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.