Safety and Effectiveness of Stellate Ganglion Cryoablation in Complex Regional Pain Syndrome.

This was a retrospective, observational, descriptive study to evaluate the safety and 6-month effectiveness of percutaneous cryoablation of the stellate ganglion for the treatment of complex regional pain syndrome (CRPS). Eight patients with CRPS diagnosed by Budapest criteria were treated with this procedure. CRPS symptom severity was assessed prior to the procedure and at 3-month intervals after the procedure using a novel CRPS scoring system-the Budapest score-created by the authors. The mean Budapest score prior to and 6 months (187 days, SD ± 43) after stellate ganglion cryoablation was 7.0 (SD ± 2.0) (n = 6) and 3.8 (SD ± 2.3) (n = 6), respectively, showing a decrease of 3.2 (SD ± 1.7) (n = 6; P = .006). There were no major adverse events due to the procedure, and there was only 1 minor adverse event. Stellate ganglion cryoablation is a feasible, safe, and minimally invasive procedure that may represent an efficacious adjunct treatment option for select patients with CRPS.

Risks of therapeutic versus prophylactic neurectomies.

INTRODUCTION: Neuralgia due to a peripheral nerve injury may result in chronic pain, requiring a therapeutic surgical neurectomy. Meanwhile, some neurectomies are performed prophylactically, such as during inguinal mesh removal. Outcomes and risks associated with neurectomies are largely unknown despite consensus panels recommending them. METHODS: All patients who underwent neurectomy 2013-2020 were analyzed. Data collection included demographics, preoperative symptoms, and postoperative outcomes. Indications for neurectomy were categorized as "therapeutic" if the patient had preoperative neuralgia or "prophylactic" if neurectomy was deemed necessary intra-operatively. RESULTS: 66 patients underwent 80 operations and a total of 122 neurectomies. On average, 1.5 neurectomies were performed per operation. Therapeutic neurectomies were performed in 42 (64%) patients and prophylactic in 34 (52%). The most commonly transected nerve was the ilioinguinal nerve. Average preoperative pain score was 5.8/10. On paired analysis, there was a significant reduction in pain after prophylactic neurectomy (2.5 points, p = 0.002) but not after therapeutic neurectomy. None of the nerves transected prophylactically had postoperative neuralgia, whereas 35% of the nerves transected therapeutically resulted in persistent or recurrent neuralgia (p < 0.001). To treat this, 21% required only nerve blocks and 9% required ablation or reoperative neurectomy. Three patients had complex regional pain syndrome (CRPS), a severe complication; all three were diagnosed with chronic pain syndrome pre-operatively. DISCUSSION: We demonstrate that prophylactic neurectomy is largely safe. In contrast, a therapeutic neurectomy had a 35% risk of persistent or recurrent neuralgia, 9% required additional ablative or reoperative neurectomy. Three patients advanced from chronic pain syndrome to CRPS. We recommend the decision to perform a neurectomy be judicious and selective, especially in patients with known chronic pain syndrome. Prior to planning surgical neurectomy, other less invasive modalities should be exhausted and patients should be aware of its risks.

Complex regional pain syndrome patient treated with a below knee amputation, implanting nerves directly into muscle: A case report.

Persistent, disabling lower extremity pain, outside the distribution of a single nerve, is termed chronic regional pain syndrome (CRPS), but, in reality, this chronic pain is often due to multiple peripheral nerve injuries. It is the purpose of this report to describe the first application of the "traditional," nerve implantation into muscle, usually used in the treatment of a painful neuroma, as a pre-emptive surgical technique in doing a below knee amputation (BKA). In 2011, a 51-year-old woman developed severe, disabling CRPS, after a series of operations to treat an enchondroma of the left fifth metatarsal. When appropriate peripheral nerve surgeries failed to relieve distal pain, a BKA was elected. The approach to the BKA included implantation of each transected peripheral nerve directly into an adjacent muscle. At 5.0 years after the patient's BKA, the woman reported full use of this extremity, using the prosthesis, and was free of phantom limb and residual limb pain. This anecdotal experience gives insight that long-term relief of lower extremity CRPS can be achieved by a traditional BKA utilizing the approach of implanting each transected nerve into an adjacent muscle.

