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CRPS: A surgical view….
Dominic Power
CRPS: Historical Perspective
• 1864
– Silas Weir Mitchell described “causalgia” in American
Civil War veterans
• 1946
– Evans popularised term “RSD” following successful
treatment of patients using sympathetic blockade
• 1986
– IASP Working Party redefined RSD as CRPS I and II
• 1999
– Harden proposed modified diagnostic criteria
including trophic and motor signs
CRPS: Associations
• Distal radius fractures
• Limb fractures
• Vascular injury
• Nerve injury (CRPS II)
• MI
• CVA
CRPS: Pathophysiology
• Trauma
– Activation of inflammatory cascade
• Ischaemia-reperfusion
– Reactive Oxygen Species & Free Radicals
• Immobilisation
– Free radicals
– Mast cell activation
– Osteoclast differentiation
CRPS: Pathophysiology in Trauma
• Trauma
• Ischaemia-reperfusion
• Immobilisation
“Plaster disease”
Trophism, pain, stiffness & loss of function in
immobilized limb
Tight cast – cause or effect?
Incidence declining with ORIF radius fractures?
CRPS: Physiological Theories
• Neuroinflammatory factors
• Abnormal sympathetic nervous system - SMP
• Central sensitization in dorsal horn cells
• Spinal cord microglia
• Cortical re-organization
CRPS: A Simple Surgeon’s View
Traumatic
Event
Inflammatory
Response
Resolution
Functional
Recovery
CRPS: A Simple Surgeon’s View
Traumatic
Event
Inflammatory
Response
Resolution
Functional
Recovery
Exaggerated
Response
CRPS: A Simple Surgeon’s View
Traumatic
Event
Inflammatory
Response
Resolution
Functional
Recovery
Exaggerated
Response
Further
Injury
CRPS: A Simple Surgeon’s View
Traumatic
Event
Inflammatory
Response
Resolution
Functional
Recovery
Exaggerated
Response
Further
Injury
CRPS: A Simple Surgeon’s View
Traumatic
Event
Inflammatory
Response
Resolution
Functional
Recovery
Exaggerated
Response
Further
Injury
Chronicity
& Memory
CRPS: A Simple Surgeon’s View
Traumatic
Event
Inflammatory
Response
Resolution
Functional
Recovery
Exaggerated
Response
Further
Injury
Chronicity
& Memory
Functional
Deficit
CRPS: A Simple Surgeon’s View
Traumatic
Event
Inflammatory
Response
Resolution
Functional
Recovery
Exaggerated
Response
Further
Injury
Chronicity
& Memory
CRPS
Treatment
CRPS: “An allergic reaction to trauma”
Traumatic
Event
Inflammatory
Response
Resolution
Functional
Recovery
Exaggerated
Response
Further
Injury
Chronicity
& Memory
CRPS
Treatment
CRPS: Clinical Syndrome
• Disproportionate pain
• Sensory
– Hyperaesthesia, hyperalgesia, allodynia, hyperpathia
• Vasomotor
– Skin temperature and colour asymmetry
• Motor
– Reduced ROM, weakness, tremor, dydtonia
• Sudomotor
– Oedema, sweating dysfunction and asymmetry
• Trophic changes
– Neglect
– Hair, nail and skin trophic changes
CRPS: The Typical T&O Patient
• Female (3:1)
• Age 40-50
• Upper limb injury
• Psychosocial issues
– No evidence of CRPS preconditioned personality
– Definite evidence that psychological stress and
prolonged pain may lead to behavioural changes
and may influence the perception and response to
pain
The Problems
• Patient dysfunctional behaviour?
• Loss of confidence
– Difficult to diagnose in first 3 months
– High index of suspicion
– Pain and stiffness greater than expected
– Symptoms often dismissed in early phase
• Poor understanding
• Loss of function
• Fear regarding permanency
• Pain
My approach
• Listen
• Explain the underlying problem
• Honesty regarding timeframe for recovery
• Develop a strategy for treatment
• Treat underlying disorder (eg CTS)
• Review medications
• Access appropriate services
• Provide resources
• Review regularly
CRPS: My Explanation
• The nerves carry signals to the brain and retuen signals to
the muscles, skin and blood vessels
• Sensitivity is tightly controlled
• In CRPS the sensitivity mechanism is dysfunctioning
• Compare to a faulty movement sensor in a burglar alarm
system
• Alarm triggers with normally non-injurious stimulus
• Alarm may not trigger when it should
• Strategy is to deal with sequelae and allow the sensitivity
settings to return to normal
• Delay in treatment may produce permanency
• Early treatment may allow resolution in 12-24 months
Surgery is more art than science…
• There are some patients that shouldn’t be
treated with surgery
• …. But there are some surgeons who shouldn’t
treat patients
CRPS: My Treatment Strategy
• Look for reversible causes
– Eg treat CTS
• Pain relief
– Neuromodulators, Nsaids, Opioids
• Other agents
– Alpha Blockade, Vitamin C, Bisphosphonates, Capsaicin
• Therapy
– Splints, Active ROM, education
• Encourage hand use
– Normalisation of function
• Mirror therapy
– Use of mirror neurons to suppress cortical re-organisation
• Pain clinic support
– Sympathetic blockade, Spinal cord stimulation

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CRPS: A surgeon's perspective

  • 1. CRPS: A surgical view…. Dominic Power
  • 2. CRPS: Historical Perspective • 1864 – Silas Weir Mitchell described “causalgia” in American Civil War veterans • 1946 – Evans popularised term “RSD” following successful treatment of patients using sympathetic blockade • 1986 – IASP Working Party redefined RSD as CRPS I and II • 1999 – Harden proposed modified diagnostic criteria including trophic and motor signs
  • 3. CRPS: Associations • Distal radius fractures • Limb fractures • Vascular injury • Nerve injury (CRPS II) • MI • CVA
  • 4. CRPS: Pathophysiology • Trauma – Activation of inflammatory cascade • Ischaemia-reperfusion – Reactive Oxygen Species & Free Radicals • Immobilisation – Free radicals – Mast cell activation – Osteoclast differentiation
  • 5. CRPS: Pathophysiology in Trauma • Trauma • Ischaemia-reperfusion • Immobilisation “Plaster disease” Trophism, pain, stiffness & loss of function in immobilized limb Tight cast – cause or effect? Incidence declining with ORIF radius fractures?
