CRPS after hip arthroscopy with labral repair and femoral osteoplasty

[willabeast]

40 ish female s/p hip arthroscopy with labral repair and femoral osteoplasty . three weeks after surgery during PT session develops what neurology is calling CRPS (severe pain LE) . has numbness femoral nerve distribution. negative 3 phase bone scan. MRI negative low back. i know femoral nerve problem is possible after hip arthroscopy but why would Sx begin 3 weeks after procedure during PT session?
i have an article which seems fairly complete
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3629445/
i am hoping someone has seen this before. Thank you.

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[lobelsteve]

Need pain diagram and pics. Try steroids as it is early. But on the face of it this does not sound like a setup for crps.

 

[Gauss]

If it hasn't been done I would re image the hip. The timeframe of it occurring about 3weeks postop during PT is suspicious of an MSK injury. The structures are not strong enough yet so re or new injury is most likely.
iliopsoas bursitis, paralabral cyst, ischiofemoral impingement, AVN, femoral neck fracture, psoas tendon tear, rectus femoris tear, adductor/abd tear, osteitis pubis, ... hernia, vascular...

 

[Dr. Ice]

I have seen some of these odd smpathetically mediated type pain syndromes following different types of surgeries. Most of them don't meet the Budapest criteria for crps but I also can't necessarily explain the allodynia and neuropathic type pain. These things do seem to respond to steroids and neuropathic agents..

 

[bedrock]

Numbness after this type of surgery is common, but pts notice it as soon as they wake up, not 3 weeks later during PT.

Agree this is likely an MSK issue related to PT. PT could have stretched femoral nerve, torn muscles, stressed surgerized hip capsule.

If patient has severe pain like you stated, I would update her hip MRI, this would also rule out hematoma

 

[101N]

You need a thorough pre-op pain history. Hip labral repairs are often then domain of surgical yahoos.

 

[bedrock]

You need a thorough pre-op pain history. Hip labral repairs are often then domain of surgical yahoos.

Agree that 90% of orthopods doing arthroscopic hip surgery don't have enough training to know what they are doing and not make the patient worse.

However, if pt sees one of the few academic gurus that focused on this type of surgery, then they can do quite well.

 

[willabeast]

fellow who did the surgery is pretty experienced - has done hundreds of hip arthroscopies . as far as i know this is only the second time he has referred to us for neuropathic pain. is a good doc.
patient has not responded at all to steroids. that was when i got worried. ESR is normal. is responding a little bit to gabapentin and nortriptyline (able to sleep now > 4 hours).
re-imaging the hip is something i was wondering about. will do it. anyone think NCS/EMG would help?
pain diagram has no low back pain, anterior RLE numbness and pain from top of thigh to ankle, numbness and pain extend a little bit medial ankle and medial knee. had fascia iliaca block immediately post surgery.
remember patient was doing fine until 3 weeks post op, when she saw me she had pain for 3 weeks so she is a little less than 7 weeks post op now. posterior thigh lateral thigh on pain diagram is without pain at all.

 

[Dr. Ice]

Had a similar patient with similar distribution of pain. Patient had ankle surgery with preop saphenous and popliteal nerve block. Very shortly after surgery she developed neuropathic pain in groin, medial thigh, circumferentially around knee and medial compartment lower leg. Emg/ncs had technical issues bc she had edema and she had difficulty relaxing during needle exam. She did however have low amplitude saphenous ncs. My running theory is saphenous neuropathy and she only gets mild relief from neuropathic agents and desensitization treatments. I'm now sending her for neuroprolotherapy with my partner. Idk..but crossing my fingers..

 

[PainDrain]

This woman has a nerve injury from her block. She does not have CRPS. I know it's 3 weeks post op but it's still possible they caused nerve injury and it just started to manifest. I would get an EMG. Also I would agree with others that hip arthro for labral tears is voodoo. Hip MRIs are much like those of the lumbar spine, a huge percentage will have findings of labral tears and mild DJD or other pathology and the majority of those will have no pain.

 

[Dr. Ice]

If a patient has a chief complaint of groin pain and a positive stinchfield test and positive FADIR with a normal neuro exam and xray showing mild djd and/or cam/pincer/mixed impingement, I think it's conceivable that symptomatic fai/Labral pathology is present. Intra articular anesthetic injection and pain diary. MR arthrogram for confirmation in positive responders. I've seen some patients benefit from osteoplasty/Labral repair. Does it take a skilled surgeon..yes. Is it potentially over done..yes. Are all diagnoses of symptomatic Labral tears voodoo..no. There are no absolutes in medicine.

 

[IN2B8R]

Doubt this is CRPS. Consider either local trauma from PT or a neuropathy (unlikely to first show up 3 weeks out..). Consider also a conversion reaction. I'd go with Gabapentin, NSAIDs, prednisone and TCAs. Can also consider TENS, contrast baths (alter cold & hot water), desensitization techniques--all benign enough at this point. I'd start be re-imaging the hip.

 

[melancholy]

Had a similar patient with similar distribution of pain. Patient had ankle surgery with preop saphenous and popliteal nerve block. Very shortly after surgery she developed neuropathic pain in groin, medial thigh, circumferentially around knee and medial compartment lower leg. Emg/ncs had technical issues bc she had edema and she had difficulty relaxing during needle exam. She did however have low amplitude saphenous ncs. My running theory is saphenous neuropathy and she only gets mild relief from neuropathic agents and desensitization treatments. I'm now sending her for neuroprolotherapy with my partner. Idk..but crossing my fingers..

neuroprolotherapy? where are you practicing?

