Complex regional pain syndrome of the lower extremity: a retrospective study of 33 patients

Successful therapy of complex regional pain syndrome after hip arthroscopy for femoroacetabular impingement syndrome: a case report

BACKGROUND

Complex regional pain syndrome is a neuropathic pain disorder associated with ongoing pain that persists beyond the usual expected tissue healing time and that is disproportionate to the degree of tissue injury present. Complex regional pain syndrome after hip arthroscopy has not been reported before. Hip arthroscopy is a fast-growing domain that could lead to an increasing number of complex regional pain syndrome cases, probably owing to the high traction forces that are necessary.

CASE PRESENTATION

We report the case of a 30-year-old German female semiprofessional tennis player who presented with complex regional pain syndrome type I in the lower leg 3 weeks after hip arthroscopy for femoroacetabular impingement syndrome with suture anchor labral repair and femoroplasty. After 2 months of immediate multimodal conservative therapy including administration of gabapentin, prompt full weight-bearing, and intensified physiotherapy, complete recovery was achieved.

CONCLUSION

Complex regional pain syndrome does occur after elective hip arthroscopy. Disproportionate postoperative pain or other symptoms raising suspicion of complex regional pain syndrome should be promptly evaluated and treated through a multimodal approach. Postless hip arthroscopy may be advantageous.

Vitamin C prevention of complex regional pain syndrome after foot and ankle surgery: a prospective randomized study of three hundred and twenty nine patients

PURPOSE

Complex regional pain syndrome (CRPS) after foot and ankle surgery has a significant impact on the ability to walk. As the symptomatic treatment of this disaster complication is poor and has low efficacy, a preventive treatment would be beneficial. Vitamin C has been reported to be efficient in preventing CRPS in elective scheduled surgery. Few authors explored this efficiency in foot and ankle surgery. We, therefore, evaluated the efficacy of vitamin C in preventing this complication after foot and ankle surgeries for both trauma and elective surgery.

MATERIAL AND METHODS

Between January 2018 and December 2019, 329 patients were included in the study. We conducted a prospective randomized study on the efficiency of vitamin C (one group with and one without vitamin C) to prevent CRPS risk in patients operated in our institution on foot or ankle surgery. The incidence of CRPS after foot and ankle surgery was evaluated in both groups; the diagnostic of CRPS was made using the Budapest criteria associated with three-phase bone scintigraphy.

RESULTS

Among the 329 patients included in the study (232 women and 97 men), 121 patients were included in the vitamin C group and 208 in the control group (without vitamin C). Vitamin C was statistically linked with a decreased risk of CRPS (OR 0.19; CI 95% from 0.05 to 0.8; p = 0.021). Alcoholism and cast immobilization were increased risks factors of CRPS (respectively p = 0.001 and p = 0.034).

CONCLUSION

Taking 1 g per day of vitamin C during 40 days after a foot or ankle surgery reduces the risk of CRPS.

Type 1 Complex Regional Pain Syndrome After Subacromial Shoulder Surgery: Incidence and Risk Factor Analysis

INTRODUCTION

Complex Regional Pain Syndrome type 1 (CRPS1) is a potential complication, affecting the prognosis of functional joint recovery. Its incidence ranges from 2 to 40% depending on the series and the joints involved. Very few studies have evaluated the incidence of CRPS after shoulder surgery. The objective of our study was to determine the incidence of CRPS1 and to identify any pre-operative risk factors associated with its emergence after extra-articular subacromial space surgery.

MATERIAL AND METHODS

This is a retrospective single-centre study of patients who underwent surgery for a subacromial extra-articular shoulder pathology from January 2016 to December 2016 and included a follow-up period of at least 6 months. The primary inclusion criterion was developing a CRPS1 as defined by Veldman. A pre- and post-operative clinical assessment was performed based on the Constant (Cst) score.

