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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Spinal cord stimulation in the treatment of complex regional pain syndrome type 1: Is trial truly required?

OBJECTIVE: Spinal cord stimulation has been proven highly effective in the treatment of Complex Regional Pain Syndrome (CRPS). The definitive implantation of a neurostimulator is usually preceded by a therapeutic test (trial), which has the purpose of identifying whether the patient would respond positively to neuromodulation or not. The present study aims to analyze the surgical results of spinal cord stimulation in type 1 CRPS patients who have not undergone trial. PATIENTS AND METHODS: From January 2011 to August 2017, 160 patients underwent implantation of spinal cord neurostimulator. Out of that total number of surgeries, 33 patients were unequivocally diagnosed with type 1 Complex Regional Pain Syndrome and selected for this study. The efficacy of the surgical procedure concerning pain improvement was analyzed through the application of the Pain Disability Index and the Visual Analog Pain Scale. RESULTS: The mean sample age was 48.08 years. The majority of the study subjects were female (66.66%). In respect to the Pain Disability Index, a 65% improvement in disability was observed subsequently to the neurostimulator implantation; in addition, the means of the scores for preoperative and postoperative periods were, respectively, 55 ±â€¯8.69 (p < 0.0001) and 18.90 ±â€¯11.58 (p < 0.0001). Regarding the Visual Analogue Scale, the mean pain in the preoperative period was 9.43 ±â€¯0.77 (p < 0.0001), while the mean in postoperative period was 2.86 ±â€¯2.08 (p < 0.0001). Thus, an average reduction of 70% of painful symptoms was observed after the surgical procedure. CONCLUSION: Implantation of a spinal cord neurostimulator presented significant improvement in pain and disability of patients with type 1 CRPS in all cases. These results were obtained following the criteria: 1) patients presenting unequivocal diagnosis of type 1 CRPS; 2) submitted to constant current spinal cord neurostimulator implant; 3) underwent intraoperative tests for precise location of the spinal cord electrode implantation. Therefore, it is possible to suggest that a trial may be unnecessary in that subgroup of patients. Further studies would be required to confirm these findings.

Sacral epiduroscopic laser decompression for complex regional pain syndrome after lumbar spinal surgery: A case report.

RATIONALE: CRPS after a lumbar surgery has symptoms that are similar to PSSS. However, standard criteria for distinguishing CRPS from PSSS do not exist. We present a case report of a 31-year-old female with CRPS symptoms after lumbar spinal surgery treated by performing SELD. PATIENT CONCERNS: This patient was referred to our pain clinic for left ankle pain. She received a lumbar discectomy for a herniated lumbar disc (L5/S1) but the pain was aggravated after surgery. DIAGNOSES: The characteristics of the pain were burning, tingling, and cold, and were accompanied by other symptoms such as swelling, color change and mail dystrophy. The patient was diagnosed with CRPS. INTERVENTIONS: Medications and interventional therapies were not effective in reducing pain. SELD was performed and severe adhesive inflammation was observed in the L4-S1 epidural space. We performed mechanical adhesiolysis and injected hyalurodinase and dexamethasone near the L5 and S1 root. One month after, a second SELD was performed as same manner. OUTCOMES: After second SELD, the patient's pain markedly decreased. On the second visit in the outpatient clinic, the patient was absent of pain without any other medications. LESSONS: CRPS like symptoms can appear after lumbar spinal surgery due to adhesion and inflammation in the epidural space. In such cases, SELD can be considered as diagnostic and therapeutic option.

Does Temperature Increase by Sympathetic Neurolysis Improve Pain in Complex Regional Pain Syndrome? A Retrospective Cohort Study.

