A brief summary about Complex Regional Pain Syndrome( Def, Aetiology, Pathophysiolog, Diagnosis and Treatment options. If you like it, most welcome to share it

1. Complex Regional Pain
Syndromes (CRPS)
Dr. Ahmed Youssef
MD Orthopedics
Mubarak Alkabeer Hospital
Kuwait

2. Sustained sympathetic
activity in a perpetuated
reflex arc characterized
by pain out of proportion to
physical exam findings

3. Terminology: RSD vs CRPS
RSD = traditional term
Complex regional pain syndrome (CRPS)
Includes disorders not related to sympathetic nervous
system dysfunction
CRPS I = RSD
CRPS II = causalgia (involves nerve injury)

4. Historical Background
Weir Mitchell : After the American Civil War in
1872. Soldiers —gun-shot wounds —“bizarre”
symptoms — “Causalgia”
Peter Sudeck : Early 20th century described
features of pain, swelling, atrophy etc. following
minor injury to limb
Reflex sympathetic dystrophy —its
association with the sympathetic nervous
system
Complex Regional Pain Syndromes (CRPS)

5. Epidemiology
• Age: common in younger adults, mean age at time of
injury 37.7 years
• Sex: 2.3 to 3 times more frequent in females than
males
• Site: usually involves a single limb in the early stage

8. Swelling and Color Changes

9. Skin Discoloration

10. Abnormal Sweating in CRPS

11. Lankford and Evans Stages of RSD
Stage Onset Exam Imaging
Acute 0-3 months
Pain, swelling,
warmth, redness,
decreased ROM,
hyperhidrosis
Normal x-rays,
Positive three-
phase bone scan
Subacute 3-12 months
Worse pain,
cyanosis, dry skin,
stiffness, skin
atrophy
Osteopenia on x-
ray
Chronic >12 months
Diminished pain,
fibrosis, glossy
skin, joint
contractures
Sever osteopenia
on x-ray

12. International Association for the Study
of Pain Classification
Type I
• CRPS without demonstrable nerve lesions
• Most common from trauma, cast or tight bandage
Type II
• CRPS with identifiable nerve damage
• Minimal positive response with sympathetic blocks

13. Differential Diagnoses
• Deep vein thrombosis
• Cellulitis
• Vascular insufficiency
• Lymphedema
• Erythromelalgia ( rare
disorder characterized by burning
pain, warmth, and redness of the
extremities )
• Diabetic neuropathies
• Entrapment
neuropathies
• Thoracic outlet
syndrome
• Discogenic disease

14. Imaging
• X -rays: Osteopenia in late
stages, Patellar osteopenia in
knee CRPS
• Three-phase Bone Scan: To
rule out CRPS type I (has high
negative predictive value)

15. Infrared Thermography
• Uses an electronic thermographic apparatus to create
computer-generated images that display changes in
temperature.——Questionable utility

16. EMG& NCV
May show slowing in known nerve distribution e.g.
slowing of median nerve conduction for CRPS type II
in forearm

17. Prevention
Vitamin C 500 mg daily x 50 days in distal radius
fractures treated conservatively
200mg daily x 50 days if impaired renal function
Vitamin C also has been shown to decrease the
incidence of CRPS (type I) following foot and ankle
surgery
Avoid tight dressings and prolonged immobilization

18. Treatment
Goals
• Rehabilitation
• Pain management
• Psychological treatment
Multidisciplinary
• Physiotherapy
• Medical
• Psychological
Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.

19. Rehabilitation
Mobilization and isometric strengthening
Stress loading, isotonic strengthening, range of
motion
Postural normalization and aerobic conditioning

20. Pharmacalogic Pain Management
Most drugs used for neuropathic pain are used to treat
CRPS
NSAIDs
Alpha blocking agents (phenoxybenzamine)
Antidepressants
Calcium channel blockers
GABA agonists
IV Alendronate

21. Minimally Invasive Therapies
Sympathetic, IV regional, and somatic nerve
blocks—>Patients with a sympathetic component
For patients without…—>a somatic block or
epidural infusion

22. More Invasive Therapies
Neuroaugmentation
Spinal cord stimulation
Intrathecal drug delivery
Stanton-Hicks M et al. Pain Practice. 2002;2:1-16.

23. Surgical Therapies: Sympathectomy
Controversial procedure
In carefully selected patients, may result in reduction
in pain severity and disability —>Patients with SMP
who respond to selective sympathetic blockade
Radiofrequency and neurolytic techniques are
alternatives to a surgical sympathectomy
Bandyk DF et al. J Vasc Surg. 2002;35:269-277.

24. Prognosis
Difficult to predict
Earlier intervention may be more
likely to be successful

25. Take Home Messages
CRPS is a chronic neurologic syndrome
Not all patients have the same set of
symptoms
Early diagnosis and appropriate
treatment is essential
Ideal treatment should be
multidisciplinary

26. Thank You