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Yao & Artusio > Chapter 47- Complex Regional Pain Syndrome > Flashcards

Chapter 47- Complex Regional Pain Syndrome Flashcards

1
Q

What is complex regional pain syndrome?

A

pain + sudomotor or vasomotor instability
Caused by
- Type I–> noxious stimuli
- Type II–> nerve injury
pain is out of proportion to inciting event

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2
Q

What are the 2 types of CRPS?

A

CRPS-I is triggered by noxious stimulus NOT in single nerve distribution

CRPS-II is triggered by nerve injury and is usually in the distribution of that nerve.

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3
Q

What is the diagnostic criteria for CRPS?

A

A) history of trauma to area with pain that is out of proportion to inciting event plus 1 of the following

  • Abnormal function of the sympathetic nervous system
  • swelling
  • movement disorder
  • changes in tissue growth (dystrophy and atrophy)
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4
Q

Describe the pain that typical of CRPS?

A

continuous burning type pain that is not limited to dermatomal pattern

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5
Q

Define allodynia

A

pain caused by a stimulus that normally does not provoke pain (light touch)

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6
Q

Define hyperalgesia

A

increased response to stimulus that is normally painful (increased response to pinprick)

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7
Q

Define hyperesthesia

A

increased sensitivity to a stimulus that is either due to a diminished threshold or increased response to stimuli that are normally recognized ==includes both allodynia and hyeralgesia

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8
Q

Define dysesthesia

A

An abnormal sensation that is unpleasant to patient, either spontaneous or evoked (lumbar radiculopathy)

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9
Q

What are the stages associated with CRPS?

A

Stage I

  • onset of severe pain limited to site of injury
  • hyperesthesia
  • localized swelling
  • stiffness and limited mobility of affected area
  • skin is red, warm and dry
  • lasts a few weeks

Stage II

  • pain becomes more severe and more diffuse
  • swelling spreads and may change to hard/brawny type
  • hair and nail changes- course and scant hair, brittle nails
  • osteoporosis of bones
  • muscle wasting

Stage III

  • marked wasting of tissue- irreversible
  • pain is intractable and involves entire limb
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10
Q

What is the pathophysiology of the development of CRPS?

A

multiple hypothesis but all involve:

  • abnormal discharges in sympathetic and nociceptive afferents after trauma
  • sensitization of the peripheral sensory receptors after the sympathetic hyperactivity
  • formation of artificial synapes after peripheral nerve injurery
  • spontaneous neuronal ectopy at the site of demyelination
  • central reorganization of pain processing like central sensitation
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11
Q

What receptor is often implicated in central pain sensitization?

A

NMDA receptor

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12
Q

What happens with central sensitization?

A

Injury results in lower threshold to fire pain transmission nuerons and increases in the receptive fields

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13
Q

What is sympathetically mediated pain?

A

(SMP) is pain that is maintained by sympathetic innervation or circulating catecholamine- describes a pain mechanism NOT a clinical syndrome

If a sympathetic block provides pain relief, it is SMP.

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14
Q

What is sympathic independent pain?

A

(SIP) is are pain conditions that show features of sympathic activity but DO NOT respond to sympathetic blocks.

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15
Q

How does CRPS differ from neuralgia?

A

Neuralgia is paroxsymal and follows the distribution of the nerve WITHOUT vasomotor or sudomotor changes

CRSP is sustained, diffuse, burning WITH vasomotor and/or sudomotor changes

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16
Q

How can you work up a patient that you think has CRPS?

A

You must rule out other things as CRPS is a diagnosis of exclusion. Can try tests such as:

  • sweat test- excessive sweating is suggestive of CRPS
  • xray imaging- osteoporosis limited to painful area is suggestive of CRPS
  • positive diagnostic sympathetic blocks will confirm the sympathetically mediated portion of the CRPS
17
Q

Describe the sympathetic nerve supply to the arm

A

Preganglionic sympathetic outflow is from T2-T9, these fibers synapse with the postganglionic nerve fibers in the stellate ganglion so doing a stellate ganglion block will block the sympathetic supply

18
Q

Describe the anatomic location of the stellage ganglion.

A

Located between the base of the C7 transverse process and first rib.

  • behind carotid sheath and vertebral artery
  • recurrent laryngeal nerve is nearby
  • pleura is close
19
Q

After performing a stellate ganglion block, how can you tell if you were successful?

A

Expect Horner’s syndrome: ptosis, miosis and anhidrosis= however this ONLY TELLS YOU IF YOU BLOCKED the sympathetics to the head and neck. You should use temperature monitoring to watch for increased temperature of the extremity.

20
Q

What types of nerve fibers are blocks with a stellate ganglion block?

A

preganglionic B fibers and postganglionic unmyelinated C fibers

21
Q

Please review local anesthetic sections

A

please review local anesthetic sections

22
Q

How can you treat CRPS?

A
  • physical therapy (early and aggressive)
  • if pain is SMP (sympathetically mediated) can use series of sympathetic blocks
  • pain medications
23
Q

What are drug options for treatment of CRPS

A

If pain is SMP…
- oral sympatholytic agents: phenoxybenzamine, prazosin, topical clonidine

Tricyclic antidepressants are first line treatment, anticonvulsants (gabapentin, pregabalin), corticosteroids and opioids

24
Q

How can you do a Bier block in the diagnosis and treatment of CRPS?

A

Bier block wit phentolamine causes alpha adrenergic block and can be used to identify patients with SMP and acts as predictor before more invasive blocks are done

25
Q

What is windup phenomeon?

A

amplification of the incoming pain signal at the level of the second-degree neurons in the dorsal horn of the spinal cord

26
Q

How can you ketamine to treat CRPS?

A

There are 3 ways: low dose inpatient infusion, low dose outpatient infusion, ketamine coma

By providing long enough ketamine infusion you may get reversal of effects of sensitization process

27
Q

What are more invasive ways of treating CRPS

A

surgical, chemical and radiofrequency sympathectomy can cause short term pain relief of the SMP pain, but long term results are inconsistent.

Can also use spinal cord stimulator

28
Q

What are complications of stellate ganglion block?

A

intraarterial injection of local: seizure and hematoma
recurrent laryngeal nerve paralysis- hoarseness
brachial plexus block- motor weakness of arm
epidural or subarachoid injection
pneumothorax
esophageal injury

Yao & Artusio (5 decks)

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