RESULTS

Among the 287 patients, with an average follow-up period of 6.5 months, included in the study, 38 (13%) presented with post-operative CRPS1. Treated hypothyroidism (OR = 3.79; 95% CI 1.58;9.07; p = 0.003), open surgery (OR = 2.92; 95% CI 1.35-6.32; p = 0.007) and the level of daily physical activity from the Cst score (OR = 0.088; 95% CI 0.79;0.97; p = 0.015) were found to be significantly associated with the onset of CRPS1.

CONCLUSION

CRPS1 affected more than 10% of patients who underwent surgery for a subacromial shoulder pathology. The current study identified hypothyroidism, open surgery, and pre-operative clinical status as risk factors for the onset of this complication. These parameters should, therefore, be taken into consideration during the patient's pre-operative consultation.

The long-term effect of complex regional pain syndrome type 1 on disability and quality of life after foot injury

PURPOSE

To study the long-term evolution of patients with lower-limb Complex Regional Pain Syndrome (CRPS), focusing on functional and proprioceptive aspects and quality of life.

METHODS

In 20 patients suffering from chronic distal lower-limb CRPS diagnosed using Budapest criteria, we assessed joint position sense and strength of the knee muscles at the CRPS and unaffected leg, functional exercise capacity, pain, CRPS severity score, quality of life and kinesiophobia. Similar assessments were performed in 20 age-matched controls.

RESULTS

The joint position performance (at 45°) was significantly lower for the CRPS leg as compared to controls. The knee extensor strength of the CRPS leg was significantly reduced as compared to the unaffected leg (-27%) and controls (-42%). CRPS patients showed significantly reduced performance at the 6 min-walk test as compared to their age group predicted value and controls. Patients suffering from CRPS for 3.8 years in average still exhibit high pain, severity and kinesiophobia scores.

CONCLUSIONS

Long-term deficits in strength and proprioceptive impairments are observed at the knee joint of the CRPS leg. This persistent functional disability has significant repercussions on the quality of life. We highlight the importance of including strength and proprioceptive exercises in the therapeutic approaches for CPRS patients.IMPLICATIONS FOR REHABILITATIONThe long-term evolution of patients suffering from lower-limb Complex Regional Pain Syndrome is associated with persistent disability, pain and impacts the quality of life.Strength, proprioceptive, functional and subjective assessments are necessary to better identify deficits.Rehabilitation should focus on the overall deficit of the affected and contralateral limb.

Fibromyalgia as a Predictor of Complex Regional Pain Syndrome After Distal Radius Fracture

Background: Complex regional pain syndrome (CRPS) can be a devastating complication following extremity injury, but risk factors are not well understood. The purpose of this study was to investigate the association between fibromyalgia and the development of CRPS after distal radius fracture. Methods: The PearlDiver Medicare database was queried using International Classification of Diseases, 9th Revision (ICD-9) and Current Procedural Terminology (CPT) codes for diagnoses and treatments of distal radius fractures. Patients were separated into fibromyalgia and control cohorts, and the prevalence of CRPS was measured at 3, 6, 9, and 12 months from the date of injury or procedure. Demographic factors, treatment modality, and comorbid conditions were analyzed by multivariable logistic regression to reduce confounding and identify additional risk factors. Results: Database queries yielded 853 186 patients diagnosed or treated for distal radius fracture, with 6% having previous diagnosis of fibromyalgia. The prevalence of CRPS following distal radius fracture was increased at 3, 6, 9, and 12 months in the fibromyalgia cohort compared with the control c, with a 1-year incidence of 0.51% compared with 0.20% (odds ratio [OR], 2.54, P < .001). Multivariable logistic regression supported the association, with estimated OR of 2.0 (P < .001). In addition, female gender, surgical or manipulative treatment, and anxiety were positively associated with CRPS, and age >65, diabetes, and heart failure were negatively associated. Conclusions: While the basis of the association between fibromyalgia and CRPS is unknown, our data suggest that it could serve as a useful predictor of CRPS risk, promoting increased vigilance for CRPS symptoms and earlier recognition and treatment, thereby improving patient outcomes.

