CRPS treatment

[paindoctor2014]

I’m talking true crps here, not what our ortho friends send us, lol.

How are you incorporating sympathetic nerve blocks? For treatment? Diagnostic purposes? Not at all?

a friend of mine argues that terminal treatment is scs, so stellate or lumabr sympathetic blocks are useless. I’ve seen clinically people get better after a series of blocks however.

What if it’s true crps that doesn’t respond to sympathetic block? Still stim?

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[Ferrismonk]

Meds, lots of dedicated PT, especially after a nerve block. I use therapeutic blocks before SCS and have several who do well with them. If refractory, worth a SCS trial. Always go with the least invasive treatment first.

 

[willabeast]

Key is PT AKA getting patient to use the extremity. Best way to do that depends on the patient and the skill of the doctor. I am somewhat of a nihilist on treatment options. Some patients respond well to a detailed explanation of their CRPS and how they can make themselves better. For example had a patient once who developed CRPS foot after a horse stepped on it. She was tough as nails but afraid to stand. After an explanation that included the more you use the foot the better and some meds, she disappeared and a few months later sent me a video that included her being able to use her affected foot to hold a fork and feed herself, along with a video of her doing a 360 dismounting from her horse onto the ground along with a very nice thank you note. Also had patients that only responded to a stim.

 

[Orin]

The terminal treatment is the one that works. The end of the algorithm depends on the clinician. A neurosurgeon might take them to DREZ or DBS. A pain doc might try pumps, SCS, PNS, or just blocks.

As willabeast said, CRPS can often be cured with education and PT. Sympathetic blocks facilitate the PT, as does the other more invasive stuff. In 5 years, most CRPS cases resolve.

 

[Agast]

Some people are fine with sympathetic blocks prn and a TCA. I’m not sure what purpose pushing them into neuromodulation serves.

 

[NJPAIN]

The terminal treatment is the one that works. The end of the algorithm depends on the clinician. A neurosurgeon might take them to DREZ or DBS. A pain doc might try pumps, SCS, PNS, or just blocks.

As willabeast said, CRPS can often be cured with education and PT. Sympathetic blocks facilitate the PT, as does the other more invasive stuff. In 5 years, most CRPS cases resolve.

Very true. Literature supports eventual resolution or stabilization at low level. After all, ever meet an 80 yo who had CRPS for decades? I haven’t.

 

[Ferrismonk]

Some people are fine with sympathetic blocks prn and a TCA. I’m not sure what purpose pushing them into neuromodulation serves.

$$$

 

[Laryngospasm]

Yeah.. money for the stim company.. ridiculous what they get for the stims and leads.

 

[clubdeac]

The terminal treatment is the one that works. The end of the algorithm depends on the clinician. A neurosurgeon might take them to DREZ or DBS. A pain doc might try pumps, SCS, PNS, or just blocks.

As willabeast said, CRPS can often be cured with education and PT. Sympathetic blocks facilitate the PT, as does the other more invasive stuff. In 5 years, most CRPS cases resolve.

Hold up is this true? Most CRPS burns out in 5 years? That's news to me. And we have long term longitudinal studies to prove it?

 

[clubdeac]

I stopped doing stim. For my CRPS patients, I now just do LSBs, get them started on mirror therapy and tell them to pick up a copy of "The Divided Mind" by John Sarno MD. Works every time

 

[Orin]

Hold up is this true? Most CRPS burns out in 5 years? That's news to me. And we have long term longitudinal studies to prove it?

A few studies out there that comment on prognosis.

Complex regional pain syndrome–up-to-date

The pathophysiology of complex regional pain syndromes includes inflammation and central reorganisation. The treatment should be adjusted to the prevailing pathophysiology including possible psychosocial factors.Complex regional pain syndrome (CRPS) was ...

www.ncbi.nlm.nih.gov

Regarding the prognosis, Bean et al reported in a longitudinal study that within the first year, 70% improved, especially in the function of the extremity and the visible symptoms (edema, skin color, and sweating). (Extent of recovery in the first 12 months of complex regional pain syndrome type-1: A prospective study - PubMed primary source of Bean et al)

Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study - PubMed

The objective of this study is to undertake a population based study on the incidence, prevalence, natural history, and response to treatment of complex regional pain syndrome (CRPS). All Mayo Clinic and Olmsted Medical Group medical records with codes for reflex sympathetic dystrophy (RSD)...

pubmed.ncbi.nlm.nih.gov

Seventy-four percent of patients underwent resolution, often spontaneously.

