JOURNAL TRANSCRIPT
PAIN MEDICINE FOR THE NON-PAIN SPECIALIST 2017 FEBRUARY 16-18, 2017 JW MARRIOTT DESERT SPRINGS RESORT & SPA PALM DESERT, CALIFORNIA
Learn the latest treatment strategies and multidisciplinary management options for patients with acute and chronic pain. ©2016 MFMER | 3572499-1
Complex Regional Pain Syndrome (CRPS) Halena M. Gazelka, MD Anesthesiology and Perioperative Medicine Division of Pain Medicine Mayo Clinic, Rochester, MN February 17, 2017
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Disclosure • No financial disclosures • I will discuss off label use of some medications
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Objectives • Recognize the criteria for diagnosis of CRPS • Review diagnostic studies utilized in CRPS • Discuss current treatment strategies
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17th Century – King Charles IX
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19th Century – Silas Weir Mitchell
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CRPS
• PAINFUL neuropathic condition • Occurs following trauma • Remains after healing • Out of proportion to initial injury
*No other explanation for the signs/symptoms * ©2016 MFMER | 3572499-8
Two types Type I:
initial event may or may not have been painful (no overt nerve injury)
Type II: definable nerve injury present
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Stats • Women > men • Middle age • Upper extremities • Fracture most common inciting event
De Mos, et al. Pain. 2007;129:12-20. Sandroni, et al. Pain. 2003;103:199-207. ©2016 MFMER | 3572499-10
Mrs S • Healthy 56 y.o. • Bunionectomy • Presented to follow up w/podiatrist describing: “terrible burning pain in my foot! It’s swollen, bright red, and hot!”
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Signs/Symptoms 1. Sensory:
allodynia (non-painful touch is painful) hyperalgesia (painful stimuli hurt more) neuropathic pain (burning, lancinating, etc)
2. Vasomotor: temp asymmetry (hotter or colder than other limb) skin color change 3. Sudomotor/edema: edema sweating changes 4. Motor /trophic: decreased range of motion motor dysfunction (weakness, tremor, etc) trophic changes (hair, nails, skin)
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Diagnosis • CRPS is a CLINICAL diagnosis • Diagnosis of exclusion • Some tests may be useful/supportive • Sweat test • Useful in the evaluation of small fiber neuropathy • May help document presence/absence of sudomotor dysfunction • Thermography • Infrared thermometer measures multiple points on extremities • Difference of 10 C is considered significant • QSART • Measures sweat output to a cholinergic challenge • Measure sweat bilaterally and symmetrically • Bone densitometry • Decreased bone mineral density and bone mineral content • 3 Phase bone scan • Increased periarticular activity = increased bone metabolism • Sensitivity and specificity of 80% ©2016 MFMER | 3572499-14
But what causes CRPS?
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Pathophysiology of CRPS • Lots of theories…. • Sympathetically maintained pain • Somatic nervous system • Inflammation • Hypoxia/Endothelial dysfunction • Likely an interplay of nervous system dysfunctions….
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Treatment of CRPS….
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Treatment of CRPS • Physical therapy/restoration • Medical • Interventional • Neuromodulation
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Treatment of CRPS
• Goals:
reduce pain preserve limb function return to activity
= FUNCTIONAL RESTORATION
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Medical Treatment of CRPS • Opioids • Oral corticosteroids • Ca2+ channel blockers • Anticonvulsants • IVIG • Sildenafil • Cannabanoids • Botulinum toxin • Topical agents (capsacin) • Epidural infusions • Ketamine infusions • Vit C • Bisphosphonates
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Practical medical therapy of CRPS • Neuropathic agent: gabapentin or pregabalin
• TCA: nortriptyline or amitriptyline
• SNRI: duloxetine (lowest efficacious dose = 60 mg)
• Topical agents: lidocaine (5% patch FDA approved) ketamine (compounded products) capsaicin (Qutenza) • IV: Bisphosphonates (improvement in pain. ? Improvement in osteopenia) ©2016 MFMER | 3572499-23
Interventional therapies • Upper extremity stellate ganglion block
• Lower extremity lumbar sympathetic block
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Neuromodulation • Spinal cord stimulation • FDA approved • good evidence • Effective therapy for “non-responders”
• Cost effective
• Early, rather than late
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Mr S • Very motivated patient! • Aggressive, early intervention
• PT – desensitization
• Pregabalin 225 mg twice daily
• Nortriptyline 75 mg nightly
• Off of all meds within 9 mos of diagnosis
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Summary • CRPS: a type of neuropathic pain • Diagnosis is clinical • Focus: functional restoration • Medical therapy similar to other neuropathic pain • Spinal cord stimulation can be “life changing” for nonresponders to more conservative therapy ©2016 MFMER | 3572499-28
[email protected]
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