Targeted muscle reinnervation at the time of amputation in the management of complex regional pain syndrome of the lower extremity.

BACKGROUND: Complex regional pain syndrome (CRPS) is a chronic, posttraumatic condition defined by severe pain and sensorimotor dysfunction. In cases of severe CRPS, patients request amputation, which may cause phantom limb pain (PLP) and residual limb pain (RLP). Targeted muscle reinnervation (TMR) reduces the risk of PLP and RLP. This report describes the use of TMR at the time of amputation in a series of patients with CRPS. PATIENTS AND METHODS: Four patients (ages 38-71 years) underwent TMR at the time of amputation for CRPS between April 2018 and January 2019. Three patients had a history of trauma and surgery to the affected limb. All patients attempted pharmacologic and interventional treatments for 1-7 years before requesting amputation. Three patients underwent below-knee amputations (BKA) and one had an above-knee amputation (AKA). Target muscles included the soleus, gastrocnemius, and flexor hallucis longus (BKA), and semitendinosus, biceps femoris, and vastus medialis (AKA). Postoperative phantom and residual limb pain symptoms were collected via a telephone survey adapted from the Patient-Reported Outcomes Measurement Information System (PROMIS). RESULTS: There were no complications related to the TMR procedure. Average follow-up time was 12.75 months. Patients reported varied outcomes: two had RLP and PLP, one had RLP only, and one had PLP only. All patients reported successful prosthetic use. CONCLUSION: TMR may be performed at the time of amputation for CRPS. Further study is necessary to determine the effect of TMR on pain, pain medication use, prosthesis use, and other domains of function.

Spinal cord stimulation for a woman with complex regional pain syndrome who wished to get pregnant.

A woman with complex regional pain syndrome (CRPS) in the right lower extremity who wished to discontinue medications to get pregnant underwent implantation of a spinal cord stimulation system (SCS). An electrode lead was placed at Th(10-11) in the epidural space, accessed via the L(2-3) interspace with a paramedian approach, and a pulse generator was implanted in the left buttock. She kept the SCS on 24 h a day. After she had experienced several chemical abortions, finally she got pregnant via artificial insemination. She had an uneventful delivery of a healthy baby by cesarean resection under spinal anesthesia. In a patient with CRPS who has an implanted SCS system and wishes to get pregnant, the electrode lead into the low thoracic epidural space should be accessed via the high lumbar intervertebral space in consideration of a future requirement for spinal or epidural anesthesia for cesarean section. The generator should be placed in the buttock to prevent impairment of the SCS system being caused by the enlarged abdomen during pregnancy. Although we were apprehensive of adverse effects owing to the electromagnetic field force and change of blood flow in the pelvic viscera, our patient had a successful delivery. SCS is a favorable option for patients with CRPS who wish to get pregnant.

[The use of sensory-sympathetic coupling indices for diagnosing of sympathetically maintained pain with laser Doppler flowmetry].

For the first time the objective diagnosis of sympathetically maintained pain was created with laser Doppler flowmetry (LDF), directed specially to discovery of skin sensory-sympathetic coupling at 49 patients with posttraumatic complex regional pain syndrome. Sensory-sympathetic coupling was diagnosed as combination of sympathetic vasomotor activity with the existence of sensory peptidergic blood flow oscillations in frequency range of 0.047-0.069 Hz in LDF wavelet-spectrum. The results of LDF diagnosis were compared with clinical evaluation of sympathetically maintained pain carried out after desympathization surgery (thoracoscopic clipping above and below the Th3 ganglion of sympathetic chain at 33 patients and perivascular sympathectomy at the level of brachial artery and veins at 16 patients). Sensitivity of preoperative LDF-diagnosis was 90.2%, specificity--87.5%, positive predictive value--97.3%, negative predictive value--63.6%, diagnostic effectiveness--89.8%.

Determinants of Complex Regional Pain Syndrome Type I among Radial Head Fracture Patients with Unilateral Arthroplasty.

