BRIEF DISCUSSION

COMPLEX REGIONAL PAIN

SYNDROME
25-08-2009

MODERATORS: - Professor & HOD B J Kamath

Dr Deepak M Naik
PRESENTER: - Dr Praveen Babu K H
Department of Orthopaedics
Kasturba Medical College,
Mangalore

Introduction
Complex regional pain syndrome (CRPS) is a
chronic progressive disease characterized
by severe pain, swelling and changes in the
skin.
The exact cause of this syndrome is
currently unknown.

Synonyms

Reflex Sympathetic
dystropy

Sudecks osteodystrophy

Algo dystrophy

Causalgia after nerve injury

Pour four du petit syndrome

Sympathetic paralysis

Synonyms Cont

Leriche posttraumatic

pain syndrome

Sympathic maintaince

pain syndrome

Transient osteoperosis

Acute atrophy of bone

Shoulder-hand syndrome

History and
Nomenclature

Ambroise in the 17th century

1864 S W Mitchell during the

American Civil War

1900 Sudeck described regional

demineralization

1946, Evans reflex sympathetic

dystrophy.

1993, a special consensus

workshop held in Orlando, Florida

S W Mitchell

Epidemiology

Age common in younger adults

Mean 41.8 years
Mean age at time of injury 37.7 years

Mean duration of symptoms before pain center

evaluation = 30 months

2.3 to 3 times more frequent in females than

males

Usually involves a single limb in the early stage

Classification
The International
Association for the
Study of Pain
Type I, does not have
demonstrable nerve
lesions.
Type II, also known as
causalgia, has evidence
of obvious nerve
damage.

Etiology
Triggered

In

by a variety of events
Minor trauma ranks as the leading provocative
event
Ischemic heart disease and myocardial infarction
Cervical spine or spinal cord disorders
Cerebral lesions
Infections
Surgery
Repetitive motion disorder or cumulative trauma

approximately 10% of patients, no precipitant can be

identified

Clinical Features
History
Symptoms develop following injury
Single extremity.
Burning pain.
Hyperalgesia
Swelling.
Asymmetry or instability of temperature or color.
Asymmetry or instability of sweating.
Trophic changes of skin, nails, hair.

Clinical Features cont

On examination
Hyperalgesia or allodynia.
Edema
Vasomotor changes
Sudomotor changes
Trophic changes
Shiny Skin,
Hair Loss,
Abnormal Nail Growth.

Impaired motor function

Stage I (Acute stage)

Characterized by mild
Symptoms
Begins within days or weeks
Sharp, burning pain, swelling
and dysfunction are localized
Symptoms are mild
Allodynia is generally absent
Hyperesthesia
Limb is relatively immobile
and sensitive
Last up to 3 months.

Stage II CRPS
(Dystrophic)
Increasing dysfunction
Chronicity of the symptoms.
Pain & sensitivity persists
Moist , cold & edematous
The skin becomes mottled.
Increasing joint stiffness
Myofascial contractures
Can last 3 to 12 months.

Stage III CRPS

(atrophic)

Most severe stage

Severe aching and throbbing pain
Functionally useless
Chronic autonomic dysfunction
Dystrophic changes
Halted growth
Regional osteoporosis
Symptoms are unresponsive
Considered permanent

Differential Diagnosis
Diabetic and small-fiber
peripheral neuropathies
Entrapment neuropathies
Thoracic outlet
syndrome
Vascular insufficiency

Deep vein
thrombosis
Cellulitis
Lymphedema
Erythromelalgia
Discogenic disease

Investigations
Thermography may be helpful
CT, MRI, bone scan may be normal
X-ray may show osteoporosis
Modified Sympathetic Blockade Testing

Treatment
Physical therapy
Pharmacologic management
Bisphosphonate
Baclofen
Adrenergic active drugs
Systemic steroids
Other therapies

Treatment Cont

Invasive treatments

Ganglion blocks
Intravenous regional
blocks
Epidural clonidine
Regional sympathetic
nerve block

Treatment Cont
Dorsal column
spinal cord
stimulation
Sympathectomy
Tender point
injections
Nerve stimulation