COMPLEX REGIONAL PAIN SYNDROME

Introduction

• CRPD presents in 1-15% of patients with cases of peripheral nerve injury.
• 10-30% of CRPD cases come to light after fracture, sprain or other soft tissue injuries.
• While no one is immune to this pain syndrome, the affected population is overwhelmingly white and female. 96% with CRPD are white and 80% are female.
• All age groups have been affected by this syndrome.
• Children have had the best overall response to treatment to CRPD.

Classification

• Type 1 CRPD is caused by injury and/or illness that had no direct damage on the nerves in the affected area. Of all the reports of this syndrome, 90% of cases are type 1.
• Type 2 CRPD (used to be called causalgia during the civil war) is the first recognized case of this syndrome and is caused by severe and direct nerve injury.
• Several cases of this syndrome appear when a forceful and traumatic injury is done to the leg or arm. (Fracture, amputation, crush).
• Other causes that have been noted are heart attack, sprained wrist/ankle and various infections.

Causes & Risk factors

• Fractures
• Lacerations
• Stroke
• Multiple Sclerosis
• Burns
• Frostbite
• Surgery
• Crush injury
• Penetrating injury
• Blood draws
• Diabetic Neuropathy
• Trauma

Symptoms and signs

• Changes in hair and/or nails
• Being sensitive to light touches
• Excessive sweating
• Swelling found in the leg or the arm
• Skin is unusually hot or cold
• The pain is that of burning and is feels much deeper than it should for the injury received

• Slowing of hair growth
• Nails become very brittle and begin to crack
• The injured limb becomes very cold feeling
• Muscle weakness sets in along with spasms
• The original swelling in the injured part becomes hard feeling
• The burn reaches past the initial area of injury and appears to be spreading

• Loss of  muscle function
• Joint mobility becomes limited
• Skin may appear pale and take on a shiny blue sheen

Diagnosis

• Investigation into patients physical medical history
• Complete physical exam
• Bone scan to see if there have been changes in the bones
• A sympathetic nervous system test to check for any disturbance within the sympathetic nerve system
• X-rays to see if there has been mineral loss in the bones
• Magnetic resonance imaging (MRI) is used to check all other aspects of the symptoms as this test can revel many things that other imaging tests miss

• Arterial insufficiency
• Cellulitis
• Central pain syndrome
• Conversion disorder
• Malignancy
• Osteomyelitis
• Pain disorder
• Rheumatoid arthritis
• Septic arthritis
• Tenosynovitis
• Thromophlebitis
• Peripheral vascular disease
• Factitious disorder
• Breast cancer with involvement of lymph nodes

Treatment

• Pain relieving medications, both over the counter and prescribed
• Acupuncture
• Biofeedback
• Physical therapy
• Mirror box therapy
• Transcutaneous nerve stimulation
• Anti-anxiety medications
• Antidepressants
• Sympathetic nerve block
• Sympathectomy
• Therapy and other psychological support for anxiety and depression

Complications Of Disease

• Atrophy is one complication that should be of great concern. This is where your muscle tissue wastes away for lack of use. Atrophy makes moving the limbs difficult because they are so stiff. In addition to the muscles atrophying, the bones and skin may do so as well.
• The other complication that should be taken notice of is contracture. This tightening of the muscles can lead to the fingers and hands and feet and toes to contract and stay in a fixed position for good.

Prognosis

• Remission happens in certain cases
• In some cases there is never any improvement
• 30% of patients will have the pain spread to other areas in spite of the treatment
• Prognosis is best when this syndrome is caught early and treatment begins as soon as possible after the onset

Prevention

• After you have a break or a fracture, begin a strict vitamin c regimen. This has proven to be especially helpful in prevention when there is a wrist fracture involved.
• After a stoke occurs, the patient should try to do as much moving around as possible, such as getting out of bed and walking around, even for a few minutes per day. This has shown to lower the risk of developing CRPD.

References