Role of Interventional Pain Management in Patients with Complex Regional Pain Syndrome (CRPS)
Interventional pain constitutes an important arm in the management of chronic pain and in the palliative care of patients, to improve their quality of life and thereby reduce the need for opioids. This article describes the various interventional pain management strategies that were performed in a patient with Complex Regional Pain Syndrome, who was not responding to the medical line of management.
A 44-year-old male with a known history of Complex Regional Pain Syndrome (CRPS) presented in March 2016 with a two-week history of severe pain (10/10), swelling, and discoloration in the left hand and forearm shortly after completing strenuous physical labour. Patient had reported similar symptoms in the lower extremities, resulting in below knee amputation (BKA) of the left leg in 2007 and BKA of the right leg in 2014. According to him, this all began with a traumatic injury to his left toe which had resulted in a fracture of the toe in 2000. There was no other relevant past or family medical history.
On examination, there was intense pain and paraesthesia (tingling and burning) in the left hand extending upwards to the elbow. The left hand was also diﬀusely swollen and boggy, with a dusky, mottled appearance due to bruising and ecchymosis of left forearm and hand (Figure 1). Pulses were intact. A venous & arterial study was done which was also normal. Due to severe pain, the arm was elevated in a sling.
A diagnosis of CRPS was made. Patient was optimized on a combination of medications for the pain that included morphine injected at 15 milligrams per milliliter (mg/ml) through a previously placed intrathecal pump, gabapentin 900 mg thrice daily, and amitriptyline 75 mg once a day. The patient was also undergoing concurrent physical/occupational therapy. Inspite of this, there was just a mild improvement in pain and symptom. The surgical team was consulted who recommended a trial percutaneous sympathetic block to determine if he would beneﬁt from a permanent thoracic sympathectomy.
Fluoroscopy and ultrasound guided stellate ganglion block (Figure 2) was performed using 6 ml of bupivacaine 0.5 % injected using a 21- gauge (G), 7 centimetre (cm) Chiba needle (Cook Medical Inc.). Patient reported about 80 % improvement in pain within a few minutes of the procedure that lasted about 72 hours. A repeat stellate block was performed, again with temporary improvement in symptoms.
Due to a good response to the stellate block, a computed tomography (CT) and ultrasound guided pulsed radiofrequency ablation (RF) of the stellate ganglion was performed (Figure 3) using a 22 G 10 cm, 5 mm active tip radiofrequency probe (Cosman Medical Inc., Burlington, USA) for 3 minutes at 42 degrees. Patient tolerated the procedure well. A mild facial droop and ptosis was noted after the procedure (expected) which resolved in 1 hour. His pain improved from 10/10 to 6/10 after the procedure which persisted for 6 weeks. When symptoms recurred, another RF ablation was performed.
The patient was now oﬀered permanent thoracic sympathectomy which he declined. It was now decided to place a spinal cord stimulator (SCS) for neuromodulation. After a successful stimulator trial for 7 days, it was elected to proceed with a permanent stimulator. A permanent stimulator with paddle centered on C6 vertebral body (St. Jude Medical Inc.) was placed using x-ray guidance. Six months later, the patient is doing very well. His pain is at about 5/10 now and his quality of life has improved.
Complex regional pain syndrome (CRPS) is a painful and disabling condition that usually manifests in response to trauma or surgery, and is thought to arise and persist because of a maladaptive pro-inﬂammatory response and disturbances in sympathetically-mediated vasomotor control. Due to the complexity and broad spectrum of symptoms, guidelines recommend an interdisciplinary pain management team, as well as input from various clinical specialties including orthopedic surgeons, anesthetists, rheumatologists and rehabilitation physicians.[1,2]
Regarding the management of pain in CRPS, there are contrasting views regarding the use of opioid therapy. While opioids are useful in the acute phase of tissue injury, their long-term use for both peripheral and central neuropathic pain is less eﬃcacious and require larger doses. An alternative approach is sympathetic blockade, which has shown to provide substantial and a longer duration of reduction in pain, which enables patients to improve their participation in functional therapies. In patients who have good but transient relief from sympathetic blockade, sympathectomy can be performed. Given the permanent nature of this approach and the possible associated complications such as post- sympathectomy neuralgia, anhidrosis and Horner’s syndrome, sympathectomy is only generally considered in patients where alternative treatment options have failed. Open surgical sympathectomy is highly invasive and has been replaced by minimally invasive percutaneous techniques, which include destruction of the stellate ganglion using chemicals and RF. RF sympathectomy provides a longer lasting pain relief, with 40% of patients reporting greater than 50% pain reduction even after a year.
Neuromodulation using spinal cord stimulators (SCS) may also play a role in treating CRPS. SCS are associated with sustained improvements in functional capability, quality of life, depression and pain levels. As compared to sympathectomy, complications are less dramatic and may include lead displacement, pulse-generator pocket revision, pulse-generator failure and infection.[7,8]
Our patient, underwent several non-surgical, percutaneous procedures, which in combination helped to provide signiﬁcant relief from symptoms with an improved quality of life and without the need of more invasive surgery.
Chronic pain management services include complex prescription medication regimens, often involving opioids. Interventional pain involves minimally invasive procedures, many of which can be performed on an outpatient basis and are performed under ﬂuoroscopic, CT, or ultrasound guidance to facilitate the precise and proper placement of the medication at the site of pain. Examples of these procedures include epidural steroid injections, radiofrequency ablation, sympathetic blocks, spinal cord stimulation, and neurolytic blocks.
In the ﬁeld of cancer palliation, recent advances in intrathecal analgesia, celiac plexus and splanchnic blockade, radiofrequency ablation ( tumors and nerves) and vertebroplasty have led to the extensive use of these techniques. Thus, interventional pain constitutes an important arm in the management of chronic pain and in the palliative care of patients to improve their quality of life and thereby reduce the need for opioids.
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7.Geurts JW, et al. Spinal cord stimulation for complex regional pain syndrome type I: a prospective cohort study with long-term follow-up. Neuromodulation, 2013. 16(6):523-9; discussion 529.
- Kemler MA, et al. Eﬀect of spinal cord stimulation for chronic complex regional pain syndrome Type I: ﬁve-year ﬁnal follow- up of patients in a randomized controlled trial. J Neurosurg, 2008. 108(2): 292-8.
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