[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.

[Complex regional pain syndrome in a patient with acute drug poisoning: a case report].

We report a case with transition to complex regional pain syndrome (CRPS) caused by nerve injury associated with crush syndrome. The diagnosis was delayed because of coma due to acute drug poisoning. A 44-year-old man had attempted suicide by taking massive amounts of psychotropic drugs 2 days earlier and was transported to our hospital by ambulance. His arms had been compressed due to the prolonged (2 days) consciousness disturbance, and he experienced non-traumatic crush syndrome and rhabdomyolysis. Acute renal failure was prevented with massive infusion and hemofiltration. However, he experienced muscle and nerve injury at the compressed area, which presumably led to CRPS. In cases of suspected crush syndrome associated with acute drug poisoning, it is also important to recognize the possibility of developing CRPS.

Type II complex regional pain syndrome of the hand resulting from repeated arterial punctures during transradial coronary intervention.

Coronary catheterization using a transradial approach has become a common procedure, as the risks of local complications are low and this procedure affords relatively expeditious postprocedural patient mobilization. Access site complications--such as radial artery spasm, hematoma, and compartment syndrome--have been reported in the literature; however, cases of complex regional pain syndrome (CRPS) of the hand related to the procedure are extremely rare. We describe a case of type II CRPS affecting the hand after a transradial coronary intervention that was complicated by repeated periprocedural arterial punctures. In this case, a 55-year-old woman underwent a percutaneous coronary intervention for the treatment of unstable angina. After successful completion of the procedure, the patient complained of severe pain along the median and radial nerve distributions and resulting disability of the right hand. Although subsequent duplex sonography showed no abnormalities, a nerve conduction study uncovered injury to multiple nerves on the right. A diagnosis of type II CRPS was then made and the patient was treated with a nerve block as well as multiple medical modalities. This case demonstrates a very unusual complication resulting from the transradial approach to percutaneous coronary intervention.

[Pronounced symptom deterioration in complex regional pain syndrome type II after isolated application of a highly concentrated capsaicin patch. A case report]. / Ausgeprägte Symptomverschlechterung bei CRPS Typ II nach einmaliger Applikation eines hochprozentigen Capsaicinpflasters. Ein Fallbericht.

Topical 8 % capsaicin is an established therapeutic option for the treatment of peripheral neuropathic pain. In accordance with the internationally accepted definition, complex regional pain syndrome (CRPS) type II is a form of neuropathic pain so that capsaicin plasters represent a treatment option. However, for the treatment of CRPS it is recommended that painful stimuli should be avoided but capsaicin induces a strong nociceptive stimulation and so its use is at present controversial. We report on the course of such an application in a patient who developed CRPS type II with intractable neuropathic pain after hallux surgery. As a result of a single treatment with capsaicin a pronounced recurrence developed with central nervous symptoms.

[Complex regional pain syndrome--pathophysiology, clinical presentation and treatment]. / Kompleksni regionalni bolni sindrom--patofiziologija, klinicka slika i lijecenje.

In 1994, a consensus group of experts gathered by the International Association for the Study of Pain (IASP) agreed on new diagnostic criteria for the reflex sympathetic dystrophy (RSD) and causalgia, and renamed them complex regional pain syndrome (CRPS) types I and II, respectively. CRPS is a complex pathophysiological entity characterised by pain, trophic and vasomotoric changes, limited function of affected body part and relatively fast development of osteoporosis of affected region. We described possible pathophysiological mechanisms which caused the pain, clinical presentation of the disease and treatment which includes all available pharmacological modalities as well as interventional procedures.

Predilection to deafferentation pain syndrome after radiosurgery in cluster headache.

Cluster-tic syndrome is a rare, disabling disorder. We report the first case of cluster-tic syndrome with a successful response to stereotactic radiosurgery. After failing optimal medical treatment, a 58-year-old woman suffering from cluster-tic syndrome was treated with gamma knife radiosurgery. The trigeminal nerve and sphenopalatine ganglion were targeted with a maximum dose of 85 and 90 Gy respectively. The patient experienced a complete resolution of the initial pain, but developed, as previously described after radiosurgical treatment for cluster headache, a trigeminal nerve dysfunction. This suggests that trigeminal nerve sensitivity to radiosurgery can be extremely different depending on the underlying pathological condition, and that there is an abnormal sensitivity of the trigeminal nerve in cluster headache patients. We do not recommend trigeminal nerve radiosurgery for treatment of cluster headache.

