Proximal CRPS?

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knoxdoc

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I have an ortho PA in town who keeps sending me sympathetic blocks for joints that don't respond well to surgery. He insists that its all CRPS. He just sent another who recently had knee surgery and her pain continues, but she has no allodynia, color changes, reduced ROM, edema, etc. Its just plain knee pain. Anywho, this PA is so damn insistent that I want to put this out there to maintain my sanity: has anyone seen CRPS isolated to a proximal joint with no distal symptoms (for example, just symptoms at the knee with absolutely no ankle or foot symptoms whatsoever)?

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Long answer: not very often (maybe closer to never).

Short answer: kinda

Long answer: probably some weird neuropathic thing post-op, or likely just old somatic pain from a ****ty hack job on the joint, as you have implied
 
Maybe one every few years. A bunch from one PA = I can't fix it, it must be CRPS.
 
Maybe it wasn't joint pain to begin with? Does that mean it is CRPS now, dunno?
 
knoxdoc:
You answered your own question. The patient does not meet clinical or experimental criteria for CRPS. So don't label it as such. Labeling it CRPS-nos is kinda weak as well for your case.
 
I have one patient with isolated knee pain s/p TKA. Lumbar sympathetic block x 1 completely eliminated her pain, have not seen her in over a year.
 
I have one patient with isolated knee pain s/p TKA. Lumbar sympathetic block x 1 completely eliminated her pain, have not seen her in over a year.

Which means either:

1) A wonderful, prolonged placebo response, since neither LSB nor any other nerve block produces long-term effects
2) She never had CRPS
3) She found someone else to treat her

:D
 
what I really love is when ortho/ or NS sends the patient to rads for all their injections then to you afterwards when they still have pain. apparently we are unqualified to inject but know so much that we'll solve a problem their six previous doctors could not....:confused:
 
i have one surgeon whose diagnosis for all joint pain that looks normal on imaging without evidence of inflammatory arthropathy as CRPS and refers them to me for sympathetic blocks... of course, i have to admit all of those patients also have severe psychiatric issues...

is there psychogenic joint pain? i'd rather just refer to psych...
 
DUMP syndrome... actually they don't expect you to figure anything out... in fact, they just want you to deal with the patient because they no longer have anything to gain from that relationship
 
what I really love is when ortho/ or NS sends the patient to rads for all their injections then to you afterwards when they still have pain. apparently we are unqualified to inject but know so much that we'll solve a problem their six previous doctors could not....:confused:

yeah its funny when the radiologists injects them and then sends them back to ortho/ns, and then they end up on my door for meds... or more precisely, for Refills! my poor NP.
 
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For non-mechanical knee pain which worsened or started after TKA, consider infrapatellar branch of saphenous nerve neuralgia.
 
For non-mechanical knee pain which worsened or started after TKA, consider infrapatellar branch of saphenous nerve neuralgia.

She doesn't have saphenous neuralgia, but funny you should bring it up because I do have another patient that showed up this week with it. Have you tried blocks for those? If so, where do you block it and what kind of success are you seeing. I'm hijacking my own thread.
 
i basically do field blocks from the lateral aspect of the knee towards the midline with about 10cc of local with 5-10mg of triamcinolone --- have had some success w/ it --- tends to work well in those patients w/ clear neuralgias (allodynia,hyperalgesia) -- not great for pts w/ just pain/aching...
 
i basically do field blocks from the lateral aspect of the knee towards the midline with about 10cc of local with 5-10mg of triamcinolone --- have had some success w/ it --- tends to work well in those patients w/ clear neuralgias (allodynia,hyperalgesia) -- not great for pts w/ just pain/aching...

Cool, thanks. Hey did you mean to say the medial aspect of the knee?
 
sorry... medial... - thanks for correcting me...

i used to do these under U/S - find the saphenous vein and then injecting around the area... now i just do monster field blocks (tend to be more ecchymosis) but my results are better... so much for U/S aiding in outcomes..
 
She doesn't have saphenous neuralgia, but funny you should bring it up because I do have another patient that showed up this week with it. Have you tried blocks for those? If so, where do you block it and what kind of success are you seeing. I'm hijacking my own thread.

Finding the decending genicular artery is the best, o/w I just go in the plane between vastus and sartorius/adductor.

http://www.usra.ca/sb_saphenous
http://neuraxiom.com/html/saphenous_block.php

But I really like US. I still like to stim it just to see if the paresthesia is concordant. Some get better with steroids. All are happy to have a diagnosis. Some actually have scar neruomas of the infrapatellar branch that get better with botox or alcohol. For alcohol, if botox doesn't work, I never go above 8-10% and repeat weekly until better. Necrosis is bad.