OBJECTIVE: This study aims to assess the proportions of complex regional pain syndrome type I (CRPS I) in radial head fracture patients undergoing unilateral arthroplasty and to explore associated factors. METHODS: This is a prospective observational study. From March 2016 to May 2019, a total of 221 adult patients with radial head fracture patients were included in consecutive studies and completed the 1-year follow-up. All patients were treated by unilateral arthroplasty. At each follow-up visit, the visual analogue scale was used to measure patients' pain level. Occurrence of CRPS I, which was diagnosed by Budapest criteria, was the main outcome collected at baseline and the 1-, 3-, 6-, and 9-month follow-ups. The baseline data were collected before surgery and included demographic and clinical data. Independent t-tests and χ2 tests were used as univariate analyses to compare the baseline data of patients with and without CRPS I. Multivariate analysis (Backword-Wald) was used to identify factors independently associated with CRPS I. RESULTS: The proportion of CRPS I cases among radial head fracture patients undergoing unilateral arthroplasty was 11% (n = 24). A total of 19 (79%) patients were diagnosed with CRPS I within 1 month after surgery. Multivariable logistic regression analysis revealed that female gender (odds ratios [OR]: 1.537; 95% confidence interval [CI]: 1.138-2.072), age younger than 60 years (OR: 1.682; 95% CI: 1.246-2.267), moderate and severe Mayo Elbow Performance Score (MEPS) pain (OR: 3.229; 95% CI: 2.392-4.351) and anxiety (OR: 83.346; 95% CI: 61.752-112.320) were independently associated with CRPS I. CONCLUSIONS: This exploratory study reported that the incidence of CRPS I developing after radial head arthroplasty was 11%. Female sex, younger age, moderate and severe MEPS pain and anxiety patients seems more likely to develop CRPS I.

Our 15-year experience of complications of Chow's technique for endoscopic carpal tunnel releasing.

PURPOSE: Our objective in this study was to summarize our 15-year experience treating carpal tunnel syndrome released with Chow technique, focusing on the complications and how to avoid them. METHOD: We systematically evaluated the postoperative complications in 211 patients who underwent endoscopic carpal tunnel release (ECTR) with Chow technique. We recorded the incidence of complex regional pain syndrome type I (CRPS I), median nerve and digital nerve injury, superficial palmar arch injury, and tendon injury. RESULT: The overall incidence of complications was 5.6%, and involved 10 cases of CRPS I, 1 case of median nerve trunk injury, and 1 case of superficial palmar arch injury. No other complication occurred. We used oral pregabalin and neurotropin to relieve CRPS I symptoms, and performed second operations for the other two complications. CONCLUSIONS: Our study revealed that ECTR could reduce structural and cutaneous complications, but increase the incidence of nerve injury. we speculated that the incidence of CRPS I may be higher in the Asian population.

Outcomes of Carpal Tunnel Release in Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy/Sudeck Disease Patients.

BACKGROUND: The clinical features of classic carpal tunnel syndrome are well known. However, some patients who display atypical symptoms and signs of pain and dysesthesias in the hand, worsening of symptoms at night, and above all, inability to make a full fist, respond equally well to carpal tunnel release. This same clinical picture was shared by some patients labeled as having complex regional pain syndrome. Because of the poor outcome of complex regional pain syndrome patients with current regimens, the authors tested the hypothesis that carpal tunnel release could be effective on them. The purpose of this article is to report the outcome of carpal tunnel release in complex regional pain syndrome patients who presented the above signs and symptoms. METHODS: Fifty-three patients with an average age of 55 years presenting the above cluster of symptoms were operated on. All were unilateral cases, had sustained trauma, and were treated for complex regional pain syndrome before referral for an average of 16 months. All patients underwent carpal tunnel release. RESULTS: At a minimum of 6 months' follow-up, pain dropped 7.5 points on a numerical rating scale of 0 to 10 ( p < 0.001). Disabilities of the Arm, Shoulder and Hand scoring fell from 82 to 17 ( p < 0.001). Six patients had an unsatisfactory result. CONCLUSIONS: Some patients with complex regional pain syndrome may respond successfully to a carpal tunnel release operation. Recognition of this possibility is crucial, as the symptoms and signs might lead the clinician away from the proper diagnosis and treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparing partial and total tibial-nerve axotomy: long-term effects on prevalence and location of evoked pain behaviors.