Complex regional pain syndrome type II associated with lumbosacral plexopathy: a case report.

INTRODUCTION: Complex regional pain syndrome (CRPS) is a well-known clinical entity, first described in the 1800s, consisting of pain, hyperalgesia, edema, and sudomotor changes either without (Type I) or with (Type II) a definable nerve injury. CRPS Type II is most commonly caused by high velocity missile injuries, mononeuropathies, and partial nerve transections. CASE REPORT: In this case, a 25-year-old soldier who sustained a blast injury causing multiple spinal compression fractures, extremity fractures, and pelvic and sacral fractures was transferred to a U.S. Army medical center for surgical management and rehabilitation. He complained of weakness, sensory changes, and pain in his left lower extremity. The patient also demonstrated swelling and hyperesthesia of the left foot and ankle. Undiagnosed soft tissue injury, fracture, and deep venous thrombosis were ruled out by imaging studies. The patient had an electromyogram/nerve conduction study (EMG/NCS) that showed widespread left sided lumbosacral plexopathy as well as possible cauda equina injury. Triple phase bone scan demonstrated findings consistent with CRPS of the left foot and ankle. He was started on a tricyclic antidepressant and an anticonvulsant. Physical and occupational therapy were quickly engaged to incorporate range of motion exercises, mirror therapy, and physical modalities. The patient continued conservative management and rehabilitation and eventually was discharged with significantly improved function and decreased pain. CONCLUSION: Although many causes of CRPS Type II have been described, this is only the second reported case of CRPS Type II secondary to lumbosacral plexopathy in the literature.

Practical management of complex regional pain syndrome.

Complex regional pain syndrome (CRPS) describes a diversity of painful conditions following trauma, coupled with abnormal regulation of blood flow and sweating, trophic changes, and edema of skin. The excruciating pain and diverse autonomic dysfunctions in CRPS are disproportionate to any inciting and recovering event. CRPS type I is formerly identified as "reflex sympathetic dystrophy." CRPS type II is the new term for "causalgia" that always coexists with documented nerve injury. The present diagnostic criteria of CRPS I and II depend solely on meticulous history and physical examination without any confirmation by specific test procedure (or gold standard). There are only few clinical studies with large-scale randomized trials of pharmacologic agents on the treatment of CRPS. Bisphosphonates have been studied in multiple controlled trials, based on theoretical benefit of bone resorption, to offer pain relief and functional improvement in patients with CRPS. Many current rationales in treatment of CRPS (such as topical agents, antiepileptic drugs, tricyclic antidepressants, and opioids) are mainly dependent on efficacy originate in other common conditions of neuropathic pain. There are additional innovative therapies on CRPS that are still in infancy. No wonder all the treatment of individual CRPS case nowadays is pragmatic at best. Although the interventional therapies in CRPS (such as nerve blockade, sympathetic block, spinal cord and peripheral nerve stimulation, implantable spinal medication pumps, and chemical and surgical sympathectomy) may offer more rapid response, yet it is still controversial with unpredictable outcome. Nevertheless, we need to start pain management immediately with the ambition to restore function in every probable case of CRPS. An interdisciplinary setting with comprehensive approach (pharmacologic, interventional, and psychological in conjunction with rehabilitation pathway) has been proposed as protocol in the practical management of CRPS. It is crucial to have a high sensitivity value combined with a fair specificity in revising diagnostic criteria of CRPS. The validation and consensus for new rationalized diagnostic criteria of CRPS could facilitate further research to enhance clinical outcome including quality of life. These endeavors to minimize suffering from CRPS would certainly be appreciated by many patients and their loved ones.

Complex regional pain syndrome type II arising from a gunshot wound (GSW) associated with infective endocarditis and aortic valve replacement.

