Peripheral nerve pathology in patients with severely affected complex regional pain syndrome type I.

Complex regional pain syndrome type I (CRPS-I) is a chronic pain syndrome with no clinical evidence of nerve injury; however, recently, changes in muscle tissue have been found in case of CRPS-I. Our aim was to search for histological changes in peripheral nerves of amputated limbs from patients with therapy-resistant CRPS-I that could justify muscle tissue changes. Fifteen patients with CRPS-I (duration >1 year) were included. Multiple nerve samples were taken from upper (n=4) and lower (n=11) amputated limbs. Histological changes (signs of nerve fiber loss and regeneration), fiber diameters, fiber diameter distribution, and fiber density were studied through microscopy and morphometry. Samples from three healthy sural nerves were used as control data as well as data from the literature. All patients (93% of tissue samples) showed histological signs of nerve fiber loss and fiber regeneration, varying in severity. No specific preference was found for any nerve or the location within the nerve. Sural nerves showed loss of especially larger nerve fibers (>12 µm) in comparison with control data. Sympathectomy did not influence this finding. The morphometric results of the other nerves are more difficult to interpret because of the absence of good-quality control data from the literature. However, the percentages of nerve fibers greater than 12 µm seem to lie within the normal range. Besides the known pathology of thin nerve fibers innervating the skin or blood vessels in CRPS-I, this study also shows pathological changes more proximal in the nerves, especially in the sural nerve.

Informed Decision-Making Regarding Amputation for Complex Regional Pain Syndrome Type I.

BACKGROUND: Literature on complex regional pain syndrome type I (CRPS-I) discussing the decision to amputate or not, the level of amputation, or the timing of the amputation is scarce. We evaluated informed decision-making regarding amputation for CRPS-I. METHODS: We describe our findings in a retrospective study of the decision-making process of thirty-six patients who underwent amputation for CRPS-I at our university medical center from 2000 to 2012. Additionally, we present the incidents preceding the CRPS-I, the reasons for and the levels of the amputation, and the outcomes after the amputations. RESULTS: Team members and the patient decided together whether or not to amputate and the level of amputation. Issues such as level of pain or allodynia, infection, desired length of the residual limb, joint range of motion, strength of all extremities, ability to use walking aids, and psychological "green, yellow, and red flags" were weighed in this process. There were no complications during the amputation surgery, a 22% rate of complications (infection in all but one patient) immediately postoperatively (reamputation not required), a 72% rate of phantom pain immediately after or within the first three months after the amputation, and a 77% rate of phantom pain more than one year after the amputation. CONCLUSIONS: Informed decision-making regarding amputation for CRPS-I remains a complex process for which little evidence is available to support patient choices; patient-specific outcomes are not predictable. However, amputation should not be ignored as a treatment option for long-standing therapy-resistant CRPS-I. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Resilience in patients with amputation because of Complex Regional Pain Syndrome type I.

PURPOSE: Although controversial, an amputation for longstanding and therapy-resistant Complex Regional Pain Syndrome Type I (CRPS-I) may improve quality of life and pain intensity. Resilience, the way people deal with adversity in a positive way may be related to these positive outcomes. This study focused on the relationship between resilience and post-amputation outcomes, i.e. quality of life, pain and recurrence of CRPS-I and psychological distress. METHOD: Twenty-six patients with an amputation related to CRPS-I filled in the Connor-Davidson Resilience Scale (CD-RISC), World Health Organisation -- Quality of life Assessment (WHOQOL-Bref) and the Symptom Checklist-90 Revised (SCL-90-R). An interview was conducted and a physical examination performed. Results were compared with reference groups from literature and a control group from the outpatient rehabilitation clinic at our medical center. RESULTS: Resilience correlated significantly with all domains of the WHOQOL-Bref (ρ ranged from 0.41 to 0.72) and negatively with all domains of the SCL-90-R (ρ ranged from -0.39 to -0.68). Patients with an amputation because of CRPS-I have higher scores on resilience and quality of life than the control group. Resilience was lower in patients who reported CRPS-I symptoms compared to those who did not. CONCLUSIONS: The results confirmed our hypothesis that patients with an amputation because of CRPS-I who have a higher resilience also have a higher quality of life and experience lower psychological distress. The prognostic value of resilience in this patient group requires further research. Implications for Rehabilitation Until characteristics of patients with positive quality of life outcome have been further unraveled, amputation for CRPS-I should only be performed in expertise centers. Resilience, the process of adapting well in the face of adversity, should be further explored in Rehabilitation Medicine research in general. Measurement of resilience should be a standard procedure when patients with CRPS-I request an amputation. Improving resilience of patients in in- and outpatient rehabilitation clinics might be an additional treatment in rehabilitation care.

Amputation for long-standing, therapy-resistant type-I complex regional pain syndrome.

