A Novel Use of Epidural Continuous Infusion in the Outpatient Setting

Local Anesthetic ◽

Pain Syndrome ◽

Outpatient Setting ◽

Epidural Infusion ◽

Right Hand ◽

Complex regional pain syndrome (CRPS, type 1 and type 2) describes a variety of disorders characterized by spontaneous or stimulus-induced pain that is disproportional to the inciting event and is accompanied by a myriad of autonomic and motor disturbances in highly variable combinations. Physical therapy, started as early as possible, is the mainstay of treatment, and pharmacological management and interventional techniques can be used to facilitate the participation in rehabilitation programs. Epidural local anesthetic (LA) use has been reported in the inpatient setting for the treatment of CRPS, but outpatient options are limited. Elastomeric pumps are commonly used for peripheral nerve blocks, postoperative pain, and palliative care in outpatient settings, but not described with epidural infusions. We describe a case of a cervical epidural catheter placed under fluoroscopy, utilizing an elastomeric pump in an outpatient setting. The system consists of a 270 mL elastomeric pump which is filled with 0.05% bupivicaine, delivering a constant 10 mL/hour. The system has a clamp that can be used by the patient to start and stop the infusion. A 23–year-old man presented with right hand/ thumb pain of approximately 2 months duration after an injury while cutting meat at work, resulting in an incomplete fracture of the proximal phalanx and injury to the extensor tendons of his thumb, which were repaired by orthopedics, and a thumb spica splint was placed. The patient described the pain as constant and stabbing, scored as a 5 – 6/10 on a numerical rating scale (NRS), and increased with any activities. The pain was associated with intermittent temperature changes, hypersensitivity to cold water, and occasional color changes. Physical examination was remarkable for a well-healed right thumb, mottling skin discoloration over the right thumb and hand, and hypersensitivity and allodynia to light touch and pinprick over the right hand and radial aspect of the wrist. Previous treatments consisted of physical therapy and oxycodone-acetaminophen as needed. A 3-week trial of pregabalin was tried, without improvement. After discussing alternative treatments (stellate ganglion block), the patient elected to try a local anesthetic (LA) infusion through a cervical epidural catheter. The epidural space was accessed at the C7-T1 level via left paramedian approach under fluoroscopy; the catheter was threaded 5 cm, and a 0.05% bupivacaine infusion was started via an elastomeric pump. On post-procedural day 4 the bupivacaine concentration was increased to 0.1% due to insufficient pain relief. The patient had good pain relief on day 8 and discontinued the infusion on day 16. The catheter was removed on day 18. We report a case of successful treatment of CRPS with an outpatient cervical epidural infusion. This modality has been used successfully for years at Geisinger Medical Center. Our goal is to bring attention to the outpatient use of elastomeric pumps for epidural infusion in the treatment of CRPS. The successful resolution of debilitating symptoms in this patient is encouraging, and the use of elastomeric pumps should be considered for further investigation into its efficacy in patients with CRPS. Key words: Complex regional pain syndrome (CRPS), cervical epidural, outpatient epidural infusion, tunneled epidural catheter

Epidural Anesthesia to Effectively Manage Pain and Facilitate Rehabilitation in a Pediatric Case of Complex Regional Pain Syndrome

Pain Management Case Reports ◽

10.36076/pmcr.2018/2/209 ◽

2018 ◽

pp. 209-212

Author(s):

Goran Tubic

Keyword(s):

Pain Management ◽

Physical Therapy ◽

Epidural Catheter ◽

Epidural Anesthesia ◽

Pain Syndrome ◽

Epidural Infusion ◽

Lumbar Catheter ◽

Interventional Pain Management ◽

And Function

There is a paucity of information related to treatment of pediatric CRPS. Treatment of CRPS in pediatric patients has been guided by adult recommendations, which consist of a multidisciplinary approach involving pharmacotherapy, physical therapy, and psychotherapy, as appropriate. Patients unable to tolerate physical therapy with traditional oral pharmacotherapy may require more invasive pain management techniques such as sympathetic blocks, epidural infusion of analgesics, or spinal cord stimulation to facilitate restoration of function. This case report describes the successful use of epidural infusion of fentanyl, clonidine, and bupivacaine through a tunneled epidural lumbar catheter for pain management in an 11-year-old girl who developed complex regional pain syndrome I (CRPS I) approximately 2 months after sustaining an injury to her right knee. Following short-lasting pain relief from 3 repeated blocks, she underwent an implant of a tunneled epidural catheter (TEC) and a 4-week infusion of fentanyl (2 mcg/mL), clonidine (1 mcg/mL), and bupivacaine (0.04%). At last follow-up, approximately 3.5 months after implant of the TEC, the patient’s pain and symptoms were completely resolved, her range of motion and function were completely restored, and her physical activity had returned to pre-injury levels. Key words: Complex regional pain syndrome (CRPS), tunneled epidural catheter, pediatric, continuous regional anesthesia, epidural analgesia, continuous epidural anesthesia, interventional pain management

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):

Pain Syndrome ◽

Hand Injury ◽

Psychological Status ◽

Interventional Treatment ◽

Bolus Administration ◽

Right Hand ◽

Foot Injury ◽

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.