 

[melancholy]

40 ish female s/p hip arthroscopy with labral repair and femoral osteoplasty . three weeks after surgery during PT session develops what neurology is calling CRPS (severe pain LE) . has numbness femoral nerve distribution. negative 3 phase bone scan. MRI negative low back. i know femoral nerve problem is possible after hip arthroscopy but why would Sx begin 3 weeks after procedure during PT session?
i have an article which seems fairly complete
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3629445/
i am hoping someone has seen this before. Thank you.

questions:
- comb through notes and ask patient exactly what the OPQRST's of the pre-op pain and other symptoms were. may help give an idea if some symptoms are similar from before. don't forget to ask whether there were mechanical symptoms before and/or afterwards.
- any other positive findings on physical exam after surgery to suggest a mechanical etiology for symptoms still?
- subtle reflex or motor str changes in patellar reflexes or knee extension?
- 3 weeks after PT, did pt experience onset of symptoms the next day or right after the PT session? assume it sounds neuropathic with distinct pain qualities, numbness/tingling as you mentioned. any evidence of quad weakness or adductor weakness? sensory impairments in femoral nerve + saphenous? (i think you said yes).
- how much activity had the patient been doing prior to PT after the surgery? sometimes structures don't really get tested that much until you start PT after surgery. may not apply for this, but for some spine surgery patients i see, they say their pain feels better after surgery temporarily then gets worse and I find that it is actually because they were resting a ton after surgery and not doing anything close to normal activities that would always provoke pain.
- any localized hip pain after that PT session in addition to the lower extremity pain along the thigh?

thoughts:
- re-image hip +/- pelvis/proximal thigh if some positive findings to suggest something to re-evaluate in the hip itself as mentioned above. may want to mention concern for femoral nerve as well to ensure no space occupying lesion. maybe do with contrast.
- get someone good to do NCS/EMG to evaluate for a mononeuropathy, femoral, etc, hopefully if there are some abnormal findings, there may be something you can serially track in terms of improvement over time.
- review PT notes and discuss session with PT as to what things they tested or did during the session i.e. hip extension to end range of motion which might be akin to a femoral stretch test?
- consider diagnostic +/- therapeutic U/S femoral nerve block with local to confirm pain generator?
- any psychiatric co-morbidities for patient, hx of domestic violence or child abuse, etc. that indicate you may be in this with the patient for quite some time?
- can try desensitization and such, but if it's not really a centrally mediated process, not sure how well will respond to it. cannot hurt i guess.
- throw some low dose naltrexone at patient if they are not taking and not interested or needing opioids for this subacute phase?
- check labs for vitamin B or 12 deficiencies. throw in some alpha lipoic acid lol.

 

[willabeast]

questions:
- comb through notes and ask patient exactly what the OPQRST's of the pre-op pain and other symptoms were. may help give an idea if some symptoms are similar from before. don't forget to ask whether there were mechanical symptoms before and/or afterwards.
- any other positive findings on physical exam after surgery to suggest a mechanical etiology for symptoms still?
- subtle reflex or motor str changes in patellar reflexes or knee extension?
- 3 weeks after PT, did pt experience onset of symptoms the next day or right after the PT session? assume it sounds neuropathic with distinct pain qualities, numbness/tingling as you mentioned. any evidence of quad weakness or adductor weakness? sensory impairments in femoral nerve + saphenous? (i think you said yes).
- how much activity had the patient been doing prior to PT after the surgery? sometimes structures don't really get tested that much until you start PT after surgery. may not apply for this, but for some spine surgery patients i see, they say their pain feels better after surgery temporarily then gets worse and I find that it is actually because they were resting a ton after surgery and not doing anything close to normal activities that would always provoke pain.
- any localized hip pain after that PT session in addition to the lower extremity pain along the thigh?

thoughts:
- re-image hip +/- pelvis/proximal thigh if some positive findings to suggest something to re-evaluate in the hip itself as mentioned above. may want to mention concern for femoral nerve as well to ensure no space occupying lesion. maybe do with contrast.
- get someone good to do NCS/EMG to evaluate for a mononeuropathy, femoral, etc, hopefully if there are some abnormal findings, there may be something you can serially track in terms of improvement over time.
- review PT notes and discuss session with PT as to what things they tested or did during the session i.e. hip extension to end range of motion which might be akin to a femoral stretch test?
- consider diagnostic +/- therapeutic U/S femoral nerve block with local to confirm pain generator?
- any psychiatric co-morbidities for patient, hx of domestic violence or child abuse, etc. that indicate you may be in this with the patient for quite some time?
- can try desensitization and such, but if it's not really a centrally mediated process, not sure how well will respond to it. cannot hurt i guess.
- throw some low dose naltrexone at patient if they are not taking and not interested or needing opioids for this subacute phase?
- check labs for vitamin B or 12 deficiencies. throw in some alpha lipoic acid lol.

saw patient again.
went over history again
the pain did start immediately after surgery, however it was more near the ankle when the pain began.
seems as if the pain moved closer to the knee 3 weeks after surgery.
the swelling responds well to compression stockings.
on the pain diagram it looks much like a femoral distribution.
i ordered a hip MRI and NCS will get results this next week.
i think most likely Dx is femoral nerve problem, but need to verify location of injury with NCS and
make sure nothing is pressing on nerve with hip MRI.