BACKGROUND: Lumbar sympathetic neurolysis (LSN) is a treatment option for complex regional pain syndrome (CRPS). We examined whether LSN-related temperature changes are associated with clinical outcome and investigated relationships between the outcome of LSN and clinical variables in patients with CRPS-I. METHODS: We included 95 patients with CRPS-I affecting a single lower extremity, by the Budapest criteria, and who underwent LSN after successful lumbar sympathetic blocks, in this retrospective study. Fluoroscopy-guided LSN was conducted with 1.5 mL of 99% alcohol at L2 and L3 vertebral levels. Positive outcome was defined as a reduction of ≥50% on a numeric rating scale pain score at 6 months after LSN. The relationship between successful outcome and clinical variables was analyzed. RESULTS: Positive LSN outcome occurred in 49.5% of patients, and it was suggested that Sympathetically maintained pain may accompany CRPS-I in 28% of patients. The overall temperature in the affected limb was increased after LSN, without contralateral limb temperature changes, but did not differ significantly between the positive and negative outcome groups (P = 0.590). Temperature after LSN in warm-type CRPS was reduced in the affected limb, without contralateral limb temperature changes. The absolute temperature change was significantly greater in cold-type than in warm-type CRPS (P = 0.026). In multivariate analysis, a short duration of pain and concurrent cold intolerance were significant factors predicting a positive outcome after LSN. CONCLUSIONS: LSN may be effective in some patients with CRPS, irrespective of temperature changes and temperature asymmetry pattern. A short duration of pain and concurrent cold intolerance significantly predict successful LSN.

A Prospective Analysis of Neuromonitoring for Confirmation of Lead Placement in Dorsal Root Ganglion Stimulation.

BACKGROUND: Dorsal root ganglion stimulation is a neuromodulation therapy used for chronic neuropathic pain. Typically, patients are awakened intraoperatively to confirm adequate placement. OBJECTIVE: To determine whether neuromonitoring can confirm placement in an asleep patient. METHODS: This is a prospective analysis of 12 leads placed in 6 patients. Lead confirmation was confirmed by awake intraoperative testing, as well as asleep testing utilizing neuromonitoring. Patients were used as their own control. Sensory and motor thresholds for each patient with awake and asleep neuromonitoring testing were recorded. Intraoperative impedance and postoperative programming were also recorded. RESULTS: In each patient, paresthesias were generated prior to motor contractions in the awake patient. For each patient, somatosensory evoked potential responses were present after lowering below the dropout threshold of electromyogram responses with neuromonitoring. There were varying degrees of separation in the thresholds that did not appear to be consistent across level or diagnosis. Smaller degrees of separation between thresholds during awake testing also held true in the asleep patient. This was further confirmed with postoperative programming. Impedances did not alter the separation in thresholds or amount of stimulation required for responses. One patient was combative during awake testing, and therefore motor thresholds were not obtained. This same patient was determined to have a ventral placement, confirmed with awake and asleep neuromonitoring testing. CONCLUSION: This series demonstrates that the proposed neuromonitoring protocol can be used in an asleep patient to assure proper positioning of the dorsal root ganglion electrode in the dorsal foramen by generating somatosensory evoked potential responses in the absence of electromyogram responses.

Abductor Digiti Minimi Flap for Vascularized Coverage in the Surgical Management of Complex Regional Pain Syndrome Following Carpal Tunnel Release.

BACKGROUND: The development of Complex Regional Pain Syndrome (CRPS) represents a potentially devastating complication following carpal tunnel release. In the presence of a suspected incomplete release of the transverse carpal ligament or direct injury to the median nerve, neurolysis as well as nerve coverage to prevent recurrent scar has been shown to be effective. METHODS: Retrospective chart review and telephone interview was conducted for patients who underwent abductor digiti minimi flap coverage and neurolysis of the median nerve for CRPS following carpal tunnel release. RESULTS: Fourteen wrists in 12 patients were reviewed. Mean patient age was 64 years (range, 49-83 years), and the mean follow-up was 44 months. Carpal tunnel outcome instrument scores were 47.4 ± 6.8 preoperatively and 27.1 ± 10.6 at follow-up ( P < .001). Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores at follow-up were 29.4 ± 26. No significant postoperative complications were identified. CONCLUSIONS: The abductor digiti minimi flap is a reliable option with minimal donor site morbidity. It provides predictable coverage when treating CRPS following carpal tunnel syndrome.

