Central Pain Due to Injury of the Spinothalamic Tract Misdiagnosed as Complex Regional Pain Syndrome: A Case Report

Objectives: We report on a patient with whiplash injury who had central pain, due to injury of the spinothalamic tract (STT), but who was misdiagnosed as complex regional pain syndrome (CRPS). Case description: While a minivan in which a 43-year-old female was seated in the passenger seat was stopped for a signal, a truck collided with the minivan from behind, and the minivan then repeatedly collided with trucks in front and behind the minivan. Her head repeatedly struck the minivan seat resulting in whiplash injuries. After onset, she felt pain in both legs with mild motor weakness in all four extremities and memory impairment. Eight years after onset, she was diagnosed at a university hospital as CRPS type 1 with the clinical features of hyperalgesia and mild edema and motor weakness of both legs. She visited another university hospital nine years after onset and complained of pain in the right arm and both legs, constant tingling and burning pain along with allodynia and hyperalgesia. She also showed mild weakness in the four extremities, mild edema of both legs, and memory impairment. On diffusion tensor tractography (DTT), the left spinothalamic tract (STT) showed marked narrowing, and the right STT revealed mild narrowing and partial tearing. In addition, partial tears were observed in both corticospinal tracts and the right corticoreticulospinal tract. Discontinuations were observed in the left corticoreticulospinal tract and the left fornical crus. Conclusion: Injury of the STT was demonstrated on DTT in a patient with central pain following whiplash injury. Previously, the patient was misdiagnosed as CRPS.

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Venipuncture Induced Complex Regional Pain Syndrome Presenting as Inflammatory Arthritis

Case Reports in Medicine ◽

10.1155/2016/8081401 ◽

2016 ◽

Vol 2016 ◽

pp. 1-4

Author(s):

Punit Pruthi ◽

Pramod Arora ◽

Manoj Mittal ◽

Anugrah Nair ◽

Waqia Sultana

Keyword(s):

Complex Regional Pain Syndrome ◽

Inflammatory Arthritis ◽

Young Male ◽

Pain Syndrome ◽

Poor Response ◽

History Of ◽

Diagnostic Modalities ◽

Musculoskeletal Ultrasonography ◽

The Right

Venipuncture is one of the most commonly done medical procedures. We report a unique case of a 23-year-old young male who presented with features suggestive of inflammatory arthritis. The symptoms, which initially started on the right side, also involved the other side after a few weeks. Although the patient’s symptoms and signs were simulating inflammatory arthritis, he had atypical features like poor response to anti-inflammatory medicines and normal laboratory parameters. His musculoskeletal ultrasonography was also not suggestive of arthritis. His history was reviewed and on direct questioning he revealed a history of venipuncture for blood sample withdrawal, done from right antecubital region for routine health check on the day prior to the onset of symptoms. Complex regional pain syndrome was suspected and triple-phase radioisotope bone scan was done which was highly suggestive of this diagnosis. The patient was managed with multidimensional approach and responded very well to the treatment. Complex regional pain syndrome is usually not thought of in the initial differential diagnosis of inflammatory arthritis. In this report we highlight the need to elicit the often overlooked history of trivial trauma like venipuncture, especially in atypical cases of arthritis. Also the role of newer diagnostic modalities in such cases is emphasized.

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Treatment of Type 1 Complex Regional Pain Syndrome in 14 Years Old Child

N.N. Priorov Journal of Traumatology and Orthopedics ◽

10.17816/vto20140479-82 ◽

2014 ◽

Vol 21 (4) ◽

pp. 79-82

Author(s):

V. N Merkulov ◽

A. I Dorokhin ◽

A. I Krupatkin ◽

M. V Merkulov ◽

M. A Avakova

Keyword(s):

Complex Regional Pain Syndrome ◽

Pain Syndrome ◽

Hand Injury ◽

Psychological Status ◽

Interventional Treatment ◽

Bolus Administration ◽

Right Hand ◽

Foot Injury ◽

The Right

Case report on 14 years old girl with type 1 complex regional pain syndrome (CRPS) is presented. At first admission in 5.5 months after right hand injury and development of type 1 CRPS, paravasal sympathectomy on the right upper extremity was performed. Complete elimination of pain syndrome and restoration of the extremity function was achieved. Five and a half months after discharge the left foot and in 3 weeks later the right hand were injured. In both cases injuries were accompanied by pronounced CRPS clinical picture. At second admission in 6 weeks after foot injury interventional treatment with placement of catheters next to nerve trunks and bolus administration of antibiotics was performed for 1 week and enabled to achieve remission of the disease. It was noted that not only hypersymphaticotony but also psychological status of a patient were important for the disease development.

