Crps

[PainDr]

All opinions appreciated. What are your first line choices for new onset CRPS? Case in point...30 yo pt s/p arthroscopic knee surgery one month ago. Several day hx of severe allodynia of the distal lower extremity, neurologically intact. I was consulted to perform lumbar sympathetic block. Excellent but transient improvement (3 hrs). I'm thinking neurontin, elavil, maybe topical ketamine, aggressive rehab, etc. Would anyone perform serial sympathetic blocks? When would you perform a bone scan? Thanks!

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[Aether2000]

There may be a window of opportunity for continuous infusion via sympathetic catheter (through 6 inch epidural needle) or via epidural continuous home infusion. Anything you can do to mobilize will be key....
Pamidronate IV has shown benefit in some studies...
Typically I will obtain a bone scan only if immobility ensues since a positive bone scan is usually seen only in that situation...

 

[Mister Mxyzptlk]

If I get a positive response to LSB, I do LSB on a M-W-F schedule for one week. I block three levels each time - L2, L3, L4 to make sure I have a solid block of the plexus. In this case, where the block did not outlast the duration of the LA I would probably not use this approach. I usually do this if they get 24+ hours of relief with the test block.

I would do this as Algos described. My recipe is a tunneled epidural cath with continuous infusion of bup 0.0625% and fentanyl 5 mcg/ml. This does two things: continuous sympathetic blockade, and excellent analgesia that allows aggressive PT. Good PT is the single most important factor.

 

[mille125]

I agree with the above...If the above suggestions fail to give an effect, I would perform SCS sooner rather than later.

 

[Spine Specialist]

If I get a positive response to LSB, I do LSB on a M-W-F schedule for one week. I block three levels each time - L2, L3, L4 to make sure I have a solid block of the plexus. In this case, where the block did not outlast the duration of the LA I would probably not use this approach. I usually do this if they get 24+ hours of relief with the test block.

Gorback,

How many cc of LA each time?

 

[Mister Mxyzptlk]

5 cc/level. I have been using lidocaine for the past few years instead of bup. Seems to work as well and I worry a lot less about cardiotoxicity.

 

[mehul_25]

anyone ever use systemic infusion of lidocaine or ketamine?

 

[Ligament]

Agree with the above: block block block as long as the patient is getting benefit from them. If the duration of block is very short, as in your patient, consider continuous sympathetic catheter or SCS ASAP. You could even do an "extended" SCS trial for 3-4 weeks to allow PT participation and pain relief without massive SCS costs.

Now is the golden window to try to stop the progression.

 

[lobelsteve]

All opinions appreciated. What are your first line choices for new onset CRPS? Case in point...30 yo pt s/p arthroscopic knee surgery one month ago. Several day hx of severe allodynia of the distal lower extremity, neurologically intact. I was consulted to perform lumbar sympathetic block. Excellent but transient improvement (3 hrs). I'm thinking neurontin, elavil, maybe topical ketamine, aggressive rehab, etc. Would anyone perform serial sympathetic blocks? When would you perform a bone scan? Thanks!

Start Prednisone at 40-60mg daily for 1 week and back down 10mg daily as fast as tolerated. This has literature to support it and is considered the standard of care in my area. I would add a Duragesic patch at the same time and schedule an LSB.

 

[mehul_25]

We have been having a lot of success with QWeekly sympathetic blocks (L2, L3, L4) and getting people into a really good PT program (we benefit from having a Magee Rehab CRPS program in our area). In fact several of our recent patients have had complete resolution of symptoms even after a couple of years of pain.

 

[PainDr]

Thanks so much for all the responses. Gorback...do you use 1% lidocaine? I've been using 0.125% bupivicaine and haven't had any adverse effects...at least not yet. Have you ever had any actual problems with bupivicaine? Also, I may need to modify my technique. I start by placing a needle at L3, put in a couple of cc of contrast and see how much spread I get. If I get good spread both above and below, I'll stop there and slowly inject 15 cc of bupiv. Otherwise I'll place one or both of the other needles as necessary. I've gotten good outcomes with this approach, but maybe I should just always block three seperate levels. During fellowship we usually just placed two needles, at L2 and L4. I started using my current approach after reading about it, trying it and having a good response. Any thoughts?

