anesthetic and corticoids using infrared thermography as an intraprocedural support tool were performed. Clinical variables were collected at baseline, prior to each block, and one, three, and six months after blocks in a standardized checklist assessing each of the clinical categories of complex regional pain syndrome stipulated in the Budapest criteria. 23.75% of the blocks required more than one chance to achieve the desired thermal pattern and therefore to be considered as successful. A decrease in pain measured on a visual analogic scale was observed at all time points compared to pre-blockade data, but only 37% of the cases were categorized as responders, representing a ≥ 30% decrease in VAS, with the disappearance of pain at rest. An improvement of most of the clinical variables recorded was observed, such as tingling, edema, perception of thermal asymmetry, difference in coloring and sweating. There was a significant decrease of neuropathic pain and improvement of functional limitation. Logistic regression analysis showed the main variable to explain the probability of being a responder was immobilization time (odds ratio of 0.89). A series of fluoroscopy-guided lumbar sympathetic blocks controlled by infrared thermography in the treatment of lower limb CRPS showed a responder rate of 37%.

Altered visuomotor integration in complex regional pain syndrome

During self-guided movements, we optimise performance by combining sensory and self-motion cues optimally, based on their reliability. Discrepancies between such cues and problems in combining them are suggested to underlie some pain conditions. Therefore, we examined whether visuomotor integration is altered in twenty-two participants with upper or lower limb complex regional pain syndrome (CRPS) compared to twenty-four controls. Participants located targets that appeared in the unaffected (CRPS) / dominant (controls) or affected (CRPS) / non-dominant (controls) side of space, using the hand of their unaffected/dominant or affected/non-dominant side of the body. For each side of space and each hand, participants located the target using visual information and no movement (vision only condition), an unseen pointing movement (self-motion only condition), or a visually-guided pointing movement (visuomotor condition). In all four space-by-hand conditions, controls reduced their variability in the visuomotor compared to the vision and self-motion only conditions and in line with a model prediction for optimal integration. Participants with CRPS showed similar evidence of cue combination in two of the four conditions. However, they had better-than-optimal integration for the unaffected hand in the affected space. Furthermore, they did not integrate optimally for the hand of the affected side of the body in unaffected space, but instead relied on the visual information. Our results suggest that people with CRPS can optimally integrate visual and self-motion cues under some conditions, despite lower reliability of self-motion cues, and use different strategies to controls.

Use of sequential diagnostic pain blocks in a patient of posttraumatic complex regional pain syndrome-not otherwise specified complicated by myofascial trigger points and thoracolumbar pain syndrome

We are presenting a case of posttraumatic lower limb Complex regional pain syndrome – Not otherwise specified (CRPS – NOS). As it was not treated in acute phase, the pain became chronic and got complicated by myofascial and thoracolumbar pain syndrome. This case posed us a diagnostic challenge. We used sequential diagnostic pain blocks to identify the pain generators and successfully treat the patient. We used diagnostic blocks step by step to identify and treat pain generators – T12,L1 and L2 Facet joints, Lumbar sympathetic block for CRPS NOS and Trigger point injection with dry needling for myofascial pain syndrome. This case highlights the facet that additional pain generators unrelated to original pain may complicate the presentation. Identifying these pain generators requires out of box thinking and high index of suspicion.

Infrared Thermographic Pattern of Lower Limb Complex Regional Pain Syndrome (Type I) and its Correlation with Pain, Disease Duration and Clinical Signs

Purpose: So far, the use of infrared-thermography in the diagnosis of the Complex Regional Pain Syndrome (CRPS) has been described only for the upper extremity or jointly for the upper and lower extremity. Therefore, the aim of this study was the assessment of the absolute temperature side-to-side difference by infrared thermography in patients with CRPS Type I of the lower limb. It was investigated whether there are correlations between the amount of temperature side-to-side difference, pain, duration of the disease and clinical signs. Materials and Methods: 25 women and 11 men (mean age 48 years), who fulfilled the Budapest clinical criteria of CRPS type I, were investigated in this retrospective cross-sectional study. Infrared thermographic evaluation of the big toe, dorsal foot, ankle and distal anterior lower thigh was performed. The arithmetical mean of the absolute side-to-side differences of these 4 regions of interest was calculated=average side-to-side temperature difference of the distal lower limb. The correlation of the average side-to-side temperature difference of the distal lower limb with pain, duration of the disease and clinical signs (sensory, vasomotor, sudomotor/edema and motor/trophic) was assessed. Results: The average absolute side-to-side temperature difference of the distal lower limb was 1.6/1.2°C (mean/SD). A significant correlation between the temperature asymmetry was observed with the vasomotor signs. Conclusions: Infrared thermography offers an objective assessment of vasomotoric dysfunction in CRPS type I of the lower limb, and therefore serves as a useful supplementary tool in the diagnosis of CRPS type I.

Poster 377 The Mystery Case of the Edematous and Painful Foot: Refractory Lower Limb Complex Regional Pain Syndrome (CRPS) in the Setting of Lymphedema in a Patient with Endometrial Cancer and Lynch Syndrome: A Case Report.

