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Karri J, Palmer JS, Charnay A, Garcia C, Orhurhu V, Shah S, Abd-Elsayed A. Utility of Electrical Neuromodulation for Treating Chronic Pain Syndromes in the Pediatric Setting: A Systematic Review. Neuromodulation 2021; 25:671-679. [PMID: 33556220 DOI: 10.1111/ner.13365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/08/2020] [Accepted: 01/05/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Chronic pain syndromes in children can carry significant threats to psychological well-being, opioid overuse, functional impairments, and severe disability. While several high-level studies, almost exclusively in adults, have demonstrated the utility of implantable electrical neuromodulation systems for treating various chronic pain syndromes, there exists a paucity of pediatric-specific evidence. Unfortunately, evidence and practice patterns established from adults may not be fully translatable to children given differences in disease manifestations and anatomical variances. MATERIALS AND METHODS We performed a systematic review using conventional PRISMA methodology to identify studies reporting use of implantable electrical neuromodulation systems in children. The primary outcome parameters collected were analgesic relief and functional benefits. Additionally, previous interventions attempted, neuromodulation parameters, and limitations were collected as reported. RESULTS A total of 11 studies was identified, which described 19 patients who were refractory to multidisciplinary pain management strategies. The cohort was mostly adolescent (18/19), suffered from CRPS (14/19), and received SCS (17/19). Nearly all patients, both those with CRPS (13/14) and non-CRPS conditions (4/4), reported significant pain relief and functional recovery following neuromodulation. There were no severe complications reported; limitations included suboptimal benefit or loss of analgesia (3/19), lead or device revision (3/19), and subcutaneous infection (1/19), all of which were congruent with adult outcomes. CONCLUSION There exist children with chronic pain refractory to standard of care approaches who could be considered for neuromodulation interventions. The existing data, which was limited and from a low tier of evidence, suggest that these interventions are relatively safe and provide meaningful pain reduction and functional improvements. While not previously reported, we recommend careful consideration of the pubertal growth spurt prior to device lead placement-if reasonable and appropriate-given the possibility of inferior lead migration with physiologic growth in patients with SCS devices or foraminal extrusion in patients with dorsal root ganglion stimulation devices.
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Affiliation(s)
- Jay Karri
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Jeremé Sharíf Palmer
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Aaron Charnay
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX, USA
| | - Carol Garcia
- Department of Anesthesia, Division of Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Vwaire Orhurhu
- Department of Anesthesia, Division of Pain Medicine, University of Pittsburgh Medical Center, Susquehanna, Williamsport, PA, USA
| | - Shalini Shah
- Department of Anesthesiology & Perioperative Care, Division of Pain Medicine, University of California Irvine, Orange, CA, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesia, Division of Pain Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Vescio A, Testa G, Culmone A, Sapienza M, Valenti F, Di Maria F, Pavone V. Treatment of Complex Regional Pain Syndrome in Children and Adolescents: A Structured Literature Scoping Review. CHILDREN-BASEL 2020; 7:children7110245. [PMID: 33233634 PMCID: PMC7699814 DOI: 10.3390/children7110245] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/05/2020] [Accepted: 11/18/2020] [Indexed: 01/11/2023]
Abstract
Background: Complex regional pain syndrome (CRPS) is characterized by chronic, spontaneous and provoked pain of the distal extremities whose severity is disproportionate to the triggering event. Diagnosis and treatment are still debated and multidisciplinary. The purpose of this systematic review is to analyze the available literature to provide an update on the latest evidence related to the treatment of CRPS in growing age. Methods: Data extraction was performed independently by three reviewers based on predefined criteria and the methodologic quality of included studies was quantified by the Newcastle–Ottawa Quality Assessment Scale Cohort Studies. Results: At the end of the first screening, following the previously described selection criteria, we selected n = 103 articles eligible for full-text reading. Ultimately, after full-text reading and a reference list check, we selected n = 6. The articles focused on physical (PT), associated with cognitive behavioral (CBT) and pharmacological (PhT) treatments. The combination of PT + CBT shows the most efficacy as suggested, but a commonly accepted protocol has not been developed. Conclusions: Physical therapy in association with occupational and cognitive behavioral treatment is the recommended option in the management of pediatric CPRS. Pharmacological therapy should be reserved for refractory and selected patients. The design and development of a standard protocol are strongly suggested.