 

[member]

There is no evidence that a higher concentration of LA is better for LSB. Remember the sympathetics are the first ones to get blocked by LA. So i would continue with 0.125%. NO need for lido 1%

 

[lobelsteve]

There is no evidence that a higher concentration of LA is better for LSB. Remember the sympathetics are the first ones to get blocked by LA. So i would continue with 0.125%. NO need for lido 1%

Techniques in Regional Anesthesia Vol5#3, Nagy Mekhail.

"Some investigators then use
6 to 8 mL of a fast-acting local anesthetic (such as 2% to 3% of
chloroprocaine) to obtain a rapid rise in the skin temperature of
the foot.To produce total sympathectomy as assessed by an
increase in ipsilateral skin temperature, 15 to 20 mL of local
anesthetic, eg, bupivacaine 0.25% to 0.375%, usually are used."

We use 10cc of 0.5% and the en point technique with a 22G6"spinal needle.
No LOR, just 2-3cc Omnipaque 240 to light up the way. This is consistent with the technique and volume/concentration detailed by Nagy.

 

[analgesic]

Lobelsteve,

I have noticed that on the Windsor website www.georgiapainphysicians.com that Georgia Pain Physicians is now implementing MUA. I was curious if you have performed or witnessed this maneuver on any of the CRPS patients? The procedure makes alot of sense to me from a neuromodulation perspective but I haven't heard of any evidence based medicine to support utilization in this particular population of patients.

 

[Mister Mxyzptlk]

There is no evidence that a higher concentration of LA is better for LSB. Remember the sympathetics are the first ones to get blocked by LA. So i would continue with 0.125%. NO need for lido 1%

Which one would you rather give IV accidentally?

 

[lobelsteve]

Lobelsteve,

I have noticed that on the Windsor website www.georgiapainphysicians.com that Georgia Pain Physicians is now implementing MUA. I was curious if you have performed or witnessed this maneuver on any of the CRPS patients? The procedure makes alot of sense to me from a neuromodulation perspective but I haven't heard of any evidence based medicine to support utilization in this particular population of patients.

We looked at it. After a dozen or so patients (3 or 4 days total), no body was getting better, most hurt more, and the chiropractors that came into our ASC to do this were not as knowledgeable about spinal anatomy as I would want for somebody doing a procedure in my ASC.

I saw HVLA done on the C-spine in extension, I saw a CRNA drop a patient into the O2sat 60's with Propofol, and I had seen enough.

TO re-implement this- it would take the right DC, the right patient (diagnosis and attitude), and the right time. With me in the ASC is not the right time.

 

[Mister Mxyzptlk]

I have watched chiropractic MUA, which is a joke and a scam. I recall seeing one guy pop a back, and say, "That was T10" and then the others said,"Yep, I heard a pop, it sounded like T10". I felt so inadequate. I can usually only identify T10 with fluoro.

There is also allopathic MUA for doing painful manipulations such as trying to mobilize a frozen shoulder. I think all that does is allow tissues to be rent asunder without the attendant screaming and begging for mercy.

 

[analgesic]

We looked at it. After a dozen or so patients (3 or 4 days total), no body was getting better, most hurt more, and the chiropractors that came into our ASC to do this were not as knowledgeable about spinal anatomy as I would want for somebody doing a procedure in my ASC.

I saw HVLA done on the C-spine in extension, I saw a CRNA drop a patient into the O2sat 60's with Propofol, and I had seen enough.

TO re-implement this- it would take the right DC, the right patient (diagnosis and attitude), and the right time. With me in the ASC is not the right time.