Poster 377 The Mystery Case of the Edematous and Painful Foot: Refractory Lower Limb Complex Regional Pain Syndrome (CRPS) in the Setting of Lymphedema in a Patient with Endometrial Cancer and Lynch Syndrome: A Case Report.

Clonidine in lumbar sympathetic block for lower limb complex regional pain syndrome

Background Complex regional pain syndrome (CRPS) is a condition of continuing (spontaneous and/or evoked) limb pain. The pain is nondermatomal and usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor, and/or trophic findings. Sympathetic nerve blockade of the upper and lower extremities using a local anesthetic and corticosteroids is one of the modalities in the treatment of severe, sympathetically mediated pain. This randomized controlled trial studies the effect of adding clonidine to levobupivacaine in repeated lumbar sympathetic blocks for patients suffering from lower limb CRPS type 1. Methods Thirty patients of ASA physical status I and II having CRPS-1 in the lower limb were enrolled. All patients underwent lumbar sympathetic block as treatment. They were assigned to one of two groups comprising 15 patients each. Group A patients were injected with 20 ml of levobupivacaine (0.5%) +8 mg dexamethasone (2 ml)+150 µg (1 ml) clonidine. Group B patients were injected with 20 ml of levobupivacaine (0.5%)+8 mg dexamethasone (2 ml)+saline (1 ml). Patients were seen in the clinic every week for 6 weeks. During each follow-up visit, edema score (grades 0-2) and range of motion at knee and ankle joints (grades 0-2) were assessed. Repeated blocks by the same technique were performed with a maximum of five blocks for each patient over a period of 6 weeks. Repetition of blocks was dependent on exacerbation of pain if visual analogue scale (VAS) score was greater than 50. The number of blocks needed during the 6-week period in each group was recorded. Side effects after each block, such as hypotension, bradycardia, and backache, were recorded. At 6 weeks, all patients were asked to fill out a satisfaction score (grades 0-10). Results Intergroup comparison showed that the VAS score was lower in group A than in group B, but there was no statistically significant difference between them except in the fifth week. Within-group comparison revealed a statistically significant decrease in the two groups in the 6 weeks in the measured VAS score compared with the baseline VAS scores. There was improvement in edema and motion in the two groups throughout the 6 weeks, but there was no statistically significant difference between the two groups. There was a statistically significant difference between the two studied groups as regards the number of blocks, where group A had a fewer blocks compared with group B. Patients in group A were significantly more satisfied after the 6 weeks compared with patients in group B. Conclusion Adding clonidine to levobupivacaine and steroids in repeated lumbar sympathetic blocks for patients suffering from lower limb CRPS type 1 prolongs analgesia and improves edema and tolerability to physical therapy.

Lumbar Sympathetic Blockade in Children with Complex Regional Pain Syndromes

Sympathetic blockade is used in the management of complex regional pain syndromes in children, but there are no data on the efficacy or mechanism(s) by which it produces pain relief. The purpose of this study is to compare the efficacy of lidocaine administered by lumbar sympathetic to IV route. Under general anesthesia, children with unilateral lower limb complex regional pain syndromes received catheters along the lumbar sympathetic chain. In a double-blind placebo-controlled crossover design, patients received IV lidocaine and lumbar sympathetic saline or lumbar sympathetic lidocaine and IV saline. Spontaneous and evoked pain ratings and sensory thresholds were assessed before and after these two lidocaine/saline doses and between routes of lumbar sympathetic blockade and IV. Twenty-three patients, ages 10-18 yr, were enrolled. There was evidence for reduction of mean pain intensity of allodynia to brush (mean -1.4, 95% confidence interval [CI] -2.5 to -0.3) and to pinprick temporal summation (mean -1.3, 95% CI -2.5 to -0.2) with lidocaine treatment via the lumbar sympathetic blockade compared to IV route. Lumbar sympathetic blockade also produced significant reduction in pain intensity compared to pretreatment values of allodynia to brush, pinprick and pinprick temporal summation and verbal pain scores. IV lidocaine did not produce significant changes in spontaneous and evoked pain intensity measurements compared to pretreatment values. There were no carryover effects as assessed by route-by-period interaction. Under the conditions of this study, the results provide some direct evidence that a component of pain may be mediated by abnormal sympathetic efferent activity.

Management of Lower Limb Complex Regional Pain Syndrome Type 1: An Evaluation of Percutaneous Radiofrequency Thermal Lumbar Sympathectomy Versus Phenol Lumbar Sympathetic Neurolysis—A Pilot Study

Complex regional pain syndrome type 1 can be difficult to treat. The purpose of this study was to compare the safety and efficacy of two therapeutic options: percutaneous radiofrequency thermal lumbar sympathectomy and lumbar sympathetic neurolysis. We randomized 20 patients to receive percutaneous radiofrequency lumbar sympathectomy or lumbar sympathetic neurolysis with phenol 7% in lower limb complex regional pain syndrome type 1. The study end points were pain relief and side effects. Within each group, there were statistically significant reductions from baseline in various pain scores after the procedure. However, there was no statistically significant difference in mean pain scores between the groups. Based on this pilot study, radiofrequency lumbar sympathectomy may be comparable to phenol lumbar sympathectomy. A larger trial is required to confirm these findings.