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Cucchiaro G, Craig K, Marks K, Cooley K, Cox TKB, Schwartz J. Short- and long-term results of an inpatient programme to manage Complex Regional Pain Syndrome in children and adolescents. Br J Pain 2017; 11:87-96. [PMID: 28491301 DOI: 10.1177/2049463717695695] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The aim of this retrospective study was to determine whether an inpatient approach and the use of regional anaesthesia techniques can accelerate the recovery to normal functions in children with Complex Regional Pain Syndrome (CRPS). This study looked at the data of patients admitted to the rehabilitation unit with a diagnosis of CRPS from January 2010 to April 2015. Variables such as hospital stay, medications administered, regional anaesthesia procedures, changes in functional status prior to treatment and at the time of discharge, psychological evaluation and diagnosis were evaluated. A total of 31 patients (21 females and 10 males) were admitted with a diagnosis of CRPS 1 and 2. In all, 97% of the patients received a peripheral or central nerve catheter for an average of 4 days with pain scores of Verbal Numeric Scale (VNS) score = 1.0 ± 0.7 and an average length of hospital stay of 8.2 ± 2.6 days. The modified Functional Independence Measure for Children (WeeFIM) scores and Canadian Association of Occupational Therapists tests significantly improved at the time of hospital discharge, as well as their pain scores, which decreased from 8.2 ± 2 to 1.6 ± 3. In conclusion, these data suggest that the use of regional anaesthesia techniques and an intensive inpatient rehabilitation programme could accelerate the recovery of children with CRPS.
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Affiliation(s)
- Giovanni Cucchiaro
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Kevin Craig
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Kerri Marks
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Kristin Cooley
- Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | | | - Jennifer Schwartz
- Department of Anesthesiology Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Abstract
The awareness of complex regional pain syndrome (CRPS) in the pediatric population is increasing. The condition involves regional pain that is out of proportion to any initiating event (if there is one) and is associated with sensory, functional, autonomic, and inflammatory changes in the region of the pain. The signs and symptoms of CRPS can vary between patients and stage of the disease process. Like many chronic pain conditions, it is often associated with significant disability and a detrimental effect on quality of life. It has a complex pathophysiology that remains poorly understood but provides many potential targets for treatments. Management involves a biopsychosocial formulation that encompasses physical and psychological interventions alongside pharmacological strategies. We review the current evidence for the treatment of this condition in children, with particular reference to pharmacological management.
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Abstract
Complex regional pain syndrome is increasingly recognized in the pediatric population. Owing to the nature of presentation with pain, many of these children present to the emergency setting at different stages of the syndrome with or without numerous prior interactions with health professionals. Complex regional pain syndrome type 1 (CRPS1) is a clinical syndrome characterized by amplified musculoskeletal limb pain that is out of proportion to the history and physical findings, or pain due to non-noxious stimuli (allodynia/hyperalgesia), and accompanied by one or more signs of autonomic dysfunction. Differential diagnosis may include significant trauma (eg, fractures), inflammatory conditions, malignancies, and systemic illness. The diagnosis is clinical. The treatment goals for CRPS1 are restoration of function and relief of pain. Education, physical, and occupational therapy with psychotherapy and defined goals of achievement with reward are the mainstay of treatment for this population. Most children with CRPS1 will have a favorable outcome.
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Burghardt KJ, Thomas ST, Tutag-Lehr V. Off-label use of duloxetine for pediatric neuropathic pain. Ment Health Clin 2015. [DOI: 10.9740/mhc.2015.11.277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Duloxetine, a serotonin-norepinephrine reuptake inhibitor, has been used successfully for adults for the management of neuropathic pain syndromes. Pediatric data are needed because inadequate neuropathic pain management in children and adolescents results in lower psychosocial functioning, delayed development, and decreased quality of life. We aim to describe a case series on the use of duloxetine for the management of symptoms associated with chronic neuropathic pain syndromes in a pediatric population.
Methods
Data were collected in a naturalistic, consecutive, case report format, from a pediatric pain management clinic for children prescribed duloxetine for analgesia for a variety of neuropathic-type pain conditions. Follow-up data, including self-report of pain, and type and frequency of adverse reactions, were collected to describe the efficacy and safety of duloxetine.
Results
Duloxetine was prescribed for the management of self-reported average pain scores of greater than 5 out of 10 on the Faces Pain Scale–Revised for pain that was resistant to other medications. Each of these patients had comorbid psychiatric diagnoses. Reduction in pain following duloxetine therapy was not universal, and all patients discontinued duloxetine therapy prematurely because of adverse effects.
Conclusion
Further evidence is needed to demonstrate the efficacy and safety of duloxetine for use in pediatric populations with neuropathic components to their pain. Based on our experience, we suggest considering its use only after failure of other agents. The best management of a pediatric patient's pain condition is likely accomplished through a combination of pharmacotherapy and nonpharmacotherapy interventions.
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Affiliation(s)
- K. J. Burghardt
- (Corresponding author) Assistant Professor of Pharmacy Practice, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan,
| | - S. T. Thomas
- Medical Director, Pediatric Pain Medicine, Anesthesiology Department, Children's Hospital of Michigan, Detroit Medical Center, Detroit, Michigan
| | - V. Tutag-Lehr
- Associate Professor of Pharmacy Practice, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan
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Abstract
PURPOSE OF REVIEW Complex regional pain syndrome (CRPS) is a chronic pain condition typically involving a limb, which is characterized by neuropathic pain, sensory abnormalities and neurovascular findings. The exact cause of CRPS is unknown; however, proposed theories include alterations in the sympathetic and central nervous system (CNS), small fibre changes in the peripheral nervous system and psychological factors. Although this condition was previously considered rare among children and adolescents, it has been increasingly recognized in paediatric patients and can result in significant disability. RECENT FINDINGS The diagnosis of paediatric CRPS is based upon clinical criteria obtained from a thorough history and physical examination. Other possible causes, such as orthopaedic, infectious, vascular and rheumatologic disorders, should be ruled out prior to making the diagnosis. Treatment focuses on a rehabilitative strategy consisting of physical therapy, occupational therapy and cognitive-behavioural therapy with an overall focus on return to functioning. SUMMARY CRPS in children and adolescents is characterized by a painful, mottled appearing, swollen limb with allodynia and hyperalgesia. For most patients, pain is severe, resulting in significant functional disability. More recent evidence suggests that a rehabilitative programme results in improvement in both pain and functional measures.