[Prophylactic plexus catheter treatment in operations following complex regional pain syndrome (CRPS)]. / Prophylaktische Plexuskatheterbehandlung bei operativen Eingriffen nach Komplexem Regionalen Schmerzsyndrom (CRPS).

Background This paper investigates and discusses the effect of perioperative plexus catheter treatment in former CRPS patients. Patients and Methods A retrospective matched-pair analysis was conducted on 10 CRPS patients with comparable injuries, who underwent surgery in the disease-free interval. In 10 cases, the procedure was performed with perioperative plexus catheter treatment (intervention group), whereas 10 patients did not receive perioperative plexus catheter treatment (control group). Results In the intervention group, after a follow-up time of 105 (20-184) days after the last surgical procedure, pain intensity on the visual analogue scale (VAS; 0 to 10) was 6.4 (4-8), fingertip-to-palm distance averaged 3.2 (0-7.6) cm, active range of wrist motion was 47.5 (0-95), and grip strength was 9.2 (2.1-16.6) kg. In the control group, after a follow-up time of 129 (19-410) days since the last surgical procedure, pain intensity on the visual analogue scale was 6 (3-10), fingertip-to-palm distance averaged 2.7 (0-4.5) cm, active range of wrist-motion was 64 (0-125), and grip strength was 12.4 (0.8-23.8) kg. There was no significant difference between the groups. There was no recurrence of CRPS disease in either group after surgery. Conclusion There is no evidence so far for perioperative plexus catheter treatment to prevent recurrence in former CRPS patients.

Complications of volar locking plating of distal radius fractures in 576 patients with 3.2 years follow-up.

BACKGROUND: Volar plating of unstable distal radius fractures (DRF) has become the favoured treatment. The complication rates vary from 3 to 36%. The purpose of the study was to estimate the complication rate of volar plating of DRF and its association with AO/OTA fracture type, surgeon experience and type of volar plate. METHODS: Retrospectively, all patients treated with volar plating of a DRF between February 2009 and June 2013 at Aarhus University Hospital, Denmark were included. AO/OTA fracture type, surgeon experience (1st year, 2nd-5th year resident or consultant), type of plate (VariAx®, Acu-Loc®) and complications were extracted from the electronic medical records. Complications were categorized as carpal tunnel syndrome, other sensibility issues, tendon complications including irritation and rupture, deep infections, complex regional pain syndrome and unidentified DRUJ or scapholunar problems. Reoperations including hardware removal were also charted. RESULTS: 576 patients with a median age of 63 years (min: 15; max: 87) were included. 78% were female and the mean observation time was 3.2 years (min: 2.0; max: 5.4). 78% (n=451) of the patients were treated with VariAx® and 22% (n=125) with Acu-Loc®. The overall complication rate was 14.6% (95% CI 11.8-17.7) including carpal tunnel syndrome or change in sensibility in 5.2% and tendon complications in 4.7%. Five flexor tendon ruptures and 12 extensor tendon ruptures were observed. The reoperation rate was 10.4% including 41 cases of hardware removal. A statistically significant association between AO/OTA fracture type C and complications was found. No statistically significant association between complication rate and surgeon experience and type of plate was observed. CONCLUSION: The majority of DRF patients treated with a volar plate suffer no complications. However, the overall complication rate of 14.6% is substantial. Intra-articular fractures, e.g. AO/OTA-type 23C1-3, had significantly higher complication rates. Neither surgeon experience, nor type of volar plate was able to predict complications.

Complex regional pain syndrome in burn pathological scarring: A case report and review of the literature.

Chronic pain in burn pathological scarring is not an uncommon occurrence. The mechanisms of pain are not clearly understood and hence the management approach is often a daunting task. However, meticulous physical examination of these patients may classify them as complex regional pain syndrome, type I. We present a patient with classic signs and symptoms of complex regional pain syndrome associated with burn pathological scarring of her left forearm that had a favourable response to a thoracoscopic sympathectomy. The possible pathological mechanisms of burn pathological scarring, mechanisms of pain, and complex regional pain syndrome are reviewed.