That sounds like a recipe for malpractice. I whole heartedly agree. The right team is essential for this type of procedure. On the flipside I have seen this procedure go quite well in the hands of an anesthesiology pain fellow and an osteopath. However, HVLA was never performed. Like surgery manipulation is an art. It requires an understanding of articular neurology, biomechanics, physics, and spinal anatomy. So many of the physicians performing this procedure take a weekend course and hire a CRNA to reduce overhead. Perhaps more stringent guidelines will be implemented in the future

 

[jaydada]

I have a 22 y/o hockey player with right ankle and foot CRPS, who responded well to LSBs x2 with 12-14h pain relief. I have him on lyrica, elavil, lidoderm TD & TENS. I think he's a good candidate for SCS, but he's pretty young and very active, so I fear migration of the leads/paddle, and I want to delay SCS, until we exaust all the conservative stuff. My question to you all is: does anyone of you out there do RFA of the lumbar sympathetic ganglion? If so, is it better to do pulsed or thermal. If thermal, what temp and how long and which levels. My LSB worked great with single level at L3 with 15ml of 0.5% Ropiv. Does anyone out there do Phenol blocks for this anymore, if so, do you see any deafferentation pain after phenol or RFA?

Rxs for CRPS, besides lyrica & elavil, what else can I try, I'm really trying to avoid any opioids on this patient as long as possible. Does anyone have any experience with Memantine & CRPS.

 

[jaydada]

Does anyone know the name of the TENS unit device for diabetic peripheral neuropathy. I have a couple of patients with severe b/l hands and feet PN, I'm trying to prescribe a TENS unit with gloves & socks stim device. I saw a unit like that a while ago at a cancer institute for PN, I just can't remember the name. If anyone knows the name of such a unit and how to order it, I'd really appreciate it.

 

[SleepIsGood]

I have a 22 y/o hockey player with right ankle and foot CRPS, who responded well to LSBs x2 with 12-14h pain relief. I have him on lyrica, elavil, lidoderm TD & TENS. I think he's a good candidate for SCS, but he's pretty young and very active, so I fear migration of the leads/paddle, and I want to delay SCS, until we exaust all the conservative stuff. My question to you all is: does anyone of you out there do RFA of the lumbar sympathetic ganglion? If so, is it better to do pulsed or thermal. If thermal, what temp and how long and which levels. My LSB worked great with single level at L3 with 15ml of 0.5% Ropiv. Does anyone out there do Phenol blocks for this anymore, if so, do you see any deafferentation pain after phenol or RFA?

Rxs for CRPS, besides lyrica & elavil, what else can I try, I'm really trying to avoid any opioids on this patient as long as possible. Does anyone have any experience with Memantine & CRPS.

1) You are referring to a SCS trial right? Atleast I hope...because you are referring to "paddle"...which usually requires a lami. I highly doubt a 22 yo active hockey player is going to have a SCS IMPLANTED.
2)Pulse the ganglion, not thermal

 

[axm397]

I have a 22 y/o hockey player with right ankle and foot CRPS, who responded well to LSBs x2 with 12-14h pain relief. I have him on lyrica, elavil, lidoderm TD & TENS. I think he's a good candidate for SCS, but he's pretty young and very active, so I fear migration of the leads/paddle, and I want to delay SCS, until we exaust all the conservative stuff. My question to you all is: does anyone of you out there do RFA of the lumbar sympathetic ganglion? If so, is it better to do pulsed or thermal. If thermal, what temp and how long and which levels. My LSB worked great with single level at L3 with 15ml of 0.5% Ropiv. Does anyone out there do Phenol blocks for this anymore, if so, do you see any deafferentation pain after phenol or RFA?

Rxs for CRPS, besides lyrica & elavil, what else can I try, I'm really trying to avoid any opioids on this patient as long as possible. Does anyone have any experience with Memantine & CRPS.

At my fellowship, we did LSB at L2 and L3. Literature on L2, L3, and L4 for sympathetic blocks. I know different people put different things in the mix but we use some steroid in the mixture too.

