Going toe-to-toe with a rare case of a complex regional pain syndrome limited to the hallux

We report the first case of a complex regional pain syndrome (CRPS) limited to the hallux using the Budapest criteria. Limited forms of CRPS are scarce in the literature and probably overlooked. There is currently no consensus to define these forms. Due to the particular metameric topography, common to the hand and the foot, we suggest the term ‘metameric’ CRPS to describe them. A uniform nomenclature would promote future research to study its prevalence and specific treatment in more detail.

Complex regional pain syndrome of the residual limb in a transtibial lower-limb amputee: diagnosis and treatment

We present the unusual case of complex regional pain syndrome (CRPS) of the residual limb in a 54-year-old woman with transtibial lower-limb amputation. Intractable pain developed 14 months after amputation, followed by successful rehabilitation. Anamnesis and clinical findings included sensory symptoms, vasomotor symptoms and signs, and oedema. The Budapest criteria for a diagnosis of CRPS were met. After infusions of bisphosphonates during a 5-week inpatient interdisciplinary rehabilitation programme, the pain decreased. Clinicians should suspect CRPS in case of chronic or recurrent residual limb pain. The Budapest criteria seem applicable even if interpretation of symptoms and findings can be complicated in vascular polymorbid lower-limb amputation. Bisphosphonates, proposed as first-line pharmacological treatment, can be useful.

A Novel Approach to New-Onset Hemiplegic Shoulder Pain With Decreased Range of Motion Using Targeted Diagnostic Nerve Blocks: The ViVe Algorithm

Introduction: Hemiplegic shoulder pain (HSP) is the most common pain disorder after stroke with incidence estimates of 30–70% and associated with reductions in function, interference with rehabilitation, and a reduced quality of life. Onset may occur as soon as a week after stroke in 17% of patients. Management of HSP represents a complex treatment pathway with a lack of evidence to support one treatment. The pain has heterogeneous causes. In the acute setting, decreased range of motion in the shoulder can be due to early-onset spasticity, capsular pattern stiffness, glenohumeral pathology, or complex regional pain syndrome (CRPS). As contracture can form in up to 50% of patients after stroke, effective management of the painful shoulder and upper limb with decreased range of motion requires assessment of each possible contributor for effective treatment. The anesthetic diagnostic nerve block (DNB) is known to differentiate spasticity from contracture and other disorders of immobility and can be useful in determining an appropriate treatment pathway.Objective: To create a diagnostic algorithm to differentiate between the causes of HSP in the stiff, painful shoulder in the subacute setting using diagnostic techniques including the Budapest Criteria for CRPS and DNB for spasticity and pain generators.Results: Examination of each joint in the upper extremity with HSP may differentiate each diagnosis with the use of an algorithm. Pain and stiffness isolated to the shoulder may be differentiated as primary shoulder pathology; sensory suprascapular DNB or intra-articular/subacromial injection can assist in differentiating adhesive capsulitis, arthritis, or rotator cuff injury. CRPS may affect the shoulder, elbow, wrist, and hand and can be evaluated with the Budapest Criteria. Spasticity can be differentiated with the use of motor DNB. A combination of these disorders may cause HSP, and the proposed treatment algorithm may offer assistance in selecting a systematic treatment pathway.

Effectiveness of prophylactic vitamin C supplementation in the prevention of complex regional pain syndrome after distal end radius fractures in the aging population

Background/purpose Vitamin C has been proposed to prevent the incidence of complex regional pain syndrome, but the results are conflicting. We evaluated the effectiveness of vitamin C in the prevention of complex regional pain syndrome-1 after distal end radius fractures in the aging population. Methods This was a prospective, randomized study. Patients treated with either conservative or surgical management for distal end radius fracture received Vitamin C (500 mg/day) plus standard therapy or standard therapy alone for a period of 3 months. The presence of complex regional pain syndrome-1 was assessed with Budapest criteria. Results The complex regional pain syndrome-I occurred in 11.3% in Vitamin C plus Standard in compared to 26% in Standard therapy alone. Vitamin C was significantly associated with a reduction in the likelihood of exhibiting complex regional pain syndrome-1. Conclusion Vitamin C (500 mg/day) supplementation was effective and associated with a lower occurrence of acute complex regional pain syndrome-1. It can be a promising prophylactic option for the prevention of complex regional pain syndrome-1 after distal end radius fracture.

