Sympathetic Blocks: Utility in Complex Regional Pain Syndrome

BackgroundSympathetic blocks (SB) are commonly used to treat pain from complex regional pain syndrome (CRPS). However, there are currently no guidelines to assist pain physicians in determining the best practices when using and performing these procedures.MethodsA 32-question survey was developed on how SBs are used and performed to treat CRPS. The survey was conducted online via SurveyMonkey. The responses were statistically analyzed using descriptive statistics, and comparing academic versus non-academic, and fellowship versus non-fellowship-trained physicians.ResultsA total of 248 pain physicians responded with a response rate of 37%. Forty-four percent of respondents schedule the first SB at the first clinic visit; 73% perform one to three consecutive blocks; over 50% will repeat the block if a patient receives at least 50% pain relief from the previous one lasting 1–7 days.Fifty-four percent of respondents perform stellate ganglion blocks (SGB) at the C6 vertebral level, 41% at C7; 53% perform lumbar sympathetic blocks (LSB) at L3 level, 39% at L2; 50% use fluoroscopy to guide SGB, 47% use ultrasound. More respondents from academic than non-academic centers use ultrasound for SGB. About 75% of respondents use a total volume of 5–10 mL for SGB and 10–20 mL for LSB. The most commonly used local anesthetic is 0.25% bupivacaine. About 50% of respondents add other medications, mostly steroids, for these blocks.ConclusionOur study showed a wide variation in current practice among pain physicians in treating CRPS with SBs. There is a clear need for evidence-based guidelines on when and how to perform SBs for CRPS.

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Pediatric Complex Regional Pain Syndrome: Stellate Ganglion and Lumbar Sympathetic Blocks

Pediatric Anesthesia Procedures ◽

10.1093/med/9780190685188.003.0012 ◽

2021 ◽

pp. 167-174

Author(s):

Sarah Choxi

Keyword(s):

Complex Regional Pain Syndrome ◽

Early Recognition ◽

Multidisciplinary Treatment ◽

Stellate Ganglion ◽

Pain Syndrome ◽

Signs And Symptoms ◽

Nerve Blocks ◽

Distal Extremity ◽

Peripheral Nerve Blockade ◽

Sympathetic Blocks

Complex regional pain syndrome (CRPS) is a chronic, localized pain condition following an injury, typically affecting a distal extremity. Although the pathophysiology of CRPS is unclear, multiple mechanisms are implicated, including peripheral and central sensitization as well as sympathetically mediated pain. Peripheral nerve blockade can treat the somatic component of CRPS pain, while sympathetic blockade may alleviate pain that is sympathetically mediated. Signs and symptoms manifest as abnormal sensory, motor, vasomotor, and sudomotor changes that are disproportionate to the inciting event. Early recognition of the signs and symptoms, followed by rapid implementation of a multidisciplinary treatment approach—including physical therapy, psychotherapy, pharmacotherapy, and sympathetic nerve blocks, is a major factor in improving outcome and preventing treatment-resistant CRPS.

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Complex Regional Pain Syndrome

Acute Pain Medicine ◽

10.1093/med/9780190856649.003.0018 ◽

2019 ◽

pp. 262-270

Author(s):

Steven R. Hanling ◽

Ian M. Fowler ◽

C. Ryan Phillips

Keyword(s):

Chronic Pain ◽

Complex Regional Pain Syndrome ◽

Pain Syndrome ◽

Signs And Symptoms ◽

Pain Medication ◽

Channel Blockers ◽

Chronic Pain Condition ◽

Ion Channel Blockers ◽

Budapest Criteria ◽

Sympathetic Blocks

Complex regional pain syndrome (CRPS) is a chronic pain condition that typically occurs after injury to a limb or directly to a nerve. Progression of the disease can result in multiple debilitating symptoms including pain disproportionate to the inciting event. The Budapest criteria cateforize the constellation of signs and symptoms of CRPS (sensory, vasomotor, sudomotor/edema, and motor/trophic changes) and are used to diagnose the syndrome. Treatments include rehabilitation (physical and occupation therapy), multimodal pain medication (medications that target neuropathic pain such as antidepressants, membrane stabilizers, and ion channel blockers), interventional treatments (sympathetic blocks, infusion catheters, neuromodulation), and psychological therapy.

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Outcomes of Sympathetic Blocks in the Management of Complex Regional Pain Syndrome

Anesthesiology ◽

10.1097/aln.0000000000002899 ◽

2019 ◽

Vol 131 (4) ◽

pp. 883-893 ◽

Cited By ~ 2

Author(s):

Jianguo Cheng ◽

Vafi Salmasi ◽

Jing You ◽

Michael Grille ◽

Dongsheng Yang ◽

...