Can try topical ketamine (compounded cream). Am assuming he is already doing desensitization therapy?

any underlying nerve entrapment or anatomic pathology contributing to this presentation?

 

[jaydada]

Yes, I was referring to a perc trial first if we actually pursue this route, then a paddle by a surgeon if a sucessful trial. I just don't see this kid wanting SCS, but like I said, we would reserve that as the last thing.

For the pulsed RF at the ganglion, would I place 3 needels: at L2, L3 & L4? The Raj book describes this as a thermal tech at 80deg, but I'm a little leery about this (thermal). Can you actually develop develop deafferentation pain after thermal RF of the ganglion, similar to phonol neurolysis?

The other option is to keep doing the LSBs with local for several times and hope to calm things down a little. Just curious, how many LSBs do people actually do before trying something different.

 

[jaydada]

At my fellowship, we did LSB at L2 and L3. Literature on L2, L3, and L4 for sympathetic blocks. I know different people put different things in the mix but we use some steroid in the mixture too.

Can try topical ketamine (compounded cream). Am assuming he is already doing desensitization therapy?

any underlying nerve entrapment or anatomic pathology contributing to this presentation?

I did put dex 15mg with the local solution both times. I just ordered a coumpounded cream consisting of: ketamine, clonidine, gabapentin, and lidocaine, hope it works. Just curious, how many LSBs do you try before moving onto something different? Anyone do continues catheters at the ganglion with local infusion, if so any risk of migration and how long do you leave the catheter in? Any worries about the catheter ending up intravascular? Also, what kind of pump to use, so the patient can take it home with him.

I'm not sure about any underlying nerve entrappment, he sustained an ankle (lower shin) injury about 2 years ago and developed tenosinovitis, underwent tenosinovectomy x2 and ended up with characteristic CRPS pain with trophic and skin & nail changes along with allodynia, hyperalgesia and temp changes of the right foot, no bone involvement yet. My plan was to figure out other nerve intrappment if the LSBs didn't work, but he received 100% pain relief with the LSBs, only lasting 12-14h, so I'm just trying to figure out the next most logical not so invasive option for him.

 

[lobelsteve]

I did put dex 15mg with the local solution both times. I just ordered a coumpounded cream consisting of: ketamine, clonidine, gabapentin, and lidocaine, hope it works. Just curious, how many LSBs do you try before moving onto something different? Anyone do continues catheters at the ganglion with local infusion, if so any risk of migration and how long do you leave the catheter in? Any worries about the catheter ending up intravascular? Also, what kind of pump to use, so the patient can take it home with him.

I'm not sure about any underlying nerve entrappment, he sustained an ankle (lower shin) injury about 2 years ago and developed tenosinovitis, underwent tenosinovectomy x2 and ended up with characteristic CRPS pain with trophic and skin & nail changes along with allodynia, hyperalgesia and temp changes of the right foot, no bone involvement yet. My plan was to figure out other nerve intrappment if the LSBs didn't work, but he received 100% pain relief with the LSBs, only lasting 12-14h, so I'm just trying to figure out the next most logical not so invasive option for him.

SCS now is most appropriate step. Nothing else will come close to getting the desired relief and return of function.

 

[Ligament]

I'd recommend the following:
Repeat L2, L3, and L4 LSB with 0.75% ropivicaine and kenalog at least one more time.
If fails,
Prialt low dose single bolus IT trial. I've had some CRPS patients get long term relief from single dose IT bolus Prialt trials. Have no idea why.
If fails,
SCS trial

Would not suggest RFA of the LSB. I've not seen anybody have long term results from this. Pulsed RF is an option, but no insurance will cover it, as pulsed RF is 64999. Would be an out of pocket expense. I have no experience with pulsed RF of the lumbar sympathetics.