Clinical Course and Impact of Complex Regional Pain Syndrome Confined to the Knee

OBJECTIVE

Although complex regional pain syndrome (CRPS) of the knee is comparable to CRPS of the ankle/foot at time of diagnosis, no reports are available concerning the course of knee CRPS. Therefore, this study investigated the clinical course in terms of the symptoms and signs, health-related quality of life (HR-QoL), and work status of patients diagnosed with CRPS of the knee.

DESIGN

Observational, descriptive study.

SETTING

Single-center study.

SUBJECTS

Patients with CRPS of the knee.

METHODS

Patients self-reported their past and current CRPS symptoms, HR-QoL, and work status; all underwent a physical examination. A comparison was made of changes in symptoms over time between patients with CRPS of the knee and those with CRPS of more distal locations.

RESULTS

In total, 32 patients were enrolled. The follow-up time was 11.5 ± 6.29 years since diagnosis, and symptoms and signs showed a significant decrease over time. Twelve patients (37.5%) rated their health as (generally) positive. Patients who were still able to work (31.3%) stated that their physical health gave them at least some problems in the performance of their job. A change in symptoms occurred significantly less often in CRPS of the knee.

CONCLUSIONS

CRPS of the knee changes in terms of symptoms over time, but significantly less than CRPS of other locations. A change in work status was reported in 82% of the patients due to their CRPS, and in 91%, the pain interfered with their daily life. CRPS of the knee is a painful condition with persistent symptoms causing a diminished HR-QoL.

Sensory modulation dysfunction is associated with Complex Regional Pain Syndrome

OBJECTIVE

Complex Regional Pain Syndrome (CRPS), a chronic pain condition, develops mainly after limb trauma and severely inhibits function. While early diagnosis is essential, factors for CRPS onset are elusive. Therefore, identifying those at risk is crucial. Sensory modulation dysfunction (SMD), affects the capacity to regulate responses to sensory input in a graded and adaptive manner and was found associated with hyperalgesia in otherwise healthy individuals, suggestive of altered pain processing.

AIM

To test SMD as a potential risk factor for CRPS.

METHODS

In this cross-sectional study, forty-four individuals with CRPS (29.9±11 years, 27 men) and 204 healthy controls (27.4±3.7 years, 105 men) completed the Sensory Responsiveness Questionnaire-Intensity Scale (SRQ-IS). A physician conducted the CRPS Severity Score (CSS), testing individuals with CRPS.

RESULTS

Thirty-four percent of the individuals with CRPS and twelve percent of the healthy individuals were identified to have SMD (χ2 (1) = 11.95; p<0.001). Logistic regression modeling revealed that the risk of CRPS is 2.68 and 8.21 times higher in individuals with sensory over- and sensory under-responsiveness, respectively, compared to non-SMD individuals (p = 0.03 and p = 0.01, respectively).

CONCLUSIONS

SMD, particularly sensory under-responsiveness, might serve as a potential risk factor for CRPS and therefore screening for SMD is recommended. This study provides the risk index probability clinical tool a simple evaluation to be applied by clinicians in order to identify those at risk for CRPS immediately after injury. Further research is needed.

Subliminal (latent) processing of pain and its evolution to conscious awareness

By unconscious or covert processing of pain we refer to nascent interactions that affect the eventual deliverance of pain awareness. Thus, internal processes (viz., repeated nociceptive events, inflammatory kindling, reorganization of brain networks, genetic) or external processes (viz., environment, socioeconomic levels, modulation of epigenetic status) contribute to enhancing or inhibiting the presentation of pain awareness. Here we put forward the notion that for many patients, ongoing sub-conscious changes in brain function are significant players in the eventual manifestation of chronic pain. In this review, we provide clinical examples of nascent or what we term pre-pain processes and the neurobiological mechanisms of how these changes may contribute to pain, but also potential opportunities to define the process for early therapeutic interventions.