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Maladaptive Homeostatic Plasticity in a Rodent Model of Central Pain Syndrome: Thalamic Hyperexcitability after Spinothalamic Tract Lesions

Journal of Neuroscience ◽

10.1523/jneurosci.3296-08.2008 ◽

2008 ◽

Vol 28 (46) ◽

pp. 11959-11969 ◽

Cited By ~ 79

Author(s):

G. Wang ◽

S. M. Thompson

Keyword(s):

Pain Syndrome ◽

Rodent Model ◽

Homeostatic Plasticity ◽

Central Pain ◽

Spinothalamic Tract ◽

Central Pain Syndrome

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Diagnosis of Complex Regional Pain Syndrome I Following Traumatic Axonal Injury of the Corticospinal Tract in a Patient with Mild Traumatic Brain Injury

Diagnostics ◽

10.3390/diagnostics10020095 ◽

2020 ◽

Vol 10 (2) ◽

pp. 95 ◽

Cited By ~ 1

Author(s):

Sung Ho Jang ◽

You Sung Seo

Keyword(s):

Traumatic Brain Injury ◽

Brain Injury ◽

Complex Regional Pain Syndrome ◽

Mild Traumatic Brain Injury ◽

Corticospinal Tract ◽

Axonal Injury ◽

Pain Syndrome ◽

Traumatic Axonal Injury ◽

Right Hand ◽

The Right

A 54-year-old male suffered from direct head trauma resulting from a fall while working. At approximately two months after the accident, he began to feel pain (burning sensation) and swelling of the dorsum of the right hand and wrist. He showed the following clinical features among the clinical signs and symptoms of revised diagnostic criteria for complex regional pain syndrome (CRPS): spontaneous pain, mechanical hyperalgesia, vasodilation, skin temperature asymmetries, skin color changes, swelling, motor weakness. No specific lesion was observed on brain MRI taken at ten weeks after onset. Plain X-ray, electromyography, and nerve conduction studies for the right upper extremity detected no abnormality. A three-phase bone scan showed hot uptake in the right wrist in the delayed image. On two-month diffusion tensor tractography, partial tearing of the corticospinal tract (CST) was observed at the subcortical white matter in both hemispheres (much more severe in the left CST). In addition, the fiber number of the right CST was significantly decreased than that of seven normal control subjects. CRPS I of the right hand in this patient appeared to be related to traumatic axonal injury of the left CST following mild traumatic brain injury.

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Delayed diagnosis and worsening of pain following orthopedic surgery in patients with complex regional pain syndrome (CRPS)

Scandinavian Journal of Pain ◽

10.1016/j.sjpain.2015.11.004 ◽

2016 ◽

Vol 11 (1) ◽

pp. 27-33 ◽

Cited By ~ 8

Author(s):

Lars K. Lunden ◽

Inge P. Kleggetveit ◽

Ellen Jørum

Keyword(s):