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Pedemonte Stalla V, Medici Olaso C, Kanopa Almada V, Gonzalez Rabelino G. Complex regional pain syndrome type I. An analysis of 7 cases in children. NEUROLOGÍA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.nrleng.2013.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Pedemonte Stalla V, Medici Olaso C, Kanopa Almada V, Gonzalez Rabelino G. Síndrome doloroso regional complejo tipo i. Análisis de una casuística infantil. Neurologia 2015; 30:347-51. [DOI: 10.1016/j.nrl.2013.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Revised: 10/28/2013] [Accepted: 12/14/2013] [Indexed: 10/25/2022] Open
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Rodriguez- Lopez MJ, Fernandez-Baena M, Barroso A, Yáñez-Santos JA. Complex Regional Pain Syndrome in Children: a Multidisciplinary Approach and Invasive Techniques for the Management of Nonresponders. Pain Pract 2015; 15:E81-9. [DOI: 10.1111/papr.12317] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 04/07/2015] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Alex Barroso
- Pain Treatment Unit of Hospital Regional Universitario de Malaga; Malaga Spain
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Complex regional pain syndrome involving the face following snowball injury. Eur J Pediatr 2014; 173:397-400. [PMID: 24061280 DOI: 10.1007/s00431-013-2159-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 09/12/2013] [Indexed: 10/26/2022]
Abstract
Complex regional pain syndrome (CRPS) is a condition of unknown etiology characterized by autonomic, sensory, and motor disturbance. CRPS usually follows an injury in the affected limb, which is often trivial in nature. CRPS involving the facial region is rare, and there have been no previous descriptions in children. We describe a 13-year-old girl with CRPS involving the face, which developed after being struck by a snowball. The clinical characteristics were similar to those of CRPS elsewhere in the body involving burning pain, hyperalgesia, and hyperesthesia. This was later accompanied by skin edema, fluctuating color, and temperature changes, as well as loss of eyebrow hair. Following detailed but inconclusive investigations, a clinical diagnosis of CRPS was made in line with Budapest diagnostic criteria. Over the next year, her condition gradually improved with ongoing comprehensive multidisciplinary input. We present this patient to alert clinicians to consider CRPS in the differential diagnosis of similar cases who present with chronic facial pain and skin changes.
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Demirdal ÜS, Bükülmez A, Solak Ö. Complex regional pain syndrome type 1 in a pediatric patient: Case report. Turk Arch Pediatr 2014; 49:77-80. [PMID: 26078637 DOI: 10.5152/tpa.2014.1012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Accepted: 10/22/2012] [Indexed: 11/22/2022]
Abstract
Complex regional pain syndrome type 1 is one of the causes of morbidity of childhood which is also named reflex symphathetic dystrophia. The syndrome is characterized with regional pain and vasomotor, sudomotor and sensory changes in the distal parts of the extremities involved. Complex regional pain syndrome type 1 shows difference in children in terms of clinical picture and imaging methods compared to adults. The most important point is that the prognosis is generally better in children if early diagnosis and treatment is provided. On the other hand, causes including presence of psychological factors or less contribution of imaging methods in children lead to delayed diagnosis or erroneous diagnosis. In this article, a 10 year-old male patient who was diagnosed with complex regional pain syndrome type 1 was described. Thus, we aimed to remind clinicians that this syndrome should also be kept in mind in the differential diagnosis of pain in children.