Potential risk factors for the onset of complex regional pain syndrome type 1: a systematic literature review

Anaesthetists in the acute and chronic pain teams are often involved in treating Complex Regional Pain Syndromes. Current literature about the risk factors for the onset of Complex Regional Pain Syndrome Type 1 (CRPS 1) remains sparse. This syndrome has a low prevalence, a highly variable presentation, and no gold standard for diagnosis. In the research setting, the pathogenesis of the syndrome continues to be elusive. There is a growing body of literature that addresses efficacy of a wide range of interventions as well as the likely mechanisms that contribute to the onset of CRPS 1. The objective for this systematic search of the literature focuses on determining the potential risk factors for the onset of CRPS 1. Eligible articles were analysed, dated 1996 to April 2014, and potential risk factors for the onset of CRPS 1 were identified from 10 prospective and 6 retrospective studies. Potential risk factors for the onset of CRPS 1 were found to include being female, particularly postmenopausal female, ankle dislocation or intra-articular fracture, immobilisation, and a report of higher than usual levels of pain in the early phases of trauma. It is not possible to draw definite conclusions as this evidence is heterogeneous and of mixed quality, relevance, and weighting strength against bias and has not been confirmed across multiple trials or in homogenous studies.

Incidence of complex regional pain syndrome after foot and ankle surgery

Complex regional pain syndrome (CRPS) is an uncommon complication of orthopedic surgery, and few investigators have considered the incidence in foot and ankle surgery. In the present retrospective cohort study of 390 patients who had undergone elective foot and/or ankle surgery in our department from January to December 2009, the incidence of postoperative CRPS was calculated and explanatory variables were analyzed. A total of 17 patients (4.36%) were identified as meeting the International Association for the Study of Pain criteria for the diagnosis of CRPS. Of the 17 patients with CRPS, the mean age was 47.2 ± 9.7 years, and 14 (82.35%) were female. All the operations were elective, and 9 (52.94%) involved the forefoot, 3 (17.65%) the hindfoot, 3 (17.65%) the ankle, and 2 (11.76%) the midfoot. Twelve patients (70.59%) had new-onset CRPS after a primary procedure, and 5 (29.41%) had developed CRPS after multiple surgeries. Three patients (17.65%) had documented nerve damage intraoperatively and thus developed new-onset CRPS type 2. Blood test results were available for 14 patients (82.35%) at a minimum of 3 months postoperatively, and none had elevated inflammatory markers. Five of the patients (29.41%) were smokers, and 8 (47.06%) had had a pre-existing diagnosis of anxiety and/or depression. From our findings, we recommend that middle-age females and those with a history of anxiety or depression, who will undergo elective foot surgery, should be counseled regarding the risk of developing CRPS during the consent process. We recommend similar studies be undertaken in other orthopedic units, and we currently are collecting data from other orthopedic departments within Scotland.

Scar neuromas as triggers for headache after craniotomy: clinical evidence

We present four cases of headache with variable intensity, located in close proximity to a craniotomy incision which was performed for non-traumatic reasons. Since manual palpation of the scar often triggers pain, and infiltration with local anesthetics reduce or abolish the pain in some patients, we suggest that neuromas or nerve entrapment in the scars, as a result of the surgery, are responsible for headaches. Although local infiltrations or nerve blocks are often used for diagnostic reasons, herein we consider that they are also of therapeutic value. We review the current known pathophysiology of post-craniotomy headaches and present a hypothesis suggesting a greater recognition of the potential contribution of neuroma formation in areas of scars tissue to contribute to this kind of headache.

Efficacy and safety of high-dose vitamin C on complex regional pain syndrome in extremity trauma and surgery--systematic review and meta-analysis

Complex regional pain syndrome (CRPS) is a devastating condition often seen after foot and ankle injury and surgery. Prevention of this pathology is attractive not only to patients but also to surgeons, because the treatment of this condition can be difficult. We evaluated the effectiveness of vitamin C in preventing occurrence of CRPS in extremity trauma and surgery by systematically reviewing relevant studies. The databases used for this review included: Ovid EMBASE, Ovid MEDLINE, CINAHL, and the Cochrane Database. We searched for comparative studies that evaluated the efficacy of more than 500 mg of daily vitamin C. After screening for inclusion and exclusion criteria, we identified 4 studies that were relevant to our study question. Only 1 of these 4 studies was on foot and ankle surgery; the rest concerned the upper extremities. All 4 studies were in favor of this intervention with minimal heterogeneity (Tau(2) = 0.00). Our quantitative synthesis showed a relative risk of 0.22 (95% confidence interval = 0.12, 0.39) when daily vitamin C of at least 500 mg was initiated immediately after the extremity surgery or injury and continued for 45 to 50 days. A routine, daily administration of vitamin C may be beneficial in foot and ankle surgery or injury to avoid CRPS. Further foot and ankle specific and dose-response studies are warranted.

