CRPS DOESN'T HAVE TO BE COMPLEX - A STORY FOR GPS

INTRODUCTION

One of our pain specialists recently received an urgent referral from a hand surgeon. The patient had acute complex regional pain syndrome (CRPS) following a relatively minor forearm surgery.

According to our pathway, the patient was prioritised and seen as a matter of urgency. They were diagnosed with full blown complex regional pain syndrome (CRPS) according to the Budapest Diagnostic Criteria, which are as follows:

BUDAPEST DIAGNOSTIC CRITERIA FOR CRPS

These are the Budapest Diagnostic Criteria for CRPS:

  • Continuing pain, which is disproportionate to any inciting event
  • Must report at least one symptom in three (clinical diagnostic criteria) or four (research diagnostic criteria) of the following categories:
    • Sensory: hyperesthesia or allodynia
    • Vasomotor: temperature asymmetry, skin colour changes, or skin colour asymmetry
    • Sudomotor or oedema: oedema, sweating changes, or sweating asymmetry
    • Motor or trophic: decreased range of motion, motor dysfunction (weakness, tremor, or dystonia), or trophic changes (hair, nails, or skin)
  • Must display at least one sign at time of diagnosis in two or more of the following categories:
    • Sensory: hyperalgesia (to pinprick) or allodynia (to light touch, deep somaticpressure, or joint movement)
    • Vasomotor: temperature asymmetry, skin colour changes or asymmetry
    • Sudomotor or oedema: oedema, sweating changes, or sweating asymmetry
    • Motor or trophic: decreased range of motion, or motor dysfunction (weakness, tremor, or dystonia), or trophic changes (hair, nails, or skin)
  • No other diagnosis better explains the signs and symptoms

So the patient had:

  • Severe pain - check
  • Hyperalgesia, alodynia - check
  • Warm forearm and wrist - check
  • Swelling - check
  • Stiffness - check, check!
  • No other diagnosis to explain this e.g. infection or vascular insufficiency - check
 Picture reproduced by Patientenvereniging CRPS under the Creative Commons Attribution-Share Alike 3.0 Unporte

Picture reproduced by Patientenvereniging CRPS under the Creative Commons Attribution-Share Alike 3.0 Unporte

THE FOLLOWING TREATMENTS WERE STARTED:

  • Reassured the patient, we would get on top of his pain ASAP.
  • Educated the patient on what CRPS was & why it was happening.
  • Motivated the patient.
  • Called the expert hand therapists we work with & got the patient an appointment for intense hand therapy to start the following day.
  • Started the patient on 2 anti-neuropathic agents - pregabalin 75mg BD and amitriptyline 25-50mg nocte. These are pretty high starting doses but the patient had severe neuropathic pain.
  • Started the patient on high dose Vitamin C 500mg / day

THE FIRST MEDICAL REVIEW

Reviewed the patient in 7 days i.e. early, to make sure the patient was going the right way. The patient was on the mend but stiff stiff and in pain. The pregabalin was giving some side effects e.g.having problems concentrating at work.

But the patient was improving so the following aggressive next step therapies were added:

  • Reassured him, we were getting on top of his pain - building rapport.
  • Educated him on CRPS and the treatments - reinforcement.
  • Motivated him - like we do for all our patients.
  • Switched the pregabalin to gabapentin100mg TDS and quickly titrated it to 300mg TDS.
  • Continue the amitriptyline 25mg nocte.
  • Continue aggressive hand therapy.
  • Started him on a pain cream compounded with DMSO 5%, clonidine 0.2% & ketamine 10% applied TDS to the painful area. This would allow some desensitisation of the area and provide good pain reduction at no systemic side effects
  • Started a sharp course of oral steroids - prednisolone 40mg/day x 4 days, then 30mg/day x 4 days, then 20mg/day x 4 days, then 10mg/day x 4 days, then stop.

THE SECOND MEDICAL REVIEW

The plan was for a review in 2 weeks & if no improvement we would escalate to injection therapy like sympathetic blocks (stellate and/or thoracic). But when the patient was reviewed the patient was almost back to normal. The patient had self weaned off all anti-neuropathics and was only undergoing hand therapy and using the compounded pain cream.

THE MORAL(S) OF THE STORY

  • Get patients to pain specialists early, when we can do the most for patients.
  • Always educate, build rapport and motivate patients.
  • Use multiple anti-neuropathic agents systemically and locally.
  • Pregabalin is not the only anti-neuropathic agent out there. In fact there are many other good ones.
  • Use a multidisciplinary team approach - it’ll never work any other way.
  • See patients regularly.
  • Have a PLAN B and PLAN C to escalate therapy.
  • Use the right therapy, for the right patient, at the right time.
  • CRPS is an inflammatory condition so treat it as such.

A must read on CRPS here. An excellent introduction into the clinical features and pathophysiology of CRPS. 


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