Questionable CRPS...what to do?

[schmee90]

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Ive been an attending for a bout 3 years. I have seen obvious CRPS, and had patients referred to you for CRPS were they defintely dont have CRPS. Has anybody had patiens with persistent foot or extremity pain with a questionable etiology but there are some components of CRPS, and the patient is adamant they want neuromodulation, but you are on the fence if its really CRPS? Do you continue to follow the patient and try less invasivce things first that is always what I have done.

I had an experience today were records were extremely limited, but patient had a unknown surgery for some mass in calcaneus (again records limited). She has had persistent pain prior workup not coming up with another obvious diagnosis including EMG, MRI ankle, and L spine. She had seen a prior pain group who diagnosed her with CRPS had tried some gabapentin and lum symp block with no benefit. She was going to move forward with Stim trial however per patient history insurance wouldnt allow this so she in some round about way ended up at my office.

On my initial evaluation she had some aspects of CRPS, she didnt fit budapest criteria. In addition she supposedly had a 2nd opinion with a surgeon who per patient said there maybe a surgery that could help her (again per patien hx records really limited but is there another etiology contributing to patietns symptoms). I expressed apprehension about an SCS trial and possible implant, and started to explain is there another etiology and is there less invasive treatment options and she blew up. I'm an idiot and not helping her as I didnt automatically want to put a SCS in her since that's what the other pain docs wanted to do but per patient hx insurance wouldnt let them.

I have been kind of torn in that I never want a patient to push me into a procedure. Maybe I am more conservative with neuromodulation then others. I feel torn as I dont think SCS wouldt at some point be a reasonable thing but I just really reserve it if I feel I have nothing less invasvie that may help patients (ie patient hadn't evn done CRPS related PT, etc,etc. In any event patient thinks I am an idiot and is going to get another opinion.

 

[willabeast]

Suggest psych testing. R/O BPD. Am retired now, never had a patient insist on a stim. If patient thinks you are an idiot congratulations you dodged a bullet.

 

[Gnarvin]

I wouldn’t worry about it. You gave her your medical opinion and she didn’t like it; so be it. You are a consultant and are there to give your professional opinion, not just do what some other guy wanted to do or what the patient wanted you to do. If you didn’t feel that she fit criteria for CRPS, were you going to be comfortable using that diagnosis to get the stim covered?

She can keep shopping around until she finds someone to do it. She will probably convince herself it helps during the trial and then complain forever that it stopped helping after the honeymoon period with the implant. It’s a story I have seen play out many times.

 

[RM38]

Agree with the above. Have seen a number of patients convince themselves the trial worked and then be unhappy with the implant which is why I now always have a very direct conversation about that prior to the trial. Also if insurance denied the other doc, they are probably going to deny you as well if you attempt to submit an auth. Do you want to spend time doing a peer to peer and appealing a procedure that you don’t really believe is indicated? Patient will just get even more mad at you when it doesn’t go their way. Agree I would let patient get another opinion if you don’t feel SCS is indicated and you don’t think you have a different option that may help. You will be happier you did.

 

[projectpat]

Do not sweat this. Don’t even ponder if this is CRPS or not. You don’t want to stim this particular pt

 

[Agast]

The trial would probably fail, but her anger is because she had a glimmer of hope and you sort of crushed it. That’s one of the reasons the psych eval is mandatory, some people actually kill themselves when the trial fails.

 

[geauxg8rs]

Don’t be torn. I say no every day to patients. That’s what the fellowship and years of training do, teach us to say no.

 

[CleanUp]

For these patients if it is unclear what the exact diagnosis is but I get the sense that is neuropathic then I need some buy in from them. If they are whining about gabapentin 100mg then we will unlikely be able to be more aggressive in therapy. So I take the time to optimize their psychological health and work on other things while starting and titrating gabapentin, lyrica, TCA, creams, anticonvulsants etc.

If they want a quick fix then they will weed themselves out.

 

[callmeanesthesia]

If you have any doubt in your actions, you can set them aside. Some KOL sim-everything type who probably owns their own ASC told her “ah yes, clearly you have CRPS, and stim is the only thing that will help. IMHO, the biggest factors for improvement in these patients are 1. Self-efficacy (including willingness to quit smoking, do PT, etc), 2. Lack of underlying mechanical pathology, and 3. Lack of secondary gain.

Your patient at least was lacking in the first 2. When they have surgically correctable pathology, even with classic CRPS, I give them recs for pre, intra, and post-op anesthetic management and send them back to the surgeon with instructions to see me back closely after surgery for sympathetic blocks if needed.

 

[kstarm]

Two comments. I view CRPS as on a spectrum. It really isn't binary as the budapest or disability insurers make it out to be, the criteria like many pain things is very subjective. My treatments don't really change if they have "features" of CRPS and actually meet the criteria. I wouldn't have an issue offering stim to someone who had a number of "features" of CRPS that didn't improve with other conservative measures first.

Second, is that some people just aren't going to be happy with what you have to offer. You can just move on or if you wanted to go motivation interviewing with them you could go that way. I think it is important to self-examine our practices, but I would just caution that if you go down the hole of I'm a "good" or "bad" physician because my patient says "X" you are going to get frustrated, or burnout, and likely hold a lot of resentment. Like geauxg8rs said, I wouldn't be torn about this.

 

[GlowInTheDark]

The trial would probably fail, but her anger is because she had a glimmer of hope and you sort of crushed it. That’s one of the reasons the psych eval is mandatory, some people actually kill themselves when the trial fails.

No, the trial would be a “success”.

Implant would fail. Patient will be at office calling/showing up randomly/whining for the next year until they insist you take it out because it made their pain worse.

 

[schmee90]

Thank you all appreciate all the input