stage 1 cprs type I

[indytravl]

hi,
does anyone have suggestions for management of early CPRS. Pt is 60yowf who had orthopedic surgery on R foot. ~4wk post-op, developed intermittent vasomotor instability (swelling, redness, sweating) in RLE. has intermittent mild-mod neuropathic pain & is currently only on her oxycodone prn. the orthopod has recognized it & is following her pretty closely & has ordered PT.

have read something about nutrition, vit c, & maintaining rom to help with it at this early stage of the condition. she's also putting the limb in ice intermittently or rubbing with towel (guess to desensitize). notes that heat actually aggravates it in the shower. have also read that ice is NOT a good thing to use.

can anyone suggest anything that may help limit/cure early rsd?

thanks

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[Ligament]

Assuming the CRPS diagnosis is correct; send to a pain physician ASAP.

Now is the time to make the most difference for this patient:
lumbar sympathetic blocks, oral steroid burst, high dose Lyrica, cymbalta, aggressive PT to desensitize, possible extended SCS trial.

 

[indytravl]

thanks for the input...

the presentation is classic rsd so wasn't thinking it warranted a diagnostic nerve block. is there any other reason to consider doing it at this point? I would've thougth to do it if fails meds/PT. the cord stim trial is only after failing nerve blocks isn't it?

pt's not really noting a lot of pain & has good rom since worked with PT postop anyway. does have intermittent mild (maybe to mod) neuropathic symptoms, but most of it seems to be autonomic dysfunction with intermittent edema, change in color (redness), & sweating. currently on oxycodone prn, outpt PT, massage, ted's, contrast baths at home/work

could you be specific about the steroid & dosage (is it prednisone, medrol dose pack, decadron)? do you suggest pregabalin + duloxetine started simultaneously. what dosage? should they be started along with steroids?

what are your thoughts at this point about changing to scheduled long acting opioid + prn versus leaving it as current prn short-acting opioid?

appreciate your help

 

[Pain_doc]

I strongly agree with Ligament. This person needs to be seen and evaluated by a pain physician.

 

[Ligament]

Your interest in this patient is wonderful. However, this is a very time critical issue if indeed the diagnosis is CRPS. I'd strongly suggest sending to a Pain Medicine specialist for aggressive management...in my experience, I consider early CRPS as one of the few pain emergencies and "hit em hard" really early on to prevent things from becoming chronic. To do this you need a pain doc

 

[Gator05]

Also be on the lookout for a peripheral nerve entrapment for block as well. What did they do to her foot? Only ~5 nerves heading in from the ankle, shouldn't be hard to find! We've used a peripheral nerve stimulator to help localize the nerve. The effects are immediate and impressive!

 

[Tenesma]

we talk about disease modifying by doing all these "hit them early and hard" approaches - is there any good data?

i know that in pedi CRPS there is some data to show that a lot of PT helps - but that is typically what we do for adults also...

 

[joshmir]

We've used a peripheral nerve stimulator to help localize the nerve. The effects are immediate and impressive!


can you please expand on what you might see specifically (as the "impressive" effect).....and what peripheral nerve stim you use?

thanks so much

 

[Gator05]

Example: entrapment of superficial peroneal nerve. ~0.5mA, would have to look up the pulse length (pre-set), attached to the needle. Of course painful on entering skin (poor landmarks secondary to edema), needle advanced until pain agrees that needle is "on the spot". LA + steroid injected, and the edema begins to resolve within 1-2 minutes. Veins become apparent on the skin, color change, and pain resolution. Interestingly, not always confined to the localized nerve distribution. For instance, posterior tibial, sural and deep-peroneal distributions will show similiar changes (and this is NOT a field block!).

Andrea Trescot showed used this approach. Can't fully explain the effects, but then again I can't honestly explain all of CPRS either.

By the way, has anybody heard of Trescot? We've been extremely impressed with her, excellent skill set, solid diagnoses and effective treatments, superb knowledge base, one of our favorite teachers. Her patients LOVE her. She's almost single-handedly convinced me to consider pain management. Just don't understand why she's only now pursuing academics.

 

[paindefender]

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[stim111]

I have seen patients within 2 weeks of carpal tunnel syndrome, gun shot wound to the sciatic nerve within 3 months, post serial casting and on and on for CRPS with sympathetically maintained pain. My experience is that if you are totally sure of the diagnosis, it is much harder to treat. The earlier the better with lumbar sympathetic blocks as well as the meds mentioned above if they have sympathetic features.