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
