Exam Room 2: RSD following PRP

[drusso]

---

Members don't see this ad.

47 y.o. female book-keeper with right basilar thumb OA underwent non-image guided PRP injection 6 months ago. Felt excruciating and electrical sensation over dorsum of thumb during shot. Severe swelling at @24 hours in thumb and index finger. PCP did kenalog injection at 48 hours without improvement. Repeat kenalog injection at 2 weeks no improved. Oxycodone 15 mg QID and Lyrica initiated with little improvement. Referred to hand-surgeon who diagnoses "RSD Type 2" in right hand. Referred to OT for modalities. Little improvement. Now referred to me for stellate ganglion block. Block performed in office using standard fluoroscopic technique. Reported 90-100% improvement in pain post-procedurally with temperature change of 2.5 degrees in affected hand. Patient now claiming disability related to inability to use right and to operate computer mouse. Med-Mal attorney retained. I can't be retained as expert because I am now treating MD.

What's your next move?

 

[willabeast]

47 y.o. female book-keeper with right basilar thumb OA underwent non-image guided PRP injection 6 months ago. Felt excruciating and electrical sensation over dorsum of thumb during shot. Severe swelling at @24 hours in thumb and index finger. PCP did kenalog injection at 48 hours without improvement. Repeat kenalog injection at 2 weeks no improved. Oxycodone 15 mg QID and Lyrica initiated with little improvement. Referred to hand-surgeon who diagnoses "RSD Type 2" in right hand. Referred to OT for modalities. Little improvement. Now referred to me for stellate ganglion block. Block performed in office using standard fluoroscopic technique. Reported 90-100% improvement in pain post-procedurally with temperature change of 2.5 degrees in affected hand. Patient now claiming disability related to inability to use right and to operate computer mouse. Med-Mal attorney retained. I can't be retained as expert because I am now treating MD.

What's your next move?

Suggest never mentioning etiology of CRPS in written form because it won't help the patient (unless someone missed something) and you will be called upon to testify in any case. I would get an ESR because it is cheap and i had a similar patient once who turned out to have an indolent osteo. Suggest a neurology consult since you are postulating a nerve injury and sometimes surgeons can try to fix those . Suggest DCS trial after medication trials and normal ESR and neurology states only thing left.

 

[NOSfan]

As WB suggested.

Additionally, would make sure that you discuss and document any potential non-FDA treatment that you perform/recommend to the patient (neuromodulating medications, infusions, wax therapy, ketamine....whatever). Fortunately, SCS is FDA approved in this instance.

What about referring for this: Safety of Intravenous Neridronic Acid in CRPS | Clinical Research Trial Listing ( Complex regional pain syndrome ) ( NCT02972359 )

 

[SeniorWrangler]

Sure sounds like an intraneural injection to me from the history, it can be pretty hard to tell CRPS Type 2 from focal neuropathy after procedure in my experience. You could get a bone scan to help establish the CRPS diagnosis. Either way, multiple trials of neuropathy meds, physical therapy and behavioral treatment are going to be key for the outcome.

 

[lobelsteve]

CRPS is a clinical dx.

Budapest criteria checklist?

Causality established. Injected into nerve.

Treatment response irrelevant for medmal case at this point.

Your exam?
Her credibility? Not so good with regimen of qid roxy ans disability claim.

 

[SSdoc33]

what nerve would that be? some superficial branch of the radial? if so, who cares? it will get better. more likely, the injection was intra-tendonous, APL vs. EPL, and then she developed CRPS. a very quick and easy radial sensory NCS makes this diagnosis. really doesnt matter in the long run, though. id repeat a stellate or 2 and get her working on aggressive PT with your non-opioid medication of choice. really try to avoid a SCS for a little shot in the thumb especially with litigation involved.

 

[drusso]

what nerve would that be? some superficial branch of the radial? if so, who cares? it will get better. more likely, the injection was intra-tendonous, APL vs. EPL, and then she developed CRPS. a very quick and easy radial sensory NCS makes this diagnosis. really doesnt matter in the long run, though. id repeat a stellate or 2 and get her working on aggressive PT with your non-opioid medication of choice. really try to avoid a SCS for a little shot in the thumb especially with litigation involved.

I think its radial. I'm doing an EDX, but NCS often normal in CRPS.

 

[lobelsteve]

I think its radial. I'm doing an EDX, but NCS often normal in CRPS.

But radial will be abnormal because she got CRPS (if she has it- you never gave us your exam findings) from being stabbed in branch of radial nerve.


Example: Left foot CRPS, right foot not CRPS.

 

[Gauss]

Wartenbergs syndrome, aka cheiralgia paresthetica. Common risk with either cmc jt or first dorsal compartment injection. Assuming tendons were unaffected, block it and if successful you might consider further treatment. I would send to Peripheral neurosurgeon rather than neurologist

 

[SeniorWrangler]

Clearly that lady needs a star on the other foot, it's unhappy at being left out.