A 34-year-old man with a history of gunshot wound (GSW) to the right upper chest developed secondary aortic valve endocarditis (AVE) and was treated with an artificial valve placement (AVP). Three months after, he presented to an outpatient pain management clinic right arm pain and was diagnosed with complex regional pain syndrome type II (CRPS II). The patient underwent a diagnostic sympathetic ganglion block, before undergoing endoscopic thoracic sympathectomy surgery. Successful outcomes revealed decreased pain, opioid utilisation and improved tolerance to therapy and activities of daily living. To our knowledge, this is the first case reporting CRPS II arising from a GSW complicated by AVE followed by AVP, which emphasises how unforeseen syndromes can arise from the management of seemingly unrelated pathology. This case demonstrates the importance of timely and proper diagnosis of uncharacterised residual pain status post-trauma and differential diagnosis and management of chronic pain syndromes.

[Pain perioperative in surgery of the hand]. / La douleur périopératoire en chirurgie de la main.

Pain has to be treated during the perioperative period. The recent improvement in pain treatment results from a better understanding of pain mechanisms, strict evaluations and appropriate protocols for pain management. Mainly nociceptive, postoperative pain looks more and more like neuropathic pain when it persists or increases. Therefore, analgesics are no more effective and antihyperalgesiant drugs must use. Preventive treatments have to be considered first as the best pain treatment. Basically, perioperative pain has to be understood as a standard quality management by the medical and surgical team.

Multicenter study on the asymmetry of skin temperature in complex regional pain syndrome: An examination of temperature distribution and symptom duration.

According to the International Association for the Study of Pain (IASP) and American Medical Association (AMA), the diagnostic criteria for complex regional pain syndrome (CRPS) require the presence of skin temperature asymmetry. In CRPS, it is generally accepted that the temperature of skin of affected limbs changes from warm to cold; however, in our clinical practice, we have experienced many cases with different thermographic characteristics. Therefore, we conducted a retrospective multicenter study that examined the distribution of skin temperature in patients with CRPS and skin temperature asymmetry versus symptom duration.Patients diagnosed with type 1 or 2 CRPS were recruited. After confirming CRPS according to the IASP diagnostic criteria, infrared thermographic images were evaluated for skin temperature differences (ΔT) between the affected and unaffected limbs.A total of 296 patients with CRPS were included in this study. The median duration of symptoms was 6 months and the mean ±â€Šstandard deviation of ΔT was -0.72 ±â€Š1.65°C. A skin temperature difference between bilateral limbs (|ΔT|) of 1°C or less was seen in 131 patients (44.3%); thus, these 131 patients did not meet the IASP criteria for CRPS. Further, cool skin temperature was not observed in 88 patients (29.7%), meaning that these patients did not meet the AMA criteria for CRPS. There was no correlation between the symptom duration and ΔT (Spearman's rho = -0.075, P = 0.196) and there was no significant difference in the average ΔT among the 4 symptom duration groups (0-3 months, 4-6 months, 7-12 months, >12 months, P = 0.08).In conclusion, a considerable proportion of the patients that participated in this study did not meet the thermal criteria set forth by the IASP and AMA. Further, there was no correlation between symptom duration and skin temperature difference.

Soleus H-reflex tests in causalgia-dystonia compared with dystonia and mimicked dystonic posture.

Dystonia in the causalgia-dystonia syndrome is characterized by a fixed dystonic posture. To identify involvement of central pathophysiologic mechanisms, we analyzed soleus H-reflex tests in five patients with causalgia-dystonia. Soleus H-reflex test results in these patients differed from those in healthy controls but were similar to those in purely dystonic patients and healthy controls mimicking dystonic posture. The results suggest involvement of supraspinal mechanisms in the abnormal posture of causalgia-dystonia.

Causalgia: redefinition as a clinical pain syndrome.

In this report, the following criteria were used for the diagnosis of causalgia: (a) the presence of continuous, burning pain distal to a site of injury; (b) hyperalgesia and allodynia in the painful area; and (c) a traumatic event occurring proximal in the painful area and within weeks prior to the onset of pain. The McGill pain questionnaire was used to test the selected pain population for homogeneity. The scores were similar among the patients and different from the scores in other pain syndromes. It is concluded that the above criteria are sufficient to make the diagnosis of causalgia. In addition, it appears that a central nervous system abnormality best accounts for the clinical features of causalgia.

