Chronic Regional Pain Syndrome / Sudecks

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I'm currently dealing with a CRPS patient who is Type 1 Diabetic, with peripheral neuropathy, but good vasculature.

Had a fusion of the 1st mtpjt ages ago (10 years at least) and has now developed CRPS over the last 6 months dorsally to the 2nd ray, focused around the met-cuneiform joint.

The pain is not associated with activity, but classic signs of mottling, temperature changes and hypersensitivity.

X-rays were unremarkable other then the fusion.

MRI is requested.

Bone scan has been declined on basis of cost.

We have no pain clinic in this area of the NHS (whoppeeee)!

We've tried NSAIDs topical and oral, para-codeine combinations, gabapentin, amitriptyline and have exluded Charcot and osteomyelitis.

Can anyone suggest any intervention that may help?

Many thanks!

 

Have you tried any of the newer agents for DPNP, lyrica or cymbalta, some pain doc's have been using these off label (singularly and in combination) for CRPS.

 

Tricky one. Autonomic neuropathy plays a role in CRPS and diabetes .... hmmmm?? - what abot neurological referal for sympathetic blocks (maybe problematic because of diabetes).

As this has potential to be, or already is, a chronic pain problem, then psychological counselling from a pain clinic may be needed.

 

I haven't tried any of the agents mentioned but will discuss with the Endocrinologist I'm working with regarding that.

Craig, I've no pain clinic to refer to, hence why we're still dealing with it, but counselling may be an avenue. We've sent him to an anaesthetist who does the nerve block stuff in the hospital in isolation of a pain clinic and are awaiting the results of the consultation.

What's really worrying is that none of the interventions we've tried have made the slightest difference and his wife's a Pharmacist, so she'd been expermenting with him before he got to us to no effect!

I read the thread on Laser therapy and painful peripheral neuropathy and I'm qualified in LLLT, but would be extremely uncomfortable doing this given the potential to make it worse, but wondered if anyone knew of anything else such as accupuncture etc that might help?

Any thoughts appreciated!

 

This from notes I used to give students:

 

Is it true that surgery,even nail procedures are absolutely contraindicated on people with CRPS?That would seem logical but I am not 100% sure.
As for the first post,lyrica or cymbalta may help.

 

John;
from what I've read you really need to be careful doing surgery on these patient's. They are so overly sensitive that it could start an RSD reaction over again. Seems similar to frostbite at times, in that these patients never seem to go without reactoin in that area from any cold exposure.
Sincerely;
Bruce Williams, D.P.M.

 

I read that even if onee does a simple nail avulsion,not even a Frost,Winograd or P &A,that is asking for trouble for people with RCPS.

 

I don't have too much success with CRPS.

You might find that ipsilateral costo-vertebral (and/or lumbar) palpation will reproduce foot symptoms. Whether this helps is another thing.

If you know a gentle osteo/physio/chiro, 1 session may do something, even psychologically.

Like Craig said, sometimes I have referred to a local vascular surgeon for a block. I am sure they hit the major vessels rather than the minor ones.




BTW, I have never seen a driven athlete with this condition...never. It only seems to affect certain types (introverted etc.) Sorry for generalising, but that is my take on it.

 

I have had great success with CRPS. For whatever reason, I seem to catch this on many patient's per year and treat them with good to excellent success. Most repsond to injection thereapy, 1-1.5cc's of 2% carbocaine/marcaine, and 1-1/5 cc's of celstone or kenalog mixed. I ususally get 30-50% resolution from the intial injection and equal improvement with repeat injections. I have them do their own physio under wamr running water wiht ROM exercises. Once the motion returns then they are half way their. I will often send them to a neurologist but they like neurotin too much. I find that an anesthesiologidt / pain specialist can do a better regional block in the worst caess.
Bruce

 

After reading the first post I question the diagnosis. It seems that this pain is focal and not diffuse. CRPS typically involves a much larger area after 6 months. The skin changes could be a red herring. Could this be an entrapment of the SPN??? The entrapment site can be anywhere put typically occurs at the crural hiatus approx 9-13 cm above the ankle. If this area is sypmtomatic (tenderness or + tinel) you could do a cocktail block there a see what happens. In my practice, anyone with unexplained focal pain to the anterior ankle or dorsal midfoot that is not activity related and occurs hs is SPN until proven otherwise. This has rarely failed me. Tx- injection, nerve glides,Lidocaine patches,sometimes counter-irritants,sometimes TENS.

(Not to be picky, but the term is COMPLEX regional pain syndrome and not "Chronic". I made this mistake several times since the name change from RSD to CRPS.)

 

In a chronic situation Scorpio, the entrapment point may be thick and hence may also respond to massage. You may even expect P/F to be slightly reduced.

With CRPS, what is the difference between CRPS1 and 2 etc?

 

Why would you not give an antiinflammatory to someone with this entrapment?

 

You certainly could but I would not on the first visit for two reasons- First, I do only local treatments specific for the entrapment to confirm the diagnosis. If they improve while on a systemic antiinflammatory(medrol,nsaid) it tells me nothing. Second, isn't the injection the most potent anti-inflammatory? If lasting improvement is seen, it tells me the site of pathology.

 

The effect of gabapentin in earlier stage of reflex sympathetic dystrophy.
Clin Rheumatol. 2006 Aug 8;