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 ◽

Mild Traumatic Brain Injury ◽

Corticospinal Tract ◽

Axonal Injury ◽

Pain Syndrome ◽

Traumatic Axonal Injury ◽

Right Hand ◽

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.

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

N N Priorov Journal of Traumatology and Orthopedics ◽

10.32414/0869-8678-2014-4-79-82 ◽

2014 ◽

pp. 79-82

Author(s):

V. N. Merkulov ◽

A. I. Dorokhin ◽

A. I. Krupatkin ◽

M. V. Merkulov ◽

M. A. Avakova

Keyword(s):

Pain Syndrome ◽

Hand Injury ◽

Psychological Status ◽

Interventional Treatment ◽

Bolus Administration ◽

Right Hand ◽

Foot Injury ◽

Faculty Opinions recommendation of Ketamine produces effective and long-term pain relief in patients with Complex Regional Pain Syndrome Type 1.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1165148.627366 ◽

2009 ◽

Author(s):

Philippe Richebe

Keyword(s):

Pain Relief ◽

Pain Syndrome ◽

Syndrome Type

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):

Inflammatory Arthritis ◽

Young Male ◽

Pain Syndrome ◽

Poor Response ◽

History Of ◽

Diagnostic Modalities ◽

Musculoskeletal Ultrasonography ◽

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.

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

Diagnostics ◽

10.3390/diagnostics9040145 ◽

2019 ◽

Vol 9 (4) ◽

pp. 145 ◽

Cited By ~ 1

Author(s):

Jang ◽

Kwon ◽

Lee

Keyword(s):

Memory Impairment ◽

Whiplash Injury ◽

Diffusion Tensor ◽

Pain Syndrome ◽

University Hospital ◽

Central Pain ◽

Spinothalamic Tract ◽

Motor Weakness ◽

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.

Physical Therapy Management of Complex Regional Pain Syndrome I in a 14-Year-Old Patient Using Strain Counterstrain: A Case Report

Journal of Manual & Manipulative Therapy ◽

10.1179/106698107791090150 ◽

2007 ◽

Vol 15 (1) ◽

pp. 25-41 ◽

Cited By ~ 9

Author(s):

Cristiana Kahl Collins

Keyword(s):

Case Report ◽

Physical Therapy ◽

Pain Syndrome ◽

Therapy Management

Pulsed Radiofrequency Treatment of Complex Regional Pain Syndrome: A Case Series

Pain Research and Management ◽

10.1155/2014/835083 ◽

2014 ◽

Vol 19 (4) ◽

pp. 186-190 ◽

Cited By ~ 5

Author(s):

Vlad Djuric

Keyword(s):

Pain Relief ◽

Lower Extremity ◽

Effective Treatment ◽

Present Report ◽

Case Series ◽

Pain Syndrome ◽

Sympathetic Chain ◽

Type I ◽

Pulsed Radiofrequency

BACKGROUND: Various forms of sympathetic chain neurolysis (sympathectomy) have, at one time or another, held promise as effective treatment options for complex regional pain syndrome (CRPS). Complications, such as worsening pain and the development of new pain syndromes, have prevented sympathectomy from emerging as a standard intervention. In an effort to avoid poor outcomes associated with neurolysis, pulsed radiofrequency (PRF) has been proposed as a potential treatment alternative for a number of chronic neuropathic pain states, including some forms of CRPS.METHODS: The present report describes three cases in which patients diagnosed with lower extremity CRPS type I obtained substantial and lasting intervals of pain relief following PRF of the lumbar sympathetic chain. Over a period of four years, 14 fluoroscopically guided procedures using PRF lesioning of the lumbar sympathetic chain at L2, L3 and L4 were performed in three individuals with CRPS type I of the lower limb. Outcome measures included pre- and post-treatment self-reported pain and medication requirements.RESULTS: Substantial pain relief (>50%) was achieved in 91.7% of PRF applications at three months and 83.3% at six months, with some treatments resulting in persistent relief well beyond 12 months. Medication use decreased to a comparable degree, with discontinuation of opiates after all but three treatments.CONCLUSIONS: PRF lesioning of the lumbar sympathetic chain can be an effective treatment for patients with CRPS type I of the lower extremity, with the potential to provide ≥6 months of substantial pain relief.