post-amputation finger neuritis

[PMR 4 MSK]

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I'm seeing a 25 yo s/p traumatic amputation of the distal phalange of his little finger, dominant hand. He works as a meat cutter, that's how he amp'd it. It is quite hypersensitive, somewhat allodynic, reddish but not sweating, no edema, no color or temperature abnormalities. Doesn't fit classic CRPS, but may be on the spectum. Only painful at the stump/tip, not spreading proximally or to other digits. I think it is neuroma/neuritis.

He's back at work full time, but it bothers him a lot. We've tried gabapentin, pregabalin, amitripytline, lidoderm, capsaicin and most recently voltaren gel. Nothing has really helped without significant side effects. Norco helps (of course) but he doesn't want it due to side efforts. OT did not help.

I haven't tried any of the compounded meds, that's next. I don't find injections help much for these cases, except for a few hours. I reluctant to try SGB as it is not CRPSy enough, but that's also on the options list.

Looking for thoughts on other treatment options or experiences.

 

[lobelsteve]

5%lido,10%keto,5%gaba cream.
then
SPG.

 

[PMR 4 MSK]

5%lido,10%keto,5%gaba cream.
then
SPG.

By "keto" do you mean ketoprofen or ketamine?

 

[Mister Mxyzptlk]

Maybe the prosthesis doesn't fit right. 😀

Dang this was my early retirement plan. Cut off the tip of the index finger of the dominant hand and collect disability. Not worth it to end up with CRPS though, and there's always the chance that in this economy the insurance carrier will go belly up trading the Zimbabwe dollar.

 

[lobelsteve]

By "keto" do you mean ketoprofen or ketamine?

10% ketoprofen. Unsure % ketamine, but that would work as well.

 

[Tenesma]

i would start cheap with a lidocaine ointment --- or see if your compounder can get lidocaine w/ DMSO as a vehicle (better/cleaner penetration)....

i would have him apply lidocaine ointment and then place a finger condom over it.

digital nerve blocks (remember no epi) can sometimes be quite effective and help calm things down...

i agree that stellate pointless based on your description...

he has his young age going for him.

 

[clubdeac]

i would start cheap with a lidocaine ointment --- or see if your compounder can get lidocaine w/ DMSO as a vehicle (better/cleaner penetration)....

i would have him apply lidocaine ointment and then place a finger condom over it.

digital nerve blocks (remember no epi) can sometimes be quite effective and help calm things down...

i agree that stellate pointless based on your description...

he has his young age going for him.

So one of the dermatologist in my area prescribed DMSO cream for one of my CRPS patients saying there is evidence in the literature to back it up. Has anyone used/heard of DMSO for CRPS???

 

[lobelsteve]

So one of the dermatologist in my area prescribed DMSO cream for one of my CRPS patients saying there is evidence in the literature to back it up. Has anyone used/heard of DMSO for CRPS???

Free radical scavengers

A prospective crossover study [22] with 20 patients found a positive effect of dimethylsulphoxide (DMSO) on the function of the affected limb. In 26 CRPS-I patients DMSO was found to be significantly more effective than the conventional regional ismelin block [23] in reducing pain. A randomised double-blind trial conducted with 32 CRPS-I patients [24] showed that 5 times daily use of DMSO in cremor vaselini cetomacrogolis provided significantly better results on CRPS-I symptoms than placebo after two months of treatment. A randomized double-blind study in 146 CRPS-I patients found comparable results for DMSO cream and N-acetylcysteine [9]. In general, DMSO generates lower (direct and indirect) costs than N-acetylcysteine. Subgroup analysis indicates that N-acetylcysteine is more cost effective in patients with a cold form of CRPS-I than DMSO. The opposite holds for warm forms of CRPS-I [25].

DMSO (dimethylsulphoxide) cream (50%) reduces the symptoms of CRPS-I patients (level 2: Perez et al (A2), Geertzen et al. (B); Goris et al. (B), Zuurmond et al. (B)).

It is likely that 600 mg of N-acetylcysteine administered three times a day reduces the symptoms of CRPS-I (level 3: Perez et al. (A2)).