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Affiliation(s)
- Ümit Seçil Demirdal
- Department of Physical Therapy and Rehabilitation, İzmir Katip Çelebi University, Faculty of Medicine, İzmir, Turkey
| | - Ayşegül Bükülmez
- Department of Pediatrics, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar, Turkey
| | - Özlem Solak
- Department of Physical Therapy and Rehabilitation, Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar, Turkey
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13
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[Chronic pain and regional anesthesia in children]. Arch Pediatr 2013; 20:1149-57. [PMID: 23953871 DOI: 10.1016/j.arcped.2013.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Revised: 06/03/2013] [Accepted: 07/13/2013] [Indexed: 11/22/2022]
Abstract
Chronic pain is usually underestimated in children, due to lack of knowledge and its specific signs. In addition to suffering, chronic pain causes a physical, psychological, emotional, social, and financial burden for the child and his family. Practitioners may find themselves in a situation of failure with depletion of medical resources. Some types of chronic pain are refractory to conventional systemic treatment and may require the use of regional anesthesia. Cancer pain is common in children and its medical management is sometimes insufficient. It is accessible to neuroaxial or peripheral techniques of regional anesthesia if it is limited to an area accessible to one of these techniques and no contraindications (e.g., thrombopenia) are present. Complex regional pain syndrome 1 is not rare in children and adolescents, but it often goes undiagnosed. Regional anesthesia may contribute to the treatment of complex regional pain syndrome 1, mainly in case of recurrence, because it provides rapid effective analgesia and allows rapid implementation of intensive physiotherapy. These techniques have also shown interest in phantom limb pain after limb amputation, but they remain controversial for erythromelalgia pain or chronic abdominopelvic pain. Finally, the treatment of postdural puncture headache due to cerebrospinal fluid leak can be treated by performing an epidural injection of the patient's blood, called a blood-patch. Finally, the management of children with chronic pain should be multidisciplinary (pediatrician, physiotherapist, psychologist, surgeon, anesthesiologist) to support the child and her problem in its entirety.
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Abstract
BACKGROUND Complex regional pain syndrome (CRPS) is a painful disorder without a known unifying mechanism. There are little data on which to base evaluation and treatment decisions, and what data are available come from studies involving adults; however, even that literature is relatively sparse. Developing robust research for CRPS in children is essential for the progress toward optimal treatment. OBJECTIVES To determine potential avenues of research in pediatric CRPS based on a review of the literature. Areas of concern include diagnostic criteria, peripheral mechanisms, central nervous system mechanisms, the role of the autonomic nervous system, possible risk factors, options for prevention and potential avenues of treatment. METHODS A literature review was performed and the results applied to form the hypotheses posited in the form of research questions. RESULTS AND CONCLUSIONS CRPS is a complicated entity that is more than a painful sensory condition. There is evidence for peripheral inflammatory and neurological changes, and reorganization in both sensory and motor cortexes. In addition, a significant motor component is frequently observed and there appear to be tangible risk factors. Many of these pieces of evidence suggest options for prevention, treatment and monitoring progress and outcome. Most of the data are derived from adult studies and need to be replicated in children. Furthermore, there may be factors unique to pediatrics due to developmental changes in neuroplasticity as well as somatic, endocrinological and emotional growth. Some of these developmental factors may shed light on the adult condition.
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Abstract
OBJECTIVES This study synthesized current research evidence on the effectiveness of physiotherapy for the management of children diagnosed with complex regional pain syndrome type 1 (CRPS-1), to provide up-to-date physiotherapy treatment recommendations, and to identify areas that require further investigation. METHODS Nine electronic databases were searched for quantitative studies that evaluated the effect of physiotherapy on children with CRPS-1. The methodological quality of the studies was evaluated using the Critical Review Form. Data were extracted regarding the study design, participant characteristics, types of outcome measures used, and physiotherapy technique used and its effectiveness. RESULTS The search strategy identified 303 potential studies, of which 12 met the inclusion criteria (1 randomized controlled trial, 1 comparative study, 10 case series). The methodological quality of all studies was rated as poor to fair. The "stand-alone" value of physiotherapy could not be determined as physiotherapy was prescribed in conjunction with psychological and medical interventions. There is low volume and poor-to-fair quality evidence which suggests that physiotherapy prescribed with other interventions may lead to short-term improvement in the signs and symptoms of CRPS-1 or functional ability in children with CRPS-1, and the relapse rate may be moderately high. DISCUSSION High-quality studies are required in this area. These studies should evaluate a package of care (which includes physiotherapy); they should investigate the effects of physiotherapy treatments that have proven effectiveness in adults with CRPS-1; they should use psychometrically sound measures to evaluate outcome; and the nature of physiotherapy should be detailed in future publications to enable replication in the clinical setting.
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Brooke V, Janselewitz S. Outcomes of Children With Complex Regional Pain Syndrome After Intensive Inpatient Rehabilitation. PM R 2012; 4:349-54. [DOI: 10.1016/j.pmrj.2012.01.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 01/21/2012] [Accepted: 01/27/2012] [Indexed: 10/28/2022]
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Finniss DG, Murphy PM, Brooker C, Nicholas MK, Cousins MJ. Complex regional pain syndrome in children and adolescents. Eur J Pain 2012; 10:767-70. [PMID: 16439174 DOI: 10.1016/j.ejpain.2005.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2005] [Revised: 10/29/2005] [Accepted: 12/13/2005] [Indexed: 10/25/2022]
Abstract
Complex regional pain syndrome (CRPS) is a disorder characterised by pain, sensory and motor disturbances and represents a significant medical entity. This report discusses two cases of CRPS in children and adolescents, highlighting several critical issues for clinicians in the diagnosis and management of CRPS in these populations. Early diagnosis, referral and appropriate intervention are essential in decreasing pain, suffering and resorting function for children and adolescents with CRPS.