  • 6. CRPS: Physiological Theories • Neuroinflammatory factors • Abnormal sympathetic nervous system - SMP • Central sensitization in dorsal horn cells • Spinal cord microglia • Cortical re-organization
  • 7. CRPS: A Simple Surgeon’s View Traumatic Event Inflammatory Response Resolution Functional Recovery
  • 8. CRPS: A Simple Surgeon’s View Traumatic Event Inflammatory Response Resolution Functional Recovery Exaggerated Response
  • 9. CRPS: A Simple Surgeon’s View Traumatic Event Inflammatory Response Resolution Functional Recovery Exaggerated Response Further Injury
  • 10. CRPS: A Simple Surgeon’s View Traumatic Event Inflammatory Response Resolution Functional Recovery Exaggerated Response Further Injury
  • 11. CRPS: A Simple Surgeon’s View Traumatic Event Inflammatory Response Resolution Functional Recovery Exaggerated Response Further Injury Chronicity & Memory
  • 12. CRPS: A Simple Surgeon’s View Traumatic Event Inflammatory Response Resolution Functional Recovery Exaggerated Response Further Injury Chronicity & Memory Functional Deficit
  • 13. CRPS: A Simple Surgeon’s View Traumatic Event Inflammatory Response Resolution Functional Recovery Exaggerated Response Further Injury Chronicity & Memory CRPS Treatment
  • 14. CRPS: “An allergic reaction to trauma” Traumatic Event Inflammatory Response Resolution Functional Recovery Exaggerated Response Further Injury Chronicity & Memory CRPS Treatment
  • 15. CRPS: Clinical Syndrome • Disproportionate pain • Sensory – Hyperaesthesia, hyperalgesia, allodynia, hyperpathia • Vasomotor – Skin temperature and colour asymmetry • Motor – Reduced ROM, weakness, tremor, dydtonia • Sudomotor – Oedema, sweating dysfunction and asymmetry • Trophic changes – Neglect – Hair, nail and skin trophic changes
  • 16. CRPS: The Typical T&O Patient • Female (3:1) • Age 40-50 • Upper limb injury • Psychosocial issues – No evidence of CRPS preconditioned personality – Definite evidence that psychological stress and prolonged pain may lead to behavioural changes and may influence the perception and response to pain
  • 17. The Problems • Patient dysfunctional behaviour? • Loss of confidence – Difficult to diagnose in first 3 months – High index of suspicion – Pain and stiffness greater than expected – Symptoms often dismissed in early phase • Poor understanding • Loss of function • Fear regarding permanency • Pain
  • 18. My approach • Listen • Explain the underlying problem • Honesty regarding timeframe for recovery • Develop a strategy for treatment • Treat underlying disorder (eg CTS) • Review medications • Access appropriate services • Provide resources • Review regularly
  • 19. CRPS: My Explanation • The nerves carry signals to the brain and retuen signals to the muscles, skin and blood vessels • Sensitivity is tightly controlled • In CRPS the sensitivity mechanism is dysfunctioning • Compare to a faulty movement sensor in a burglar alarm system • Alarm triggers with normally non-injurious stimulus • Alarm may not trigger when it should • Strategy is to deal with sequelae and allow the sensitivity settings to return to normal • Delay in treatment may produce permanency • Early treatment may allow resolution in 12-24 months
  • 20. Surgery is more art than science… • There are some patients that shouldn’t be treated with surgery • …. But there are some surgeons who shouldn’t treat patients
  • 21. CRPS: My Treatment Strategy • Look for reversible causes – Eg treat CTS • Pain relief – Neuromodulators, Nsaids, Opioids • Other agents – Alpha Blockade, Vitamin C, Bisphosphonates, Capsaicin • Therapy – Splints, Active ROM, education • Encourage hand use – Normalisation of function • Mirror therapy – Use of mirror neurons to suppress cortical re-organisation • Pain clinic support – Sympathetic blockade, Spinal cord stimulation