An unusual case of causalgia. Relevance to recent hypothesis on mechanism of causalgia.

Intravenous regional sympathetic block with guanethidine caused only limited improvement in a patient with longstanding causalgia. Lumbar sympathetic block with phenol also had little direct effect on the pain but completely abolished associated allodynia and vasomotor signs. Following sympathectomy the response to subsequent guanethidine blocks was enhanced. This improvement persisted even after 8 months when there was some return of the previous allodynia and vasomotor signs (to involve a smaller area than previously). The case would appear to have implications for a recently proposed hypothesis concerning the mechanism of pain in causalgia.

Reflex sympathetic dystrophy: changing concepts and taxonomy.

We present a revised taxonomic system for disorders previously called reflex sympathetic dystrophy (RSD) and causalgia. The system resulted from a special consensus conference that was convened on this topic and is based upon the patient's history, presenting symptoms, and findings at the time of diagnosis. The disorders are grouped under the umbrella term CRPS: complex regional pain syndrome. This overall term, CRPS, requires the presence of regional pain and sensory changes following a noxious event. Further, the pain is associated with findings such as abnormal skin color, temperature change, abnormal sudomotor activity, or edema. The combination of these findings exceeds their expected magnitude in response to known physical damage during and following the inciting event. Two types of CRPS have been recognized: type I, corresponds to RSD and occurs without a definable nerve lesion, and type II, formerly called causalgia refers to cases where a definable nerve lesion is present. The term sympathetically maintained pain (SMP) was also evaluated and considered to be a variable phenomenon associated with a variety of disorders, including CRPS types I and II. These revised categories have been included in the 2nd edition of the IASP Classification of Chronic Pain Syndromes.

A hypothesis on the physiological basis for causalgia and related pains.

A hypothesis is presented concerning the neuronal mechanisms which subserve the sympathetically maintained pains such as causalgia and reflex sympathetic dystrophy. The hypothesis rests on two assumptions: that a high rate of firing in spinal wide-dynamic-range (WDR) or multireceptive neurons results in painful sensations; and that nociceptor responses associated with trauma can produce long-term sensitization of WDR neurons. The hypothesis states that chronic sympathetically maintained pains are mediated by activity in low-threshold, myelinated mechanoreceptors, that this afferent activity results from sympathetic efferent actions upon the receptors or upon afferent fibers ending in a neuroma and that these afferent fibers evoke sufficient activity in sensitized spinal WDR neurons to produce a painful sensation. This hypothesis is based on known characteristics of these neuronal populations studied in experimental animals and on the observed sensory disturbances reported in patients successfully treated with sympathetic blocks. This hypothesis does not require nerve injury or dystrophic tissue. It explains both the continuous pain and the allodynia that are common to these syndromes and their abolition by sympathetic block. Specific changes are proposed in the diagnosis and treatment of post-traumatic pains.

Diagnosis and treatment of genitofemoral and ilioinguinal entrapment neuralgia.

During the past 7 years 30 patients were diagnosed as having either ilioinguinal or genitofemoral entrapment neuralgia. A multidisciplinary approach (surgeon, neurologist, and anesthesiologist), as well as local blocks of the ilioinguinal nerve and/or paravertebral blocks of L-1 and L-2 (genitofemoral nerve), were essential to determine accurately which nerve was specifically involved. Fifteen of the 17 patients (88%) diagnosed as having ilioinguinal neuralgia after previous inguinal herniorrhaphy are pain free after resection of the entrapped portion of the nerve. Thirteen patients were diagnosed as having genitofemoral neuralgia after previous inguinal herniorrhaphy, blunt abdominal trauma, or other surgery. Neurectomy of the genitofemoral nerve proximal to the entrapment controlled the persistent pain in 10 of 13 (77%) of these patients. Ilioinguinal or genitofemoral nerve entrapment neuralgias are rare complications of surgery in the inguinal region. When accurately diagnosed, neurectomy of the specific nerve is highly successful in relieving severe pain and paresthesia without significant morbidity.