Role of Interventional Pain Management in Patients with Complex Regional Pain Syndrome (CRPS)

Article by

K. Pereira

 

Abstract

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.

Case report:

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.

TC- Jan 2018 - 017 - Fig 1 Initial presentation of patient CPRS

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.

 

TC- Jan 2018 - 018 - Fig 2 Fluoroscopy guided stellate ganglion block

 

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.

 

TC- Jan 2018 - 019 - Fig 3 CT guided RF ablation of the stellate ganglion

 

 

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.

 

TC- Jan 2018 - 020 - Fig 4 Fluoroscopy guided placement of the SCS lead at the epidural level of C6 vertebra

 

Discussion:

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.[3] 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.[4] 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.[5] RF sympathectomy provides a longer lasting pain relief, with 40% of patients reporting greater than 50% pain reduction even after a year.[6]

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.[9]  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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References:

 

  1. Tran, DQ, et al. Treatment of complex regional pain syndrome: a review of the evidence. Can J Anaesth 2010; 57(2): 149-66.
  2. Goh, EL, Chidambaram S, Ma D. Complex regional pain syndrome: a recent  update. Burns & Trauma. 2017; 5: 2.
  3. Rowbotham MC, et al. Oral opioid therapy for chronic peripheral and central neuropathic pain. N Engl J Med. 2003; 348(13): 1223-32.

4 .  Stanton TR, et al. Local anaesthetic sympathetic blockade for complex regional pain  syndrome.  Cochrane  Database Syst Rev. 2013(8):  Cd004598.

  1. Nelson, DV, Stacey BR. Interventional therapies in the  management  of complex regional pain syndrome. Clin J Pain. 2006.22(5): 438-42.
  2. Forouzanfar T, van Kleef M, Weber WE. Radiofrequency lesions of  the  stellate ganglion in chronic pain syndromes: retrospective analysis of clinical efficacy in 86 patients. Clin J Pain. 2000. 16(2): 164-8.

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.

  1. 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.
  2. Fairchild AH, Rilling WS. Palliative Interventional Oncology. Cancer J, 2016.22(6): 411-417.