 

[clubdeac]

1) You are referring to a SCS trial right? Atleast I hope...because you are referring to "paddle"...which usually requires a lami. I highly doubt a 22 yo active hockey player is going to have a SCS IMPLANTED.
2)Pulse the ganglion, not thermal

I had a guy with CRPS of the foot who failed SCS trial and LSBs. I thought, well I didn't have much to offer him from an interventional standpoint but he wanted something so i thought, what the heck, I'll try and pulse the L4-S1 DRGs. Now his foot pain is worse! Not good. Don't think I'll be trying that on any more CRPS patients. Ligament, how much prialt are you injecting?

 

[ultm8frisbee]

You could also consider inpatient IV subanesthetic ketamine infusion + epidural catheter or popliteal cathter and daily PT.

 

[hyperalgesia]

I have a 22 y/o hockey player with right ankle and foot CRPS, who responded well to LSBs x2 with 12-14h pain relief. I have him on lyrica, elavil, lidoderm TD & TENS. I think he's a good candidate for SCS, but he's pretty young and very active, so I fear migration of the leads/paddle, and I want to delay SCS, until we exaust all the conservative stuff. My question to you all is: does anyone of you out there do RFA of the lumbar sympathetic ganglion? If so, is it better to do pulsed or thermal. If thermal, what temp and how long and which levels. My LSB worked great with single level at L3 with 15ml of 0.5% Ropiv. Does anyone out there do Phenol blocks for this anymore, if so, do you see any deafferentation pain after phenol or RFA?

Rxs for CRPS, besides lyrica & elavil, what else can I try, I'm really trying to avoid any opioids on this patient as long as possible. Does anyone have any experience with Memantine & CRPS.

I'd go with the SCS trial. I've participated in the care of a few young and active pts like this who did well long term with SCS. Avoid opioids like the plague.

 

[jaydada]

All very good recs, thank you all.

What dose Prialt do you recommend?

If we do the ketamine infusion + epidural, how many days should I do it for?

I also like the idea of doing the LSBs at L2, L3 & L4 with the 0.75% Ropiv + kenolog.

And my all time favorite SCS, just not sure if he'll go for that, I want to try and avoid opioids at all cost if possible, but if we have no other choice, does anyone here think methadone might be a better choice? What about Namenda, anyone here use that for CRPS and have good sucess with it. What about Cymbalta, would that help?

 

[ultm8frisbee]

All very good recs, thank you all.

What dose Prialt do you recommend?

If we do the ketamine infusion + epidural, how many days should I do it for?

I also like the idea of doing the LSBs at L2, L3 & L4 with the 0.75% Ropiv + kenolog.

And my all time favorite SCS, just not sure if he'll go for that, I want to try and avoid opioids at all cost if possible, but if we have no other choice, does anyone here think methadone might be a better choice? What about Namenda, anyone here use that for CRPS and have good sucess with it. What about Cymbalta, would that help?

Ketamine infusion for 5-7 days.

 

[medolas]

For our Prialt single-shot trials (for pump placement), we do 1 mcg in 2 mL of PFNS. I'll go to up to 3 mcg if there is no response - patient either experiences pain relief or goes nuts for 24 hours...

 

[joshmir]

-alendronate 40mg daily for 6 weeks, then taper down..there is data on this

- in fellowship I saw one clear-as day responder to lanolidomide/thalidomide in a young lady with severe CRPS (trophic changes got better on it, worsened off it, got better agian on it, worse again off it)

-botox in your LSB in pts who respond to local anesthetic LSBs ...I know it sounds crazy but they have had very good results and no safety issues as far as I know with this at stanford...google Ian Carrol (spelling?) botulinum annals of neurology. very elegant crosoover design with each patietn acting as their own control

botox works much better when you have other neuropathic analgesics such as snri's, gabapentinoids, tca's on board...a threshhold effect

-saw something recently about immunoglobulin in CRPS, didn't read it yet

-calcitonin?

 

[clubdeac]

joshmir, I'm startin to think that you must have some major Allergan stock considering all your botox recommendations I do agree however that we're probably just at the tip of the iceberg when it comes to applications for botulinum toxin