Complex regional pain syndrome: An updated comprehensive review

Complex regional pain syndrome (CRPS) is a complex disorder that can have a significant impact on the quality of life of a person with this syndrome. The diagnosis and treatment of CRPS are often difficult as there is no one confirmatory test and no one definitive treatment. Currently, the most widely accepted clinical diagnostic criteria are the Budapest criteria, which were developed by expert consensus. Though no one single treatment has been found to be universally effective, early detection and an interdisciplinary approach to treatment appear to be key in treating CRPS. This review aims to present up-to-date clinical information regarding the diagnosis and management of CRPS and highlight the potential issues with diagnosis in the neurological population. Ultimately, more research is needed to identify the exact etiology of CRPS in order to help target appropriate therapies. In addition, more randomized controlled trials need to be performed in order to test new therapies or combinations of therapies, including pharmacological, interventional, and behavioral therapies, to determine the best treatment options for this potentially debilitating disorder.

Diagnostic Accuracy of Hand Surgeons and Pain Specialists in Diagnosing CRPS Based on the Budapest Criteria

BackgroundThe clinical presentation of complex regional pain syndrome is heterogenous. The Budapest criteria give a list of symptoms and signs for the diagnosis. But the physician will often set the diagnosis clinically from the collection of symptoms and his or her experience. This study examines the accuracy of hand surgeons and pain specialists for diagnosing CRPS using the Budapest criteria as reference.MethodsWe included 124 patients of which 120 were diagnosed CRPS either by a clinician or by Budapest criteria. We analysed epidemiologic data, the number of patients with CRPS and mode of diagnosis and determined the CRPS severity score. Sensitivity, specificity, accuracy, and predictive values were calculated for hand surgeon and pain specialist. The number of CRPS-NOS was determined. We calculated the agreement between hand surgeon and pain specialist for the diagnosis CRPS.ResultsThe Budapest criteria were met in 108 cases with a mean CSS of 10.41 points. Sensitivity of hand surgeons for the diagnosis CRPS was 92 %, specificity 31 % and accuracy 90 %. The pain specialists had a sensitivity of 74 %, specificity of 71 % and accuracy of 74 %. Prevalence of CRPS-NOS was 9 %. In cases where hand surgeon and pain specialist agreed on CRPS, the Budapest criteria were met in 96 %, in all other combinations they were met in around 70 %. The agreement of hand surgeon and pain specialist was fair.ConclusionThe Budapest criteria can support the diagnosis CRPS in clinically ambiguous cases as they were most often met in cases with agreement of both clinicians. Care must be taken not to miss patients with CRPS-NOS.Trial registrationThe study was registered in the German Clinical Trials Register: DRKS00020348Universal Trial Number (UTN): U1111-1245-4109

Fracture of the Wrist and Incidence of the Complex Regional Pain Syndrome Type 1: A Case Series Study

Background: Complex regional pain syndrome (CRPS) is a painful syndrome with signs such as swelling, restriction of motion, and discoloration of the skin and bone. CRPS is divided into two types based on neurological injuries. Type 1 CRPS (CRPS-I), which is more common, has no nerve damage. In this study, we used the Budapest Criteria to investigate the incidence of CRPS. We also evaluated the risk factors for the incidence of CRPS. Methods: This single-center case series study was performed at Shariati Hospital of Tehran University of Medical Sciences, Tehran, Iran, during 2018-2019. We evaluated CRPS-I, two and six weeks after treatment based on Budapest Criteria. The inclusion criteria included distal radius fracture confirmed by clinical and radiographic investigations. The exclusion criteria were patients with fractures in another part of the body, associated nerve damage, vascular injury, and an open fracture. Results: Sixty-two patients with distal radius fracture who underwent casting or surgical treatment enrolled in the study. A total of 9 (14.5%) patients had CRPS-I after distal radius fracture. In 5 (8.1%) patients, CRPS-I occurred within two weeks after fracture. Also, 4 (6.5%) patients had CRPS-I after six weeks from fracture. There was no significant difference between the two sex groups in terms of CRPS (P = 0.345). This complication was significantly higher in the surgical group than in the casting group (P = 0.004). Conclusions: Given the significant incidence of CRPS and its impact on patient's quality of life, further studies are recommended to explore solutions to reduce this complication.

Complex Regional Pain Syndrome

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.

Pain control in chronic, refractory CRPS by continuous brachial plexus analgesia

We report on the outcomes of treatment for severe pain associated with long-standing, refractory CRPS in 10 female patients by continuous brachial plexus analgesia. The duration of the disease prior to treatment was 3.5 years on average, and mean baseline pain intensity was 8.3 on a numeric analogue scale (NRS). All patients met the Budapest criteria for the diagnosis of CRPS. A spinal catheter was implanted into the brachial plexus via an open axillary approach. Results: Each patient underwent a mean of 4.4 (range 2–8) spinal catheter implantations. A rapid and strong analgesic effect was observed immediately after the injection of bupivacaine solution was started: Pain decreased from a mean of 8.3 to 1.6. The duration of maintaining the catheter in the brachial plexus and achieving effective analgesia was 5.3 months (range 2–12). After the removal of the catheter, the pain returned to baseline. No patient achieved a permanent, or at least partial, reduction of pain after completing this therapy.