BACKGROUND: Some patients with long-standing, therapy-resistant type-I complex regional pain syndrome consider an amputation. There is a lack of evidence regarding the risk of recurrence of the pain syndrome and patient outcomes after amputation. The goal of the present study was to evaluate the impact of an amputation on pain, participation in daily life activities, and quality of life as well as the use of a prosthesis and the risk of recurrence of the pain syndrome in patients with long-standing, therapy-resistant type-I complex regional pain syndrome. METHODS: From May 2000 to October 2008, twenty-two patients underwent an amputation of a nonfunctional limb at our institution because of long-standing, therapy-resistant type-I complex regional pain syndrome. Twenty-one of these patients were included in our study. The median age was forty-six years (interquartile range [IQR], thirty-seven to fifty-one years), the median duration of the complex regional pain syndrome was six years (IQR, two to ten years), and the median interval between the amputation and the study was five years (IQR, three to seven years). A semistructured interview was conducted, physical examination of the residual limb was performed, and the patients completed two questionnaires. RESULTS: Twenty patients (95%) reported an improvement in their lives. Nineteen patients (90%) reported a reduction in pain, seventeen patients (81%) reported an improvement in mobility, and fourteen (67%) reported an improvement in sleep. Eighteen of the twenty-one patients stated that they would choose to undergo an amputation again under the same circumstances. Ten of the fifteen patients with a lower-limb amputation and one of the six with an upper-limb amputation regularly used a prosthesis. The type-I complex regional pain syndrome recurred in the residual limb of three patients (14%) and symptoms recurred in another limb in two patients (10%). CONCLUSIONS: Amputation may positively contribute to the lives of patients with long-standing, therapy-resistant type-I complex regional pain syndrome. Patients were likely to use a prosthesis after a lower-limb amputation. The risk of recurrence of the type-I complex regional pain syndrome was 24%.

Therapy-resistant complex regional pain syndrome type I: to amputate or not?

BACKGROUND: Amputation for the treatment of long-standing, therapy-resistant complex regional pain syndrome type I (CRPS-I) is controversial. An evidence-based decision regarding whether or not to amputate is not possible on the basis of current guidelines. The aim of the current study was to systematically review the literature and summarize the beneficial and adverse effects of an amputation for the treatment of long-standing, therapy-resistant CRPS-I. METHODS: A literature search, using MeSH terms and free text words, was performed with use of PubMed and EMBASE. Original studies published prior to January 2010 describing CRPS-I as a reason for amputation were included. The reference lists of the identified studies were also searched for additional relevant studies. Studies were assessed with regard to the criteria used to diagnose CRPS-I, level of amputation, amputation technique, rationale for the level of amputation, reason for amputation, recurrence of CRPS-I after the amputation, phantom pain, prosthesis fitting and use, and patient functional ability, satisfaction, and quality of life. RESULTS: One hundred and sixty articles were identified, and twenty-six studies with Level-IV evidence (involving 111 amputations in 107 patients) were included. Four studies applied CRPS-I diagnostic criteria proposed by the International Association for the Study of Pain, Bruehl et al., or Veldman et al. Thirteen studies described symptoms without noting whether the patient met diagnostic criteria for CRPS-I, and nine studies stated the diagnosis only. The primary reasons cited for amputation were pain (80%) and a dysfunctional limb (72%). Recurrence of CRPS-I in the stump occurred in thirty-one of sixty-five patients, and phantom pain occurred in fifteen patients. Thirty-six of forty-nine patients were fitted with a prosthesis, and fourteen of these patients used the prosthesis. Thirteen of forty-three patients had paid employment after the amputation. Patient satisfaction was reported in eight studies, but the nature of the satisfaction was often not clearly indicated. Changes in patient quality of life were reported in three studies (fifteen patients); quality of life improved in five patients and the joy of life improved in another six patients. CONCLUSIONS: The previously published studies regarding CRPS-I as a reason for amputation all represent Level-IV evidence, and they do not clearly delineate the beneficial and adverse affects of an amputation performed for this diagnosis. Whether to amputate or not in order to treat long-standing, therapy-resistant CRPS-I remains an unanswered question.

[Outcomes after hand injuries]. / Uitkomsten van ernstige handletsels.

A 25-year-old male and a 41-year-old male presented at the Emergency Department with a hand injury. Although both patients received immediate surgical care and specialized rehabilitation care, outcomes were better in the first patient, who had sustained the more severe hand injury. Outcomes were influenced not only by injury severity, but also by personal and external factors. Personal factors, such as age, motivation and compliance, were more favourable in the first patient. External factors, such as complications, delayed care, language problems and social problems, mainly affected the second patient, who was less severely injured. As a result, outcomes on all functional levels of the WHO's International Classification of Functioning, Disability and Health (body functions and structure, and activity and participation) were better in the patient with the more severe injury. Specialized hand care is required in hand injuries, but professionals should also be aware that personal and external factors have a substantial influence on outcomes after hand injuries.

[Diagnostic image. A boy with a wrist deformity]. / Een jongen met een polsafwijking.

A 16-year-old boy presented with Madelung's wrist deformity.