Complex Regional Pain Syndrome ◽

Orthopedic Surgery ◽

Pain Syndrome ◽

University Hospital ◽

Nerve Lesion ◽

Adequate Treatment ◽

Pain Condition ◽

Mean Time

Abstract Background and aims Complex regional pain syndrome (CRPS) is a serious and disabling chronic pain condition, usually occurring in a limb. There are two main types, CRPS 1 with no definite nerve lesion and CRPS 2 with an identified nerve lesion. CRPS 1 and 2 may occur following an injury (frequently following fractures), surgery or without known cause. An early diagnosis and start of adequate treatment is considered desirable for patients with CRPS. From the clinical experience of the principal investigator, it became apparent that CRPS often remained undiagnosed and that the clinical conditions of many patients seemed to be worsened following orthopedic surgery subsequent to the initial eliciting event. The aim of the present retrospective study of 55 patients, all diagnosed with either CRPS 1 or 2, was to evaluate the time from injury until diagnosis of CRPS and the effect on pain of orthopedic surgical intervention subsequent to the original injury/surgery. Methods Clinical symptoms with an emphasis on pain were assessed by going through the patients’ records and by information given during the investigation at Oslo University Hospital, where the patients also were examined clinically and with EMG/neurography. Alteration in pain was evaluated in 27 patients who underwent orthopedic surgery subsequent to the eliciting injury. Results Of a total of 55 patients, 28 women and 27 men (mean age 38.7 (SD 12.3), 38 patients were diagnosed with CRPS type 1, and 17 with CRPS type 2. Mean time before diagnosis was confirmed was 3.9 years (SD1.42, range 6 months-10 years). The eliciting injuries for both CRPS type 1 and type 2 were fractures, squeeze injuries, blunt injuries, stretch accidents and surgery. A total of 27 patients (14 men and 13 women) were operated from one to 12 times at a later stage (from 6 months to several years) following the initial injury or any primary operation because of fracture. A total of 22 patients reported a worsening of pain following secondary surgical events, while four patients found no alteration and one patient experienced an improvement of pain. None of the 22 patients reporting worsening, were diagnosed with CRPS prior to surgery, while retrospectively, a certain or probable diagnosis of CRPS had been present in 17/22 (77%) patients before their first post-injury surgical event. Conclusions and implications A mean time delay of 3.9 years before diagnosis of CRPS is unacceptable. A lack of attention to more subtle signs of autonomic dysfunction may be an important contributing factor for the missing CRPS diagnosis, in particular serious in patients reporting worsening of pain following subsequent orthopedic surgery. It is strongly recommended to consider the diagnosis of CRPS in all patients with a long-lasting pain condition. We emphasize that the present report is not meant as criticism to orthopedic surgical practice, but as a discussion for a hopefully increased awareness and understanding of this disabling pain condition.

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Dorsal root ganglion stimulation for treatment of complex regional pain syndrome of the foot

Neurosurgical Focus: Video ◽

10.3171/2020.7.focvid2034 ◽

2020 ◽

Vol 3 (2) ◽

pp. V8

Author(s):

Kevin Hines ◽

Fadi Al Saiegh ◽

Aria Mahtabfar ◽

Kavantissa M. Keppetipola ◽

Caio M. Matias ◽

...

Keyword(s):

Spinal Cord ◽

Dorsal Root Ganglion ◽

Complex Regional Pain Syndrome ◽

Spinal Cord Stimulation ◽

Dorsal Root ◽

Pain Syndrome ◽

Thoracic Spinal Cord ◽

Plantar Aspect ◽

Thoracic Spinal ◽

The Right

This is a case of a 54-year-old man presenting with complex regional pain syndrome (CRPS) type 1 of the right lower extremity, which was most debilitating in the plantar aspect of the right foot. The patient had prior treatment with thoracic spinal cord stimulation; however, the foot pain remained intractable. Given that his pain was predominantly in his foot and remained debilitating despite thoracic spinal cord stimulation, it was recommended that the patient undergo a trial of dorsal root ganglion (DRG) stimulation. The surgical technique for placement of dorsal root ganglion stimulators is demonstrated in this operative video.The video can be found here: https://youtu.be/_1xMxFZa6tU

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Diagnosis of Tinnitus Due to Auditory Radiation Injury Following Whiplash Injury: A Case Study

Diagnostics ◽

10.3390/diagnostics10010019 ◽

2019 ◽

Vol 10 (1) ◽

pp. 19 ◽

Cited By ~ 1

Author(s):

Sung Jun Lee ◽

Chang Hoon Bae ◽

Jeong Pyo Seo ◽

Sung Ho Jang

Keyword(s):

Whiplash Injury ◽

Diffusion Tensor ◽

Brain Mri ◽

Pure Tone Audiometry ◽

University Hospital ◽

Hearing Status ◽

Car Crash ◽

Nose And Throat ◽

Specific Abnormality

We report on a patient with tinnitus who showed injury of auditory radiation following whiplash injury, demonstrated by diffusion tensor tractography (DTT). A 48-year-old male patient suffered from a car crash resulting in flexion-hyperextension injury of his head after being hit from behind by a moving car while waiting at a signal while driving a car. Three days after the car crash, he began to feel tinnitus in both ears and his tinnitus became aggravated with the passage of time. No specific lesion was observed on a conventional brain MRI performed two weeks after the car crash. Although he visited several hospitals, the precise cause of his tinnitus was not detected. Two years after the car crash, he underwent evaluation for his tinnitus at the ear, nose and throat department of a university hospital. The pure tone audiometry was evaluated in a sound-proof room to screen his hearing status for the frequencies of 250–8000 Hz and no specific abnormality was detected. Although he was also tested for speech audiometry, there was also no specific abnormality. In order to assess his tinnitus, a tinnitogram was conducted to evaluate the frequency content and the loudness. His tinnitus was characterized at an intensity of 40 dB and a frequency of 4000 Hz. However, no abnormality was observed in either ear on physical examination. On DTT, the auditory radiation showed severe narrowing and tearing in both hemispheres. To summarize, neural injury of the auditory radiation was demonstrated in a patient with tinnitus following whiplash injury, using DTT.

