Silas Weir Mitchell in 1864 is generally credited with describing the symdrome variously termed "Causalgia", "Sudek's atrophy", and now "COMPLEX REGIONAL PAIN SYNDROME". Dr. Mitchell was a dedicated and precise physician who ran the United States Army Hospital for the Diseases of the Nervous system in Philadelphia during the Civil War. In 1900 Sudeck desribed radiographic atrophy. Steinbrocked wrote of the "Shoulder Hand Syndrome" in 1947. Later, the term "Reflex Sympathetic Dystrophy", was introduced.
Perhaps the group of patients that can benefit most from treatment at a pain clinic are those with this most debilitating disorder.
Trauma secondary to an accident is probably the most common cause for the symdrome. What is peculiar about the syndrome, though, is that the magnitude of the injury is NOT correlated with the severity of the syndrome. Any extremity may be involved and the inciting incident may have been so mild as to escape initial notice by the patient. While injury is the most common inciting event, a variety of vascular, infectious, musculosketetal, neurologic, occupational, and visceral diseases may be responsible.
CRPS is almost invariably manifested early by pain, vascular changes, (redness or paleness), swelling, hair loss, and hypersensitivity. Later, weakness, atrophy, decreased bone density(on Xray), and limitation of motion occur. The pain is usually continuous, with spikes of almost uncontrollable worsening for no apparent reason. Severity varies with the person, and often the syndrome will spread to involve the entire extremity. Another characteristic is that the syndrome continues after the original injury has healed. The most important characteristic of CRPS is that the pain is stopped for a time after a sympathetic nerve block.
The onset varies, with pain beginning several days to several weeks after injury. If untreated, the syndrome will progress though three stages. The first stage is characterized by chronic pain, usually of a burning quality, localized to the area of the injury. The results are localized edema, muscle spasm, and tenderness. The skin is usually warm, red, and dry, but may be pale. This stage may last weeks to months. At this stage the syndrome may be reversed completely with a series of sympathetic blocks. The earlier that treatment is instituted, the fewer number of blocks will be needed. The second stage is characterized by spreading of the edema, with stiffness and muscular wasting. The skin is usually moist, cyanotic, and cold, the hair is coarse, and Xrays show osteoporosis. During this stage, which lasts three to six months, sympathetic blocks may still be effective is helping the syndrome, but a large number of them will be often needed. The third stage is