Keyword(s):

Spinal Cord ◽

Pain Relief ◽

Success Rate ◽

Complex Regional Pain Syndrome ◽

Spinal Cord Stimulation ◽

Pain Syndrome ◽

Pain Reduction ◽

Secondary Outcome ◽

Predictive Values ◽

Sympathetic Blocks

Abstract Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Sympathetic dysfunction may be present in complex regional pain syndrome, and sympathetic blocks are routinely performed in practice. To investigate the therapeutic and predictive values of sympathetic blocks, the authors test the hypotheses that sympathetic blocks provide analgesic effects that may be associated with the temperature differences between the two extremities before and after the blocks and that the effects of sympathetic blocks may predict the success (defined as achieving more than 50% pain reduction) of spinal cord stimulation trials. Methods The authors performed a retrospective study of 318 patients who underwent sympathetic blocks in a major academic center (2009 to 2016) to assess the association between pain reduction and preprocedure temperature difference between the involved and contralateral limbs. The primary outcome was pain improvement by more than 50%, and the secondary outcome was duration of more than 50% pain reduction per patient report. The authors assessed the association between pain reduction and the success rate of spinal cord stimulation trials. Results Among the 318 patients, 255 were diagnosed with complex regional pain syndrome and others with various sympathetically related disorders. Successful pain reduction (more than 50%) was observed in 155 patients with complex regional pain syndrome (155 of 255, 61%). The majority of patients (132 of 155, 85%) experienced more than 50% pain relief for 1 to 4 weeks or longer. The degree and duration of pain relief were not associated with preprocedure temperature parameters with estimated odds ratio of 1.03 (97.5% CI, 0.95–1.11) or 1.01 (97.5% CI, 0.96–1.06) for one degree decrease (P = 0.459 or 0.809). There was no difference in the success rate of spinal cord stimulation trials between patients with or without more than 50% pain relief after sympathetic blocks (35 of 40, 88% vs. 26 of 29, 90%, P > 0.990). Conclusions The authors conclude that sympathetic blocks may be therapeutic in patients with complex regional pain syndrome regardless of preprocedure limb temperatures. The effects of sympathetic blocks do not predict the success of spinal cord stimulation.

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Complex Regional Pain Syndrome

Neuropathic Pain ◽

10.1093/med/9780190298357.003.0034 ◽

2018 ◽

pp. 295-308

Author(s):

Brian A. Kim ◽

Timothy Furnish

Keyword(s):

Spinal Cord ◽

Complex Regional Pain Syndrome ◽

Multimodal Treatment ◽

Pain Syndrome ◽

Signs And Symptoms ◽

Burning Pain ◽

Patient Responsiveness ◽

Common Clinical Finding ◽

Interventional Therapies ◽

Sympathetic Blocks

Complex regional pain syndrome (CRPS) is a challenging pain condition with incompletely elucidated pathophysiology, most often affecting a single extremity after an inciting injury. The most common clinical finding is burning pain out of proportion to any identifiable initiating event, with a combination of sensory, vasomotor, sudomotor, and motor/trophic signs and symptoms. The management of CRPS emphasizes early diagnosis and aggressive multimodal treatment based on physical therapy, psychological therapy, and pain management with frequent reassessments of patient progression. In order to prevent permanent life-altering disability, all modalities including interventional therapies should be escalated in tandem, based on assessments of patient responsiveness. Clinicians should consider escalating therapy frequently if no improvement is observed, and introducing psychological evaluation if symptoms persist. Lastly, the use of interventional techniques such as sympathetic blocks or spinal cord stimulation should be employed early in refractory cases.

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Treatment of complex regional pain syndrome type I of the hand with a series of intravenous regional sympathetic blocks with guanethidine and lidocaine

Clinical Rheumatology ◽

10.1007/s10067-005-0122-0 ◽

2005 ◽

Vol 25 (5) ◽

pp. 687-693 ◽

Cited By ~ 16

Author(s):

Kosmas I. Paraskevas ◽

Alexandra A. Michaloglou ◽

Despina D. Briana ◽

Maria Samara

Keyword(s):

Complex Regional Pain Syndrome ◽

Pain Syndrome ◽

Type I ◽

Syndrome Type ◽

Sympathetic Blocks

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Invasive Treatments for Complex Regional Pain Syndrome in Children and Adolescents

Anesthesiology ◽

10.1097/aln.0000000000000573 ◽

2015 ◽

Vol 122 (3) ◽

pp. 699-707 ◽

Cited By ~ 19

Author(s):

Boris Zernikow ◽

Julia Wager ◽

Hannah Brehmer ◽

Gerrit Hirschfeld ◽

Christoph Maier

Keyword(s):