There are indications that 50% DMSO (dimethylsulphoxide) cream is more effective on primary warm CRPS-I while N-acetylcysteine (NAC) is more effective on primary cold CRPS-I (level 3: Perez et al. (C)).

From biomedcentral

 

[clubdeac]

Free radical scavengers

A prospective crossover study [22] with 20 patients found a positive effect of dimethylsulphoxide (DMSO) on the function of the affected limb. In 26 CRPS-I patients DMSO was found to be significantly more effective than the conventional regional ismelin block [23] in reducing pain. A randomised double-blind trial conducted with 32 CRPS-I patients [24] showed that 5 times daily use of DMSO in cremor vaselini cetomacrogolis provided significantly better results on CRPS-I symptoms than placebo after two months of treatment. A randomized double-blind study in 146 CRPS-I patients found comparable results for DMSO cream and N-acetylcysteine [9]. In general, DMSO generates lower (direct and indirect) costs than N-acetylcysteine. Subgroup analysis indicates that N-acetylcysteine is more cost effective in patients with a cold form of CRPS-I than DMSO. The opposite holds for warm forms of CRPS-I [25].

DMSO (dimethylsulphoxide) cream (50%) reduces the symptoms of CRPS-I patients (level 2: Perez et al (A2), Geertzen et al. (B); Goris et al. (B), Zuurmond et al. (B)).

It is likely that 600 mg of N-acetylcysteine administered three times a day reduces the symptoms of CRPS-I (level 3: Perez et al. (A2)).

There are indications that 50% DMSO (dimethylsulphoxide) cream is more effective on primary warm CRPS-I while N-acetylcysteine (NAC) is more effective on primary cold CRPS-I (level 3: Perez et al. (C)).

From biomedcentral

Hmmm, interesting. Now I feel bad for telling the pharmacist he was crazy 😀

 

[joshmir]

have you tried injecting it?

If relief lasts a few hours longer than the duration of teh local anesthetic effect chase it with botox. unsure if there are some here who would try phenol or alcohol

 

[clubdeac]

have you tried injecting it?

If relief lasts a few hours longer than the duration of teh local anesthetic effect chase it with botox. unsure if there are some here who would try phenol or alcohol

Joshmir, I did that exact thing on a patient with a 4th finger amputation after reading some of your other posts. Got relief from the anesthetic for appropriate duration but absolutely no relief from the botox. 🙁 disappointed

 

[lobelsteve]

have you tried injecting it?

If relief lasts a few hours longer than the duration of teh local anesthetic effect chase it with botox. unsure if there are some here who would try phenol or alcohol

I would not ETOH or phenol a finger. Not enough meat over the bone and would more likely cause tissue necrosis.

How small do catheters come in? If there were a 25G size catheter that could get run down the arm over the dorsal hand for continuous block.....

 

[lobelsteve]

NOTE: Pennsaid contains DMSO and diclofenac.

I did not know this until the rep came by for lunch. How cool is that...

 

[joshmir]

"I would not ETOH or phenol a finger. Not enough meat over the bone and would more likely cause tissue necrosis."

I hear what you're saying. I wonder how the the podiatrists avoid this....I hear they are using multiple dilute alcohol neurolysis treatments for foot neuromas these days and fewer operarative resections

 

[lobelsteve]

"I would not ETOH or phenol a finger. Not enough meat over the bone and would more likely cause tissue necrosis."

I hear what you're saying. I wonder how the the podiatrists avoid this....I hear they are using multiple dilute alcohol neurolysis treatments for foot neuromas these days and fewer operarative resections

I believe they use 4%, 1cc and repeat as a series. Data from 50's was mostly case series

 

[PinchandBurn]

Try pulsed RF (yup I know may not get paid)....pRF...likely less chance of a neuritis. Almost harmless.

I would say use regular RF..but you have a neuritis to begin with. Although steroids should attenuate this.

 

[PainMD23]

Agree with the lidocaine/ketoprofen/gabapentin combo. You could always add ketamine (or amitriptylene). I like the DMSO idea! I had a patient tell me the only thing that helped the CRPS in his foot was DMSO.