Complex regional pain syndrome

Complex regional pain syndrome (CRPS) is a challenging pain condition for doctors and patients, with a natural history characterized by chronicity and relapses that can result in significant disability. CRPS is difficult to diagnose and treat, and requires close follow-up to ensure that progress is being made. Early diagnosis and treatment are required to prevent a long-standing or permanent disability. Clinical features such as spontaneous pain, edema, hyperalgesia, temperature or sudomotor changes, motor function abnormality, and autonomic changes are the hallmark of this disease. The treatment of CRPS remains controversial, and includes medications, physical therapy, regional anesthesia, and neuromodulation.

Sartorial branch of the saphenous nerve in relation to a medial knee ligament repair or reconstruction

Surgical approaches to repair or reconstruct the medial knee structures note caution to avoid the sartorial branch of saphenous nerve. However, the approximate area of potential iatrogenic nerve injury has not been previously described in relation to landmarks for a medial knee reconstruction. The purpose of this study was to define the course of the sartorial branch of the saphenous nerve in relation to the superficial medial collateral ligament. A total of ten non-paired, fresh-frozen cadaveric knees, with no evidence of prior injury or disease were utilized. Dissection to identify the medial knee structures was performed. The sartorial branch of the saphenous nerve was identified in all specimens. The perpendicular distance from the anterior border of the superficial medial collateral ligament 2 cm distal from the joint line to the sartorial branch of the saphenous nerve was 4.8 +/- 0.9 cm. The distance from the anterior border of the superficial medial collateral ligament to the sartorial branch of the saphenous nerve decreased as the distance was increased distally with a mean distance of 4 cm (4.1 +/- 0.8 cm) distal from the joint line and 6 cm (3.8 +/- 0.8 cm) distal from the joint line. We have characterized the surgically relevant landmark anatomy of the sartorial branch of the saphenous nerve in regards to performing a repair or reconstruction of the medial knee structures. Familiarity with these anatomic landmarks and associated distances from the sartorial branch of the saphenous nerve, we can assess the potential area of vulnerability to this nerve branch intraoperatively.

Lower extremity complex regional pain syndrome: long-term outcome after surgical treatment of peripheral pain generators

We undertook a retrospective study to evaluate the hypothesis that complex regional pain syndrome (CRPS) I, known as the "new" reflex sympathetic dystrophy, persists because of undiagnosed injured joint afferents, cutaneous neuromas, or nerve compressions, and is, therefore, a misdiagnosed form of CRPS II, which is known as the "new" causalgia. We used a research protocol, with institutional review board approval, to review medical records for the purpose of identifying 30 patients with lower extremity reflex sympathetic dystrophy, based on their history, physical examination, neurosensory testing, and response to peripheral nerve blocks, who were treated surgically at the level of the peripheral nerve. In this report, we describe long-term outcomes in 13 of these patients who were followed up for a minimum of 24 months (mean, 47.8 months; range, 25-90 months). Based primarily on the results of physical examination and the response to peripheral nerve blocks, surgery included a combination of joint denervation, neuroma resection plus muscle implantation, and neurolysis. Outcomes were measured in terms of decreased pain medication usage and recovery of function, and the results were excellent in 7 (55%), good in 4 (30%), and poor (failure) in 2 (15%) of the patients. Based on these results, we concluded that most patients referred with a diagnosis of CRPS I have continuing pain input from injured joint or cutaneous afferents, and chronic nerve compression, which is indistinguishable from CRPS II, and amenable to successful treatment by means of an appropriate peripheral nerve surgical strategy.

