[Complex regional pain syndrome in nerve root compression and after spinal surgery]. / Komplexes regionales Schmerzsyndrom bei Nervenwurzelkompression und nach Wirbelsäulenoperation.

Complex regional pain syndrome (CRPS) is an extremely painful and partially disabling disease. It often occurs secondary to trauma, but also spontaneously. The emergence of CRPS has been reported following nerve root compression and/or spinal surgery, but its incidence is unknown. In this article, the present knowledge about the incidence of CRPS in the context of nerve root compression and spine surgery is reviewed and therapeutic and diagnostic consequences are discussed.

Intense pain soon after wrist fracture strongly predicts who will develop complex regional pain syndrome: prospective cohort study.

UNLABELLED: Complex regional pain syndrome (CRPS) is a distressing and difficult-to-treat complication of wrist fracture. Estimates of the incidence of CRPS after wrist fracture vary greatly. It is not currently possible to identify who will go on to develop CRPS after wrist fracture. In this prospective cohort study, a nearly consecutive sample of 1,549 patients presenting with wrist fracture to 1 of 3 hospital-based fracture clinics and managed nonsurgically was assessed within 1 week of fracture and followed up 4 months later. Established criteria were used to diagnose CRPS. The incidence of CRPS in the 4 months after wrist fracture was 3.8% (95% confidence interval = 2.9-4.8%). A prediction model based on 4 clinical assessments (pain, reaction time, dysynchiria, and swelling) discriminated well between patients who would and would not subsequently develop CRPS (c index .99). A simple assessment of pain intensity (0-10 numerical rating scale) provided nearly the same level of discrimination (c index .98). One in 26 patients develops CRPS within 4 months of nonsurgically managed wrist fracture. A pain score of ≥5 in the first week after fracture should be considered a "red flag" for CRPS. PERSPECTIVE: This study shows that excessive baseline pain in the week after wrist fracture greatly elevates the risk of developing CRPS. Clinicians can consider a rating of greater than 5/10 to the question "What is your average pain over the last 2 days?" to be a "red flag" for CRPS.

Spinal cord stimulation in complex regional pain syndrome and refractory neuropathic back and leg pain/failed back surgery syndrome: results of a systematic review and meta-analysis.

The drive for good quality evidence has highlighted the importance of well-conducted systematic reviews and meta-analyses that critically evaluate and grade studies for new or existing therapies. A systematic review and meta-analysis was performed to review the efficacy, safety, and cost effectiveness of spinal cord stimulation (SCS) in complex regional pain syndrome (CRPS) and refractory neuropathic back and leg pain/failed back surgery syndrome (FBSS). The results support the use of SCS in patients with refractory neuropathic back and leg pain/FBSS (Grade B evidence) and CRPS type I (Grade A evidence)/type II (Grade D evidence). SCS not only reduces pain, improves quality of life, reduces analgesic consumption, and allows some patients to return to work, with minimal significant adverse events, but may also result in significant cost savings over time.

Causalgia: a meta-analysis of the literature.

BACKGROUND: Causalgia is not familiar to most physicians whose training and experience are limited to civilian practice. HYPOTHESIS: Through a thorough review of the literature, we attempted to determine the boundaries of causalgia and separate it from other sympathetically related disorders. DATA SOURCES: Database search for English-language articles in MEDLINE and Index Medicus up to the year 2000 as both keyword and subject under causalgia. STUDY SELECTION: References that described any new cases referred to as "causalgia" by their authors were included in a meta-analysis. DATA SYNTHESIS: One hundred ten articles contained a total of 1528 cases of causalgia. High-velocity missiles caused at least 77% of the injuries. In 72% and 90% of the cases reported, the time from injury to onset of pain was within 1 week and 1 month, respectively. Median nerve alone or in combination with other nerves (56%) and sciatic trunk injury (60%) were the most common nerves involved. In 92%, the nerve injury was incomplete. The most prominent clinical manifestations included burning pain in 86%, increased sweating in 73%, relief with application of cold in 62%, warmth in 50%, paresthesias in 96%, absence of anesthesia in 81%, and sensitivity to stimuli in 98%. Response to sympathetic blocks was observed in 88%. Finally, a total of 94% of the patients undergoing sympathectomy were cured. CONCLUSIONS: Cases of causalgia are easy to recognize and treat, with excellent results. Causalgia always follows a somatic nerve injury, usually partial, and is associated with near-constant, very severe pain distal to the injury in the extremity, varied in nature but characteristically with a predominantly burning quality. An effective anesthetic block of the appropriate part of the sympathetic chain frequently immediately relieves the pain. Most cases are cured by surgical sympathectomy.

[Prospective study of prevalence and risk factors for painful phantom limb in the immediate postoperative period of patients undergoing amputation for chronic arterial ischemia]. / Estudio prospectivo de la prevalencia y factores de riesgo de miembro fantasma doloroso en el postoperatorio inmediato de pacientes sometidos a amputación por isquemia arterial crónica.