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Disruption of Homeostasis Based on the Right and Left Hemisphere in Patients with Complex Regional Pain Syndrome

NeuroImmunoModulation ◽

10.1159/000504140 ◽

2019 ◽

Vol 26 (6) ◽

pp. 276-284

Author(s):

Ye-Ha Jung ◽

Hyeonjin Kim ◽

Dasom Lee ◽

Jae-Yeon Lee ◽

Won Joon Lee ◽

...

Keyword(s):

Complex Regional Pain Syndrome ◽

Left Hemisphere ◽

Pain Syndrome ◽

The Right

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Reflex sympathetic dystrophy/complex regional pain syndrome, type 1

South African Journal of Radiology ◽

10.4102/sajr.v8i2.133 ◽

2004 ◽

Vol 8 (2) ◽

pp. 38

Author(s):

S.H. Botha

Keyword(s):

Complex Regional Pain Syndrome ◽

Weight Bearing ◽

Pain Syndrome ◽

Blood Pool ◽

Magnetic Resonance Images ◽

Stress Fractures ◽

X Rays ◽

The Right ◽

A Minor

Complex regional pain syndrome (CPRS), type 1 is a pain disorder that develops unpredictably and can follow a minor injury. A 12-year-old boy presented with severe pain in the feet and could not walk or stand weight bearing. Normal X-rays showed osteopenic changes and radiolucent lines, which appeared to be stress fractures. Three-phase bone scintigraphy showed no uptake in the left lower leg on the blood pool phase or on the immediate or delayed images. This indicated typical CPRS type 1 in children. The uptake in the right foot was increased and the stress fracture and other illness could not be differentiated. Computed tomography was done to exclude stress fractures. Only osteopenic changes in both calcaneus bones were found and there was no evidence of cortical stress fractures. Magnetic resonance images revealed oedema in the calcaneus and talus bones of both feet. The patient received epidural narcotic infusion with sympathetic blockage for 1 week combined with extensive physiotherapy. The blood pool phase of the bone scan became normal within 2 weeks, and increased uptake in both feet was noticed. The patient was followed up with MRI every 3 months and the bone marrow oedema disappeared after 6 months.

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Changes in Diffuse Tensor Imaging and Therapeutic Effect of Repetitive Transcranial Magnetic Stimulation in Traumatic Brain Injury with Central Pain

Brain Sciences ◽

10.3390/brainsci10120929 ◽

2020 ◽

Vol 10 (12) ◽

pp. 929

Author(s):

Dong-Ha Kang ◽

Gi-Wook Kim

Keyword(s):

Traumatic Brain Injury ◽

Neuropathic Pain ◽

Diffusion Tensor Imaging ◽

Magnetic Stimulation ◽

Diffusion Tensor ◽

Repetitive Transcranial Magnetic Stimulation ◽

Central Pain ◽

Spinothalamic Tract ◽

Before And After ◽

Diffusion Tensor Imaging Dti

Post-trauma chronic pain characterized by central pain is a symptom following traumatic brain injury (TBI). Studies on the effect of repetitive transcranial magnetic stimulation (rTMS) on central pain and the association between central pain and spinothalamic tract (STT) have been reported, but few studies have examined the effect of rTMS in patients with mild TBI with central pain through changes in diffusion tensor imaging (DTI)-based metrics of STT before and after rTMS. This case series aimed to investigate the therapeutic effect of rTMS in TBI with central pain and the changes in diffusion tensor imaging (DTI)-based metrics of the spinothalamic tract (STT) before and after rTMS. This study included four patients who complained of severe pain in the left or right side of the body below the neck area after a car accident. We performed numeric rating scale (NRS), bedside sensory examination, electrodiagnostic study, and DTI-based metrics of the STT before and after rTMS. According to the guidelines of the diagnosis and grading for neuropathic pain, all patients had neuropathic pain corresponding to “probable grade.” In all patients, rTMS was applied to the contralateral M1 cortex on the more painful side. There were no medication changes and other interventions during the rTMS. After rTMS, NRS decreased, bed sensory testing improved, and DTI-based STT metrics increased in all patients compared to before rTMS.

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