Children And Adolescents ◽

Complex Regional Pain Syndrome ◽

Functional Disability ◽

Invasive Procedure ◽

Pain Syndrome ◽

Current Evidence ◽

Invasive Treatment ◽

Pubmed Search ◽

Epidural Catheters ◽

Sympathetic Blocks

Abstract This review aimed to synthesize the current evidence on the effectiveness of invasive treatments for complex regional pain syndrome in children and adolescents. Studies on children and adolescents with complex regional pain syndrome that evaluated the effects of invasive treatment were identified in PubMed (search March 2013). Thirty-six studies met the inclusion criteria. Articles reported on a total of 173 children and adolescents with complex regional pain syndrome. Generally, many studies lack methodological quality. The invasive treatments applied most often were singular sympathetic blocks, followed by epidural catheters and continuous sympathetic blocks. Rarely, spinal cord stimulation and pain-directed surgeries were reported. An individual patient frequently received more than one invasive procedure. Concerning outcome, for approximately all patients, an improvement in pain and functional disability was reported. However, these outcomes were seldom assessed with validated tools. In conclusion, the evidence level for invasive therapies in the treatment of complex regional pain syndrome in children and adolescents is weak.

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Sympathetic blocks for the treatment of complex regional pain syndrome

Medicine ◽

10.1097/md.0000000000010705 ◽

2018 ◽

Vol 97 (19) ◽

pp. e0705 ◽

Cited By ~ 3

Author(s):

Semih Gungor ◽

Rohit Aiyer ◽

Buse Baykoca

Keyword(s):

Complex Regional Pain Syndrome ◽

Pain Syndrome ◽

Sympathetic Blocks

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A Historical Review of Complex Regional Pain Syndrome in the “Guides Library”

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2009.novdec01 ◽

2009 ◽

Vol 14 (6) ◽

pp. 1-9

Author(s):

Robert J. Barth

Keyword(s):

Differential Diagnosis ◽

Complex Regional Pain Syndrome ◽

Reflex Sympathetic Dystrophy ◽

International Association ◽

Historical Review ◽

Pain Syndrome ◽

Sixth Edition

Abstract Complex regional pain syndrome (CRPS) is a controversial, ambiguous, unreliable, and unvalidated concept that, for these very reasons, has been justifiably ignored in the “AMA Guides Library” that includes the AMAGuides to the Evaluation of Permanent Impairment (AMA Guides), the AMA Guides Newsletter, and other publications in this suite. But because of the surge of CRPS-related medicolegal claims and the mission of the AMA Guides to assist those who adjudicate such claims, a discussion of CRPS is warranted, especially because of what some believe to be confusing recommendations regarding causation. In 1994, the International Association for the Study of Pain (IASP) introduced a newly invented concept, CRPS, to replace the concepts of reflex sympathetic dystrophy (replaced by CRPS I) and causalgia (replaced by CRPS II). An article in the November/December 1997 issue of The Guides Newsletter introduced CRPS and presciently recommended that evaluators avoid the IASP protocol in favor of extensive differential diagnosis based on objective findings. A series of articles in The Guides Newsletter in 2006 extensively discussed the shortcomings of CRPS. The AMA Guides, Sixth Edition, notes that the inherent lack of injury-relatedness for the nonvalidated concept of CRPS creates a dilemma for impairment evaluators. Focusing on impairment evaluation and not on injury-relatedness would greatly simplify use of the AMA Guides.

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Peripheral Nerve and Brachial Plexus Impairment, AMA Guides, Sixth Edition

Guides Newsletter ◽

10.1001/amaguidesnewsletters.2017.marapr01 ◽

2017 ◽

Vol 22 (2) ◽

pp. 3-5

Author(s):

James B. Talmage ◽

Jay Blaisdell

Keyword(s):

Peripheral Nerve ◽

Brachial Plexus ◽

Complex Regional Pain Syndrome ◽

Lower Extremities ◽

Pain Syndrome ◽

Upper Extremities ◽

Motor Deficits ◽

Type I ◽

Sixth Edition ◽

Nerve Entrapments

Abstract Physicians use a variety of methodologies within the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, to rate nerve injuries depending on the type of injury and location of the nerve. Traumatic injuries that cause impairment to the peripheral or brachial plexus nerves are rated using Section 15.4e, Peripheral Nerve and Brachial Plexus Impairment, for upper extremities and Section 16.4c, Peripheral Nerve Rating Process, for lower extremities. Verifiable nerve lesions that incite the symptoms of complex regional pain syndrome, type II (similar to the former concept of causalgia), also are rated in these sections. Nerve entrapments, which are not isolated traumatic events, are rated using the methodology in Section 15.4f, Entrapment Neuropathy. Type I complex regional pain syndrome is rated using Section 15.5, Complex Regional Pain Syndrome for upper extremities or Section 16.5, Complex Regional Pain Syndrome for lower extremities. The method for grading the sensory and motor deficits is analogous to the method described in previous editions of AMA Guides. Rating the permanent impairment of the peripheral nerves or brachial plexus is similar to the methodology used in the diagnosis-based impairment scheme with the exceptions that the physical examination grade modifier is never used to adjust the default rating and the names of individual nerves or plexus trunks, as opposed to the names of diagnoses, appear in the far left column of the rating grids.

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