The management of patients with painful total knee replacement

The management of patients with a painful total knee replacement requires careful assessment and a stepwise approach in order to diagnose the underlying pathology accurately. The management should include a multidisciplinary approach to the patient's pain as well as addressing the underlying aetiology. Pain should be treated with appropriate analgesia, according to the analgesic ladder of the World Health Organisation. Special measures should be taken to identify and to treat any neuropathic pain. There are a number of intrinsic and extrinsic causes of a painful knee replacement which should be identified and treated early. Patients with unexplained pain and without any recognised pathology should be treated conservatively since they may improve over a period of time and rarely do so after a revision operation.

The effect of sequel symptoms and signs of Complex Regional Pain Syndrome type 1 on upper extremity disability and quality of life

Although properly treated, patients with Complex Regional Pain Syndrome type 1 (CRPS type 1) of upper limb may continue to have sequel signs and symptoms of the disease in long-term. The aim of this study is to analyse the effect of the sequel findings of CRPS type 1 on upper limb disability and quality of life. Thirty patients with CRPS type 1 of the upper extremity were re-evaluated for the sequel sign and symptoms of CRPS type 1 after 18 months (8-60 months). Pain, range of motion, strength, manual dexterity and touch perception thresholds of the hands, upper extremity disability [Disability of arm, shoulder and hand (DASH) questionnaire] and health-related quality of life [Short Form-36 (SF-36)] were measured and compared to 38 healthy controls. Of the 30 patients, only 3 patients (10%) were symptom free. Pain after use was the most frequently found symptom. Strength and range of motion of the involved hand was reduced in CRPS type 1 patients. Manual dexterity was impaired and touch perception threshold was elevated in CRPS type 1 patients. The involved upper extremities were more disabled in CRPS type 1 patients than controls. The severity of the pain, and numbness of the hands were the factors causing disability. Pain caused reduced quality of life in physical functioning. In conclusion, prolonged follow-up period and efforts to improve sensory disturbances (especially pain) may reduce the upper extremity disability and reduced quality of life in CRPS type 1 patients.

Characteristic trends of lower-extremity complex regional pain syndrome

Complex regional pain syndrome (CRPS) is a multifaceted, progressive, and potentially devastating disorder generally affecting the extremities. In addition, scant information is available regarding the types of patients who develop lower-extremity CRPS. This is a retrospective chart review study of 64 patients who presented to a pain clinic with CRPS of the lower extremity. The study examined 23 variables broadly classified under demographic characteristics, CRPS characteristics, and healthcare utilization. The sample was found to consist of predominantly white, middle-aged women with CRPS I. Subjective complaints consisted of burning, sharp, throbbing, or aching pain with shooting symptoms. Initial presenting clinical findings included allodynia, edema, erythema, and hyperesthesia. The most common precipitating injuries were blunt trauma of the foot with or without fracture or ankle sprain. The most common inciting surgical events were bunionectomy, tarsal tunnel release, and heel-spur surgery. Referral to the pain clinic was delayed more commonly in trauma patients than in postsurgical patients, with a corresponding increase in pain clinic visits for treatment. This study may act as a guide for physicians treating the lower extremity to aid in the recognition of lower extremity complex regional pain syndrome and its characteristics.

Complex regional pain syndrome and chronic pain management in the lower extremity

CRPS is a difficult clinical entity to manage; it requires close and regimented follow-up to ensure that progress is being made. Early recognition is important so that treatment plans to prevent a long-standing or permanent disability made be instituted. Treatments such as physical therapy, medications, regional anesthesia, and neuromodulation may decrease their morbidity and return the patient to a more functional status.

Preemptive analgesia in elective surgery in patients with complex regional pain syndrome: a case report

Complex regional pain syndrome (CRPS) can be a complication of injury or surgery or have an obscure etiology. Special precautions are indicated (i.e., preemptive analgesia) when surgery is required with a patient who has been diagnosed with CRPS. The complex case of a 44-year-old female diagnosed with reflex sympathetic dystrophy (RSD) is discussed, including current treatment options. A brief review of the literature as well as the features of complex regional pain syndrome (CRPS I/RSD and CRPS II/causalgia) are presented.