Monophasic (one-time) nerve injuries heal without clinically significant residua in most cases, but rare individuals are left with neuropathic pain, even after seemingly minor lesions. The effects of lesion size on risk for chronic pain persistence are not well understood, particularly as concerns the complex regional pain syndrome, which is defined in part by pain "disproportionate" to the severity of the causative lesion, and extending outside the autonomous territory of a single nerve. To better clarify the expected prevalence of pain behaviors after nerve injury, we compared the effects in rats of different-sized axotomies on the prevalence and location of evoked pain behaviors. To highlight clinical relevance, we also describe a patient with iatrogenic tibial-nerve injury causing similar chronic neuralgia. Adult male Sprague-Dawley rats were anesthetized and had either 1/3, 2/3 or their entire left tibial nerves tightly ligated at two sites just below the sciatic trifurcation and the interposed nerve was cut. Unoperated rats provided controls. Sensory function in the tibial and sural-innervated territories of both plantar hindpaws was assessed for as long as 6 months postoperatively. Soon after surgery, evoked pain behavior developed in the ipsilesional sural-innervated site in a subset of axotomized rats and recovery was variable. The relationship between lesion size and prevalence and severity of hyperalgesia varied for different pain behaviors, with pinprick hyperalgesia clearly more likely after larger axotomies. In summary, partial tibial-nerve injury in rats models human disease and suggests that expectations of proportionality between lesion size and development of neuropathic pain may need revision.

Amputation With Osseointegration for Patients With Intractable Complex Regional Pain Syndrome: A Report of 3 Cases.

CASES: Three patients with knee-level complex regional pain syndrome type 1 (CRPS1), recalcitrant to conservative interventions, elected for transfemoral amputation and osseointegration. Two patients gained independent ambulation; the third remains on crutches after a disrupted sciatic nerve targeted reinnervation. One uses no pain medication, one is weaning off, and one requires a reduced regimen after revision nerve innervation. CONCLUSION: Osseointegration seems suitable to optimize rehabilitation after amputation for CRPS1.

Malignancy as a possible complication of complex regional pain syndrome: a case report.

A synovial sarcoma presented in the knee of a young woman 20 years after the onset of pain which was attributed to complex regional pain syndrome (CRPS). Was this a chance occurrence, or could there be any link between the two conditions? Did the pain itself and the persistent inflammatory and immunological response to pain contribute to the development of malignancy, or could the malignancy have been present subclinically for many years and have contributed to the ongoing pain syndrome? This case report looks into the diagnosis of synovial sarcoma and CRPS and the relationship between the neurogenic inflammation seen in CRPS and that seen in malignancies. The diagnosis of CRPS is a diagnosis of exclusion. Constant vigilance of patients with this unpleasant condition is necessary.

[The use of information processes indices for prediction of sympathectomy efficiency in complex regional pain syndrome].

Key significance of information processes for ensuring optimal sanogenesis was shown by wavelet-analysis of skin microvascular blood flow oscillations at 64 patients with complex regional pain syndrome after sympathectomy Early reorganization of information in trophotropic direction at the level of microvascular tissue systems, its predomination and conservation all along the microvascular networks facilitate optimal realization of adaptive reactions and, as a result, are conductive to maximum treatment efficiency. In these cases complete elimination of disease and achievement of excellent treatment results were possible. Maximum treatment efficiency could not be reached without the above-mentioned information changing. On the contrary predomination and conservation of ergotropic information at the early periods after surgery were unfavourable to prediction of clinical results of sympathectomy Tissue desympathisation is not required to formation of information trophotropic purposefulness in microvascular networks; it is enough to achieve certain threshold of sympathetic activity decrease. The results of this work may be useful for investigation of physiological mechanisms of information treatment technologies (homeopathy etc.).