For some reason I haven't pRFed one of these yet. That might work.
 
i basically do field blocks from the lateral aspect of the knee towards the midline with about 10cc of local with 5-10mg of triamcinolone --- have had some success w/ it --- tends to work well in those patients w/ clear neuralgias (allodynia,hyperalgesia) -- not great for pts w/ just pain/aching...

funny you should mention this, b/c i have a ortho who is referring a pt for this block. question, tho: ifyou do a big volume block with 10 ccs, arent you just blocking everything from the saphenous nerve? i dont suppose it matters all that much, but im guessing you are losing some specificity.

maybe im not all that great at it, but it seems like i always have trouble getting the needle in place once i visualize where it needs to go on US. plus, i have trouble deciding if it is indeed where i want it to be.

im gonna try to localize at least 1 plane with NCS and compare it to the other side. we'll see what happens
 
I've seen a couple of these "failed knee surgery syndrome" patients myself. Has anyone ever thought about doing SNRBs at L2-4 since that's what innervates the knee. If a positive albeit short lived response, then try PRFA of the DRG. Crazy idea?? There's gotta be some neuropathic component in someone who's had multiple operations like this I would think..
 
I've seen a couple of these "failed knee surgery syndrome" patients myself. Has anyone ever thought about doing SNRBs at L2-4 since that's what innervates the knee. If a positive albeit short lived response, then try PRFA of the DRG. Crazy idea?? There's gotta be some neuropathic component in someone who's had multiple operations like this I would think..

Since pulsed RF doesn't really work (except in whoever replies that all their patients get 100% relief for 9 months at a time) and is experimental/investigational so we could not get paid for trying, it would be tough to run the data and see if it is even an option.

Why not run an IT pump, except instead of putting the cath IT, put it in the joint, or on the femoral nerve/sciatic nerve. Just run bupi in at low concentration for a delta and not sensorimotor.

Why not stim? Why not deep brain on the sensory homonculus for that knee.

Lots of things sound good, but they don't pan out. I'm sure we could dig up a case report or series on this.
 
I've seen a couple of these "failed knee surgery syndrome" patients myself. Has anyone ever thought about doing SNRBs at L2-4 since that's what innervates the knee. If a positive albeit short lived response, then try PRFA of the DRG. Crazy idea?? There's gotta be some neuropathic component in someone who's had multiple operations like this I would think..

I am a huge skeptic on pulsed RF as I am with many of our procedures. But the reality is I have had people shake my hand (opiate free) and walk out of my clinic happy, never seen again, after select DRG PRF's. Probably it's placebo effect, but if you get relief with SNRBs, I think PRF is worth a try.
 
Since pulsed RF doesn't really work (except in whoever replies that all their patients get 100% relief for 9 months at a time) and is experimental/investigational so we could not get paid for trying, it would be tough to run the data and see if it is even an option.

Why not run an IT pump, except instead of putting the cath IT, put it in the joint, or on the femoral nerve/sciatic nerve. Just run bupi in at low concentration for a delta and not sensorimotor.

Why not stim? Why not deep brain on the sensory homonculus for that knee.

Lots of things sound good, but they don't pan out. I'm sure we could dig up a case report or series on this.

Ok ok, but let me tell you about a clinical case. I think I posted it on here somewhere else. 65 y/o left hip disartic after they accidentally cannulated his fem artery and not vein for a central line. He came to me 5 yrs later after trying every opioid and neuropathic combination known to man still with sig stump and phantom pain. Did local inj into two neuromas in his stump and he had complete relief of both the stump and phantom pain for 6 hrs. Took him back and did PRF of the DRG at L4 and L5 and he's been essentially pain free for two months now. He's sent me thank you cards, candy etc. Best two months of his life since the amputation. Even the PT's that work with him can't believe it. I can't explain it but even just 2 mos is a pretty long placebo. I got the idea from a case series published in PAIN. Who knows...
 
Ok ok, but let me tell you about a clinical case. I think I posted it on here somewhere else. 65 y/o left hip disartic after they accidentally cannulated his fem artery and not vein for a central line. He came to me 5 yrs later after trying every opioid and neuropathic combination known to man still with sig stump and phantom pain. Did local inj into two neuromas in his stump and he had complete relief of both the stump and phantom pain for 6 hrs. Took him back and did PRF of the DRG at L4 and L5 and he's been essentially pain free for two months now. He's sent me thank you cards, candy etc. Best two months of his life since the amputation. Even the PT's that work with him can't believe it. I can't explain it but even just 2 mos is a pretty long placebo. I got the idea from a case series published in PAIN. Who knows...

I believe placebo data is it lasts 8-12 weeks. When it comes back, repeat it. Then you'll get the answer. I've done rf for facets via double dx paradigm. Rf lasted 2 months (strict Isis criteria/technique). Repeated rf with no better result. Chalked up to placebo.
 
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