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Regional pain syndrome and its treatments

Surya Raguthu, M.D, ABIPP, ABPMR, CIME

Surya Raguthu, M.D, ABIPP, ABPMR, CIME

by Dr. Surya Raguthu
Complex regional pain syndrome (CRPS) previously known as reflex sympathetic dystrophy is a chronic neurological disorder involving the limbs characterized by disabling pain, swelling, vasomotor instability, sudomotor abnormality, and impairment of motor function. CRPS is not uncommon after hand surgery and may complicate post-operative care. There is no specific diagnostic test for CRPS and the diagnosis is based on history, clinical examination, and supportive laboratory findings. Recent modifications to diagnostic criteria have enabled clinicians to diagnose this disease more consistently. This review gives a synopsis of CRPS and discusses the diagnosis, pathophysiology, and treatment options based on the limited evidence in the literature.
There is a growing body of literature addressing a variety of disorders known as Complex Regional Pain Syndrome (CRPS). It is a condition that presents with a pain experience that is severe and disproportionate to the inciting event and is accompanied by highly variable signs and symptoms of inflammatory, sensory, autonomic, trophic, or motor features. Anesthetists in the acute and chronic pain teams are often involved in treating Complex Regional Pain Syndromes.
The onset of CRPS can follow injuries ranging from minor injuries to fracture(s), from lesions of the central nervous system, or from surgery. For pain treatment, the WHO analgesic ladder is advised with the exception of strong opioids. For neuropathic pain, anticonvulsants and tricyclic antidepressants may be considered. For inflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. To promote peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used to increase blood flow in case vasodilatory medication has insufficient effect. To decrease functional limitations, standardized physiotherapy and occupational therapy are advised.
To prevent the occurrence of CRPS-I after wrist fractures, vitamin C is recommended. Adequate perioperative analgesia, limitation of operating time, limited use of tourniquet, and use of regional anesthetic techniques are recommended for secondary prevention of CRPS-I.
The syndrome is diagnosed purely on the basis of clinical signs and symptoms. Effective management of the chronic form of the syndrome is often challenging. Few high quality randomized controlled trials are available to support the efficacy of the most commonly used interventions. Reviews of available randomized trials suggest that physical and occupational therapy (including graded motor imagery and mirror therapy), bisphosphonates, calcitonin, subanesthetic intravenous ketamine, free radical scavengers, oral corticosteroids, and spinal cord stimulation may be effective treatments. Multidisciplinary clinical care, which centers around functionally focused therapies is recommended. Other interventions are used to facilitate engagement in functional therapies and to improve quality of life.

Dr. Surya Raguthu, M.D, ABIPP, ABPMR, CIME, has 15 years of experience in Pain Management and excels in Sports Medicine, Physical Therapy and Rehabilitative Medicine. His mission is to enhance the health and well-being of seniors, adults, and children in our communities to help them lead a quality life. His motto is “Live Pain Free.” Please visit www.acepain.com for details. Office phone 832-532-0040


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