The issue is that we as specialists see numerators, not denominators, in our clinics. If they haven't tried the usual stuff, I do that first. If they're failing that, then move to the next step, but jumping to the end of the line is not necessary for everyone.

 

[jwalker12]

Meds, lots of dedicated PT, especially after a nerve block. I use therapeutic blocks before SCS and have several who do well with them. If refractory, worth a SCS trial. Always go with the least invasive treatment first.

Are you combining lyrica/gaba + TCA's or lyrica/gaba + cymbalta. Just curious what combinations people have tried. Often I see these patients fail lyrica and gaba unfortunately

 

[willabeast]

Two early CRPS treatments you might consider trying - oral steroids or acupuncture. Not so much looking for a cure but might speed up mobilization.

 

[Ferrismonk]

Are you combining lyrica/gaba + TCA's or lyrica/gaba + cymbalta. Just curious what combinations people have tried. Often I see these patients fail lyrica and gaba unfortunately

Yes, I'll would combine, but I rarely will double similar classes. So Gaba/Lyrica + an antidepressant (Cymbalta OR TCA) is okay. I don't like doing TCA + SNRI.

 

[Sooshi]

We've had good success with ketamine. Infusions seem to put a lot of people in remission, and troches help with exacerbations. From my understanding, the literature only supports blocks in the first 6 months of insult/onset.

I just came across a case of CRPS of the face. Dead serious. Sitting here looking at a model skull, holding a needle, going ".....hmmmmm...."

 

[BobLoblaw78]

Very true. Literature supports eventual resolution or stabilization at low level. After all, ever meet an 80 yo who had CRPS for decades? I haven’t.

Maybe is called the "suicide disease" for a reason.

 

[ziggyziggy]

Someone mentioned elbow nerve block as a substitute for stellate for crps. Can’t find it now. Can anyone explain on how it’s done? Appreciate help.

 

[DOctorJay]

Someone mentioned elbow nerve block as a substitute for stellate for crps. Can’t find it now. Can anyone explain on how it’s done? Appreciate help.

DEFINE_ME

US Guided Periarterial Forearm Injections For Sympathetic Blockade In Patients With Complex Regional Pain Syndrome Jeffrey Steven Brault. Mayo Clinic

Objective: To describe a technique for ultrasound-guided periarterial sympathetic blockade in the forearm and review outcomes data from a case series of patients who underwent the procedure.

Design: Technical report/case series Setting: Tertiary care academic center

Participants: 42 patients with hand pain, associated with sympathetic dysfunction, underwent ultrasound-guided periarterial sympathetic blockade using local anesthetic in the forearm.

Interventions: A total of 68 injections were performed under Doppler ultrasound utilizing 1.5 cc 1% Lidocaine and 1.5.cc 0.25% Bupivacaine injected equally into the periarterial space surrounding the radial and ulnar arteries in the forearm.

Main Outcome Measure(s): To determine if US guided periarterial injections in the forearm produced an effect on pain and/or motion in patients with CRPS of the hand.

Results: 74% (n=31) of patients derived benefit in terms of reduced pain and/or increased range of motion. 76% (n=58) of all injections yielded beneficial results. The average duration of improvement was 29 days (range 2 hours to 18 weeks). There were no adverse side effects including new onset post-injection motor or somatosensory dysfunction reported.

Conclusions: The limited results of this case series demonstrate a comparable response rate to stellate ganglion blockade for CRPS without the risks inherent in cervical sympathetic blockade. Ultrasound-guided periarterial sympathetic blockade in the forearm is a new technique and could potentially be considered as a safe and effective treatment option for patients with distal upper extremity CRPS symptoms. Ultimately, a randomized controlled trial will be needed to best establish safety and efficacy.

Key Words: Complex regional pain syndrome, CRPS, sympathetic nervous system, sympathetic blockade. Disclosure: Jeffrey Brault has nothing to disclose.