Outcomes of amputation due to long-standing therapy-resistant complex regional pain syndrome type I.

OBJECTIVE: To assess long-term outcomes of amputation in patients with long-standing therapy-resistant complex regional pain syndrome type I (CRPS-I). DESIGN: Partly cross-sectional, partly longitudinal study. SUBJECTS: Patients who had amputation of a limb due to long-standing, therapy-resistant CRPS-I, at the University Medical Centre Groningen, The Netherlands, between May 2000 and September 2015 (n = 53) were invited to participate. METHODS: Participants were interviewed in a semi-structured way regarding mobility, pain, recurrence of CRPS-I, quality of life, and prosthesis use. Those who reported recurrence of CRPS-I underwent physical examination. RESULTS: A total of 47 patients (median age at time of amputation, 41.0 years; 40 women) participated. Longitudinal evaluation was possible in 17 participants. Thirty-seven participants (77%) reported an important improvement in mobility (95% confidence interval (95% CI) 63; 87%). An important reduction in pain was reported by 35 participants (73%; 95% CI 59; 83%). CRPS-I recurred in 4 of 47 participants (9%; 95% CI 3; 20%), once in the residual limb and 3 times in another limb. At the end of the study of the 35 participants fitted with a lower limb prosthesis, 24 were still using the prosthesis. Longitudinal evaluation showed no significant deteriorations. CONCLUSION: Amputation can be considered as a treatment for patients with long-standing, therapy-resistant CRPS-I. Amputation can increase mobility and reduce pain, thereby improving the quality of patients' lives. However, approximately one-quarter of participants reported deteriorations in intimacy and self-confidence after the amputation.

[From wheelchair dependency to the ability to walk: lumbar sympathectomy as a treatment for complex regional pain syndrome]. / Vom Rollstuhl zur Gehfähigkeit: Lumbale Sympathektomie zur Therapie langjähriger chronischer Schmerzen.

A 34-year-old woman developed walking disability with wheelchair dependency for more than 2 years due to chronic regional pain syndrome type II (CRPS II) in the feet. After excluding neurological and vascular disease, lumbar sympathectomy was performed on both sides. Surgical treatment was uneventful, and the patient's symptoms dramatically improved after 2 months. She is now able to walk some 500 m. This case illustrates the fact that surgical lumbar sympathectomy is an effective alternative or adjunct treatment even in fixed CRPS II.

The Role of Additional Spine Surgery in the Management of Failed Back Surgery Syndrome, Complex Regional Pain Syndrome, and Intractable Pain in the Setting of Previous or Concurrent Spinal Cord Stimulation: Indications and Outcomes.

OBJECTIVE: Spinal cord stimulation (SCS) is both relatively safe and reversible. Although SCS is generally regarded as a last resort, some of these patients will undergo additional spinal surgery after the device has been implanted or after its removal. We present a descriptive study of subsequent spinal surgery after SCS implantation. METHODS: A retrospective review of patients who had undergone percutaneous or paddle SCS lead placement at our institution from 2009 to 2016 was performed. Patients who had only undergone trials or who had not undergone spine surgery after SCS implantation were excluded. RESULTS: We identified 22 patients (5.7%) who had undergone spine surgery during the course of SCS treatment or after SCS removal, or both, of a total 383 patients who had undergone paddle and/or percutaneous SCS implantation. The most common additional spine interventions included lumbosacral decompression and fusion (n = 15; 42%). Of 36 surgeries, the most frequent indications for subsequent intervention were stenosis or restenosis (n = 16; 73%) and spine deformity (n = 6; 27%). The median EuroQol-5D index was 0.397 preoperatively and 0.678 postoperatively. CONCLUSIONS: To the best of our knowledge, the present study is the first to describe spine surgery in the setting of SCS implantation. Our results have indicated that spine surgery subsequent to, or concurrent with, SCS implantation appears to occur in few patients. Our study results suggest a modest improvement in quality of life outcomes. Therefore, clinicians should remember that patients might require further spine surgery despite the use of SCS implantation and, thus, might require reevaluation by the spine team.