What exactly is complex regional pain syndrome?
Complex regional pain syndrome, commonly known as CRPS, is a condition of chronic pain that usually occurs in the upper or lower extremities. Typically it occurs after a direct nerve injury to the extremity either from trauma, surgery or an overuse syndrome.
CRPS has also been called reflex sympathetic dystrophy (RSD), a term which is still commonly used today. Complex regional pain syndrome is now the preferred term as it better characterizes the frustrating condition.
What causes complex regional pain syndrome?
Researchers do not know exactly why CRPS occurs, as the inciting event is very different between most patients. For instance, CRPS may occur after a total knee replacement, whereas the vast majority of individuals undergoing surgery do not have this issue.
Some of the various conditions that may result in CRPS include a fracture, limb immobilization, surgery or trauma such as from a gunshot wind or a severe sprain. The surgery involved may simply be an arthroscopic procedure, or it can be a fracture fixation for a total joint replacement.
Essentially what happens is that there is an inciting event which sparks up the sympathetic nervous system, and it does not shut off appropriately.
Are there different kinds of CRPS?
Yes there are two kinds. CRPS I refers to the syndrome where there is chronic pain without confirmed nerve damage. CRPS II, however, refers to chronic pain that is associated with confirmed nerve damage.
What are the symptoms of the syndrome?
The predominant symptom associated with the syndrome is pain that gets worse over time rather than better. The pain is way out of proportion to what would be expected from the event. It may be so bad as to be severely tough even when a sheet touches the skin or the wind.
Typically the pain starts at the point of injury, but may spread to the complete arm or leg and then even spread to the other side overtime. Often times patients experience significant sweating in the extremity along with tissue swelling. Over time, there may be some bone and skin changes which may include a significant redness to the skin.
How is the condition diagnosed?
Individuals with CRPS have extreme pain in the affected limb. There’s often significant swelling and there will typically be temperature changes on the skin that are over 1°C different from the other side.
The overriding feature is that the pain is out of proportion to what should be seen with the condition.
While there are no definitive tests available, the physician will perform a work up that may include x-rays, a nerve conduction study, bone scan and others to rule out other conditions. A lot of the time, CRPS becomes a diagnosis of exclusion.
What are the stages of CRPS?
Initially there are typical skin temperature changes, muscle spasms, severe burning pain, nail and hair growth faster than normal, and skin changes which may look shiny or sweaty.
Between three months and a year patients may experience more skin changes, worst pain, slowing down of hair growth, stiffening joints and cracked nails.
After a year, the changes become irreversible which may include muscle atrophy, limb contractures and pain in the entire arm or leg.
What are available treatments for CRPS?
While there is no cure for CRPS, there are plenty of available treatment options. Physical therapy with desensitization modalities may be extremely beneficial. There are also various medications such as opiates, steroids, anti-inflammatories, antidepressants or blood pressure medications. A lot of these work as an off label therapy for relief.
Cognitive behavioral therapy has been shown to be of benefit to those with CRPS. One of the gold standard treatments for CRPS treatment involves lumbar sympathetic nerve blocks for the lower extremities, or stellate ganglion nerve blocks when in upper extremity is involved. These are typically beneficial to help break the cycle of the overactive sympathetic nervous system. They can help get patients back to decreased level of pain and increased function.
If the nerve block works, a surgical sympathectomy may be in order. For those with chronic symptoms that are not getting better from the above treatments, a spinal cord stimulator may be the best answer for masking one’s pain with CRPS. An additional option is an intrathecal drug pump which can provide continuous relief overtime.
What are the outcomes with CRPS?
The earlier the diagnosis and treatment initiation, the better the results. If treatment is begun within the first two years of onset, a large study out of the Journal of Bone and Joint Surgery showed over 80% successful outcomes. That same study showed outcomes between two and five years at 70%, and if five years have gone by the treatment outcomes are not good at all. Only 10 to 20% success rates.
The pain doctors at Gershon Pain offer all of these treatment options and more to help benefit those with CRPS. If you or loved one is suffering, call the office today!