OBJECTIVE: To determine the prevalence and risk factors associated with postoperative phantom limb pain (PLP) in patients amputated for chronic ischemia of a lower limb. PATIENTS AND METHOD: Prospective, longitudinal, epidemiological study of patients amputated for chronic grade IV ischemia. PLP, defined as the perception of pain > or = 3 on a verbal scale of 0 to 10, was assessed in the first week after surgery. Candidate risk factors analyzed were patient characteristics, course of ischemic disease, and features of surgery or anesthetic technique. RESULTS: The prevalence of PLP was 26% (14 patients) in a total of 53 amputations performed on the same number of patients over one year. Mean patient age was 68.4 +/- 11.2 years, and 45 (84.9%) were diabetics. Phantom limbs were felt by 9 patients (17%), and a painful stump was reported by 5 (10%). The most common PLP symptoms were a burning sensation and painful paresthesia. Risk factors identified, in order of statistical significance, were prior amputation (p < 0.0002), oral antidiabetic therapy (p < 0.02) and type of amputation (p = 0.05). Logistic regression analysis of variables revealed increased risk of PLP in patients with a prior amputation (odds ratio [OR] 8.1) and those receiving oral antidiabetic therapy (OR 3.9). Insulin treatment was a protective factor (OR 0.5). CONCLUSIONS: The prevalence of PLP among patients with chronic ischemia of the lower limb in our setting is considerable, although low in comparison to the prevalence reported for other settings. Identifying risk factors such as those described in this study helps to establish the profile of patients toward whom to direct measures to prevent PLP.

Sympathectomy for causalgia: experience with military injuries.

BACKGROUND: Causalgia is a rare disease in civilian practice, and most reports regarding causalgia in the literature are from major extended wars. To increase awareness of this syndrome, our wartime experience with this disease is presented. METHODS: The charts of patients with causalgia referred to two university hospitals for treatment from 1985 to 1989 were retrospectively studied. Characteristics of the cause, clinical manifestations, and the response to therapy were evaluated. RESULTS: Among 1,564 patients with peripheral nerve injuries, there were 54 cases (3.4%) of causalgia. All of the patients, except five, were injured in battle by high-velocity bullets or missiles. Upper extremities were involved in 28 patients (52 %) and lower extremities in 26 patients (48%). The most common presenting symptoms were as follows: burning pain, 100%; wet extremity, 100%; cold extremity, 93%; sensitivity to cold, 89%; paresthesia, 78%; and color changes in the extremities, 55%. In 48 patients (89%), pain was relieved by sympathetic block (3 patients had permanent cure). Six patients had no response to the blocks (11%). Of 45 patients who had temporary relief, all underwent sympathectomy. All of these patients had complete relief of symptoms in the immediate postoperative period and for follow-up from 1 to 6 years. CONCLUSION: Causalgia is essentially a war casualty disease. The condition is associated with burning pain, hyperesthesia, and symptoms of sympathetic overactivity. Sympathectomy is effective and the treatment of choice, particularly for patients who respond temporarily to sympathetic blocks.

Complex regional pain syndrome.

The term "complex regional pain syndrome" encompasses causalgia and reflex sympathetic dystrophy. Symptoms of burning pain with autonomic and tissue changes begin shortly after an injury, usually to a distal extremity. The diagnosis is based on the history and the clinical findings. No confirmatory tests are available, although plain radiographs or a three-phase bone scan may be helpful in diagnosing some cases. Aggressive treatment, which may include sympathetic blockade, medications, physical therapy and psychotherapy, is essential for a favorable outcome. Despite treatment, many patients are left with varying degrees of chronic pain and disability.

Computer-assisted DREZ microcoagulation: posttraumatic spinal deafferentation pain.

Our data demonstrate that approximately 23-29% of standard dorsal root entry zone (DREZ) microcoagulation procedures fail to relieve pain due to inadequate thermal lesions and that approximately 39% fail due to insufficient superior extent of lesions. The remaining failures are related to inadequate lesion placement, improper selection of patients, and, rarely, posttraumatic spinal deafferentation pain resulting from other non-DREZ mechanisms. Computer-assisted DREZ microcoagulation is a satisfactory procedure to treat intractable posttraumatic spinal deafferentation pain, brachial plexus avulsion pain, and lumbosacral nerve root avulsion pain. In all these conditions we have identified areas of abnormal focal hyperactivity in the DREZ area. Perhaps this procedure can be applied to other central pain conditions if, using this technique, abnormal focal hyperactivity is demonstrated to be present.

Sympathetic dystrophies. Recognizing and managing a puzzling group of syndromes.

The sympathetic dystrophies are poorly understood and underdiagnosed, especially in their milder forms. Although the two major syndromes, causalgia and reflex sympathetic dystrophy, are similar in many aspects, significant differences remain in clinical presentation, pathogenesis, and management. This discussion of these syndromes focuses on clinical presentation and diagnosis for the primary care physician.