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Affiliation(s)
- Damien G Finniss
- Pain Management and Research Institute, University of Sydney and Royal North Shore Hospital, Pacific Highway, St Leonards, Sydney, NSW, Australia.
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Olsson GL, Meyerson BA, Linderoth B. Spinal cord stimulation in adolescents with complex regional pain syndrome type I (CRPS-I). Eur J Pain 2012; 12:53-9. [PMID: 17889577 DOI: 10.1016/j.ejpain.2007.02.007] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2006] [Revised: 02/26/2007] [Accepted: 02/26/2007] [Indexed: 11/24/2022]
Abstract
Complex regional pain syndrome type I (CRPS-I) is not uncommon in children, particularly in adolescent girls. Most often, the condition involves a foot and is characterized by spontaneous pain, tactile allodynia and dysautonomic signs. There is usually a history of a minor, local trauma but sometimes no reasonable cause can be identified, and there are no signs of persistent tissue injury giving rise to ongoing nociception. Common analgesics are generally of no benefit, and the standard treatment includes sociopsychological support, physiotherapy, tricyclic antidepressants and antiepileptic drugs, sympathetic blocks (SB), and cognitive-behavioural therapy. For a minority of patients who prove to be resistant to such therapies, spinal cord stimulation (SCS) may be tried. The present study comprises seven girls, 11-14 years of age, presenting with severe, incapacitating and therapy-resistant CRPS-I, who were subjected to SCS. In two of them, percutaneous electrode implantation had to be performed in general anaesthesia. Trial stimulation was performed in all, but one. In two cases, it was not possible to produce paraesthesias that entirely covered the pain area. A pain relieving effect of SCS was usually not reported until after 1-2 weeks of trial stimulation. After another 2-6 weeks, pain alleviation was complete in five of the seven patients, one to eight years after the intervention. In one case, a local infection necessitated the removal of the electrode; nevertheless a few days of trial stimulation produced substantial pain relief that still persists. In four patients, the SCS use was gradually diminished and eventually the device could be removed. The favourable outcome in all seven cases with no or minor remaining symptoms and without severe recurrences illustrates that SCS may also be an efficient treatment in paediatric cases with exceptionally therapy resistant forms of CRPS I.
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Affiliation(s)
- Gunnar L Olsson
- Pain Treatment Unit, Astrid Lindgren Children's Hospital, 17176, Stockholm, Sweden
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19
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Abstract
With ultrasound, continuous peripheral nerve blocks (CPNBs) are one of the most recent developments in regional anesthesia in children. CPNBs are now used more widely in children because more suitable materials have been marketed, allowing complete, and prolonged postoperative pain control. Their use after orthopedic procedures in children and treatment for complex regional pain syndrome in adolescents has demonstrated the benefits. Perineural catheters have also shown their superiority over other techniques of continuous regional anesthesia in terms of side effects. The efficiency and the safety of these techniques may facilitate early ambulation with improved pain management, treatment at home with disposable pumps, and improved rehabilitation of children. Studies on large cohorts of patients published to date have failed to highlight any severe complications in their use compared with other adult studies. Accidents owing to systemic toxicity are very unlikely if the recommended maximum dose is not exceeded. The safety of continuous regional anesthesia techniques in children relies on the use of low-concentration l-enantiomer solutions (ropivacaine or levobupivacaine) accompanied by low plasma concentrations of local anesthetics, limiting the risk of systemic toxicity of these molecules. CPNB can ensure strong and lasting analgesia in hospital or at home.
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Affiliation(s)
- Christophe Dadure
- Department of Anaesthesia and Critical Care Unit, Lapeyronie University Hospital, Montpellier, France.
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Abstract
Complex regional pain syndrome type 1 is a rare painful syndrome in children involving an extremity which consists of pain out of proportion to the cause, loss of function, and significant evidence of autonomic dysfunction. We report a child, a known case of migraine who presented with spontaneous onset pain and sudomotor changes in an extremity not preceded by any trauma. A good clinical eye is required for the identification and diagnosis of this underreported condition to prevent doing extensive investigations. The coexistence of migraine and complex regional pain syndrome type 1 in a patient is interesting and is probably due to the common underlying pathophysiological abnormalities involving central serotonin activity and neurogenic inflammatory mechanisms.
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Affiliation(s)
- Munni Ray
- Division of Pediatric Neurology and Neurodevelopment, Department of Pediatrics, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Cebrián J, Sánchez P. [Pediatric complex regional pain syndrome affecting an upper limb: 7 cases and a brief review of the literature]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2009; 56:163-169. [PMID: 19408782 DOI: 10.1016/s0034-9356(09)70358-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVES To review the clinical, psychiatric, and social characteristics of complex regional pain syndrome in children and adolescents treated in the last 4 years at our pediatric pain clinic. MATERIAL AND METHODS We analyzed the specialty of the initial treating physician, age, sex, initial diagnosis, pain intensity, degree of disability, fear of movement, clinical stage, history of trauma, time between onset and diagnosis, psychiatric illness, family support and behavior, chronic pain in near relatives, school grades and attendance, treatment given at the pediatric pain clinic, recurrences, and course of disease. RESULTS The cases of 7 patients (4 female, 3 male) between the ages of 8 and 15 years were analyzed. Four had been referred by the child psychiatry department. The initial diagnosis was erroneous in all but 1 case. Pain intensity and associated disability were severe in 5 patients and 4 expressed intense fear of moving the limb. Five patients had initial stage I disease, 5 had a history of trauma, and 5 had been previously treated by immobilization of the limb and prescription of nonsteroidal anti-inflammatory drugs. The time between onset and diagnosis ranged from 2 to 18 months (mean [SD], 6.4 [3.5] months). In most cases psychiatric disease and concomitant social disability were present. Treatment prescribed at the pediatric pain clinic consisted of a combination of oral medication, psychologic and psychiatric counseling, and intensive physiotherapy for all but 2 children, who required regional nerve blocks. CONCLUSION The clinical course was satisfactory for all but 1 patient, who developed severe disability. Complex regional pain syndrome affecting an upper limb is uncommon in children but not rare.
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Affiliation(s)
- J Cebrián
- Departamento de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Infantil, Hospital General Universitario Gregorio Marañón, Madrid.
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Abstract
BACKGROUND The purpose of the present paper was to assess efficiency of treatment and long-term functional outcome of complex regional pain syndromes (CRPS) in children who were treated in the chronic pain clinic at a major tertiary hospital in Israel. METHODS The files of 14 children with CRPS were analyzed retrospectively. Demographic data, initiating event, referring source, time needed for referral to pain clinic, clinical evaluation, treatment, recurrence and complications were recorded. RESULTS Fourteen children with CRPS types I and II were included in the study. Girls were affected in 71%. Lower extremities were affected in 57%. The median time from onset of symptoms to seeking medical help was 4.46 weeks (range 2-82 weeks). The median time to referral to pain clinic was 24.51 weeks (range 1.2-94). In 45% the referral source was the pediatrician. A total of 85.8% of patients were referred to various consultations before the pain clinic. Most children had reduced pain and improved function on non-invasive treatment approach. Invasive treatments were used in 28.5%. Full or partial recovery was accomplished in 93%. Recurrence was observed in 29%. CONCLUSIONS CRPS in children and adolescents is still underdiagnosed, although many of the epidemiologic features of pediatric CRPS are similar in different countries/cultures. Early recognition and management is the major factor in improving outcome and preventing resistant CRPS, but even children with delayed diagnosis still have a good outcome. The management of this disease by an experienced multidisciplinary team is recommended. Because psychosocial factors play an important role, it is recommended to provide psychological evaluation and cognitive behavioral treatment as soon as possible.
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Affiliation(s)
- Ludmyla Kachko
- Chronic Pain Clinic, Pain Treatment Service, Schneider Children's Medical Center of Israel, Petah Tiqwa, Israel.
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23
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Abstract
BACKGROUND Complex Regional Pain Syndrome type I (CRPS I) is a potentially incapacitating syndrome which can occur after a minor injury or operation to a limb. It is a disorder characterized by pain, sensory and motor disturbances. CRPS I is well known in adults, but a relatively new diagnostic entity in children. The clinical presentation of CRPS I in children is, to some extent, different from adults and therefore sometimes not recognized early. The aim of this study was to search for differences in patient characteristics between children and adults with CRPS I. METHODS We have performed a retrospective chart review of 78 children (age </=16 year) with CRPS I and compared the data with those of 951 adults with CRPS I. RESULTS The child population consisted predominantly of girls and older children (median age 13 years). The child population differed from adults in that the skin temperature of the involved extremity at onset was more often cooler, the lower extremity was involved more frequently and neurological and sympathetic symptoms were less pronounced. CONCLUSIONS In several aspects, CRPS I in children has a different presentation than in adults.
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Affiliation(s)
- Edward C T H Tan
- Department of General Surgery-Traumatology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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24
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Abstract
Significant advances in the assessment and management of acute pain in children have been made, and are supported by an increase in the availability and accessibility of evidence-based data. However, methodological and practical issues in the design and performance of clinical paediatric trials limit the quantity, and may influence the quality, of current data, which lags behind that available for adult practice. Collaborations within research networks, which incorporate both preclinical and clinical studies, may increase the feasibility and specificity of future trials. In early life, the developing nervous system responds differently to pain, analgesia, and injury, resulting in effects not seen in later life and which may have long-term consequences. Translational laboratory studies further our understanding of developmental changes in nociceptor pathway structure and function, analgesic pharmacodynamics, and the impact of different forms of injury. Chronic pain in children has a negative impact on quality of life, resulting in social and emotional consequences for both the child and the family. Despite age-related differences in many chronic pain conditions, such as neuropathic pain, management in children is often empirically based on data from studies in adults. There is a major need for further clinical research, training of health-care providers, and increased resources, to improve management and outcomes for children with chronic pain.
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Affiliation(s)
- S M Walker
- Portex Department of Anaesthesia, UCL Institute of Child Health and Great Ormond Street Hospital NHS Trust, 30 Guilford Street, London WC1N 1EH, UK.
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25
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Abstract
Complex regional pain syndrome (CRPS) is a relatively new diagnostic entity in pediatrics. There is debate as to what constitutes the most effective treatment for pediatric CRPS. This study presents the patient characteristics, clinical course, and treatment outcome of 20 children diagnosed with CRPS at a major children's hospital during a 4-year period. The results showed that pediatric CRPS occurs predominantly in girls (90%) in later childhood and adolescence (mean age, 11.8 [range, 8-16 years]). It affects mainly the lower limbs (85%), with a predilection for the foot (75% of all cases), and was frequently initiated by minor trauma (80%). In many cases, there was a lengthy time to diagnosis (mean, 13.6 weeks) that delayed the institution of treatment, which consisted of intensive physiotherapy and psychological therapy. Most children (70%) required adjuvant medications (amitriptyline and/or gabapentin) for analgesia and to enable them to participate in physiotherapy. A high percentage of children had complete resolution of symptoms using this treatment regime (mean, 15.4 weeks [range, 3 days to 64 weeks]), but 40% required treatment as a hospital inpatient and 20% had a relapse episode. In conclusion, pediatric CRPS is under-recognized by clinicians, resulting in diagnostic delays, but has a favorable outcome to noninvasive treatment in that complete resolution of symptoms and signs occur in most patients. However, the lengthy period to achieve symptom resolution in some children and a high relapse rate support the need for further research into other treatment modalities.
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Affiliation(s)
- Adrian K Low
- Children's Hospital at Westmead, Sydney, NSW, Australia.
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26
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Saroyan JM, Winfree CJ, Schechter WS, Roye D, Gold AP. Sciatic neuropathy after lower-extremity trauma: successful treatment of an uncommon pain and disability syndrome in an adolescent. Am J Phys Med Rehabil 2007; 86:597-600. [PMID: 17581294 DOI: 10.1097/phm.0b013e31806dbdd2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Lower-extremity trauma is an uncommon but reported cause of sciatic nerve injury in children and adolescents. Failure to identify sciatic neuropathy after traumatic injury to the lower extremity may lead to the delayed institution of neuropathic pharmacotherapy, electrodiagnostic testing, physical therapy, and increased risk for the development of complex regional pain syndrome. This article presents a case of an adolescent male with neuropathic pain and weakness in the right lower extremity after traumatic injury. Spontaneous recovery of the injured nerve occurred with early institution of pharmacologic and physical therapies. Operative exploration and neurolysis were considered but were not ultimately necessary.
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Affiliation(s)
- John M Saroyan
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA
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27
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28
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Farid IS, Heiner EJ. Intrathecal Local Anesthetic Infusion as a Treatment for Complex Regional Pain Syndrome in a Child. Anesth Analg 2007; 104:1078-80, tables of contents. [PMID: 17456655 DOI: 10.1213/01.ane.0000260563.39299.9c] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Diagnosis and treatment of complex regional pain syndrome in children is one of the most challenging clinical pain problems encountered in the chronic pain setting. Despite the intense and debilitating nature of the pain, referral to appropriate specialists often comes too late, thereby prolonging an already arduous (and controversial) course of treatment and risking long-term disability. On the contrary, full recovery can be expected with early diagnosis and prompt treatment. The following case study describes a novel and successful use of intrathecal catheter administration of ropivacaine in a child with early, rapidly progressing, and debilitating complex regional pain syndrome.
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Affiliation(s)
- Ibrahim S Farid
- Division of Pain Medicine, Akron Children's Hospital, Akron, Ohio 44308, USA.
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29
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Connelly M, Schanberg L. Latest developments in the assessment and management of chronic musculoskeletal pain syndromes in children. Curr Opin Rheumatol 2006; 18:496-502. [PMID: 16896289 DOI: 10.1097/01.bor.0000240361.32089.97] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW As many as 25% of new patients in pediatric rheumatology clinics present with idiopathic chronic pain and recent data suggest the prevalence of these conditions is increasing. Knowledge of the latest developments in assessment and treatment is critical for providing optimal clinical care. This review summarizes advances published in the past year forwarding our understanding of chronic musculoskeletal pain syndromes in children. RECENT FINDINGS Research has recently focused on the impairment associated with chronic pain syndromes in children, issues impacting the diagnosis of these conditions, and the efficacy of pharmacological and psychosocial treatments. No diagnostic criteria have been developed for specific chronic pain syndromes in children; however, data from several studies substantiate the need for thorough assessment of the child and family in multiple domains. In addition, studies have expanded both pharmacologic and psychosocial treatment options for children with these syndromes. SUMMARY Despite a growing body of research on chronic pain syndromes in children, there are no established standards of care. Data continues to support an interdisciplinary approach for effectively assessing and managing these conditions.
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Affiliation(s)
- Mark Connelly
- Duke University Medical Center, Durham, NC 27710, USA
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30
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Dadure C, Capdevila X. [Perioperative analgesia with continuous peripheral nerve blocks in children]. ACTA ACUST UNITED AC 2006; 26:136-44. [PMID: 17174518 DOI: 10.1016/j.annfar.2006.10.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Accepted: 10/09/2006] [Indexed: 10/23/2022]
Abstract
Recently, regional anaesthesia in children has generated increasing interest. But single injection techniques have a limited duration of postoperative analgesia. Then, continuous peripheral nerve blocks have taken an important position in the anaesthetic arsenal, allowing an effective, safe and prolonged postoperative pain management. As adults, indications for continuous peripheral nerve blocks depend on the analysis of individual benefits/risks ratio. Main indications are intense postoperative pain surgical procedures, with or without postoperative rehabilitation, and complex regional pain syndrome. Contraindications to these procedures are rather similar to those in adults, plus parental and/or children refusal. Continuous peripheral nerve blocks are usually performed under general anaesthesia or sedation in children, and require appropriate equipment in order to decrease the risk of nerve injury. New techniques, such as transcutaneous nerve stimulation or ultrasound guidance, appeared to facilitate nerve and plexus approach identification in paediatric patients. Nevertheless, continuous peripheral nerve block may theoretically mask a compartment syndrome after trauma surgical procedures. Finally, ropivacaine appears to be the most appropriate drug for continuous peripheral nerve blocks in children, requiring low flow rates and concentrations of local anaesthetic. These techniques may facilitate early ambulation by an improved pain management or even postoperative analgesia at home with disposable pumps. One might infer from the current review that excellent pain relief coupled with a reduction of side effects would contribute to improve the quality of life and to decrease the frequency of disabling behavioural modifications in children, sometimes psychologically injured by hospital stay and postoperative pain.
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Affiliation(s)
- C Dadure
- Département d'anesthésie et de réanimation A, centre hospitalier universitaire Lapeyronie, 371, avenue du Doyen-Giraud, 34295 Montpellier, France
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31
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Anderson BJ, Palmer GM. Recent developments in the pharmacological management of pain in children. Curr Opin Anaesthesiol 2006; 19:285-92. [PMID: 16735812 DOI: 10.1097/01.aco.0000192802.33291.6f] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW This review explores progress in developmental pharmacokinetics, pharmacogenomics and formulations of analgesic agents, and discusses potential implications for pain therapy. RECENT FINDINGS Characterization of the developmental pharmacokinetics of morphine, tramadol, paracetamol and nonsteroidal anti-inflammatory drugs has improved dosing in children. Oral sugar solutions have replaced the brandy/sugar pacifier and are effective for single painful events in neonates. Intravenous paracetamol offers increased dosing accuracy, and avoids absorption and bioavailability variability. New nitric-oxide-releasing versions of paracetamol and nonsteroidal anti-inflammatory drugs offer safer alternatives to their parent drugs with enhanced potency. Ketamine has come under a cloud for its possible effects on the neonatal developing brain, but it is being used increasingly in children to supplement opioids for pain after major surgery. Hopes that morphine analgesia may improve neurological outcome in premature babies have not materialized. Reports concerning chronic pain are generally case series and controlled trials are rare and nearly nonexistent in children. SUMMARY Unlicensed drug use in the very young will increase as familiarity increases. Pharmacogenomic studies have the potential to tailor drug therapy to the individual and decrease between-patient variability. Unfortunately, the pharmacodynamic knowledge in children of analgesic agents remains neglected and is usually extrapolated from adult data.
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Affiliation(s)
- Brian J Anderson
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand, and Department of Anaesthesia and Pain Management, Royal Children's Hospital, Victoria, Australia.
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Lalwani K, Shoham A, Koh JL, McGraw T. Use of oxcarbazepine to treat a pediatric patient with resistant complex regional pain syndrome. THE JOURNAL OF PAIN 2006; 6:704-6. [PMID: 16202964 DOI: 10.1016/j.jpain.2005.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2005] [Revised: 05/20/2005] [Accepted: 05/24/2005] [Indexed: 10/25/2022]
Abstract
UNLABELLED We describe a 12-year-old patient with severe, protracted complex regional pain syndrome type I. His pain did not respond to gabapentin, amitriptyline, physical therapy, opioids, or nonsteroidal drugs. Sympathetic or regional block was not attempted because of persistent bacteremia and severe local sepsis. His pain responded dramatically to the addition of oxcarbazepine, with rapid improvement in his symptoms and functional status. We suggest that oxcarbazepine might be a useful adjunct in the treatment of gabapentin-resistant complex regional pain syndrome type I in children and should be considered. PERSPECTIVE Oxcarbazepine's antinociceptive effect is mediated via sodium channel inhibition in neuropathic models and by inhibition of substance P and prostaglandins in anti-inflammatory models. The efficacy of oxcarbazepine in this patient might be attributable to these mechanisms or possibly to synergism with either gabapentin or the anti-inflammatory effects produced by amitriptyline.
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Affiliation(s)
- Kirk Lalwani
- Department of Anesthesiology, Oregon Health and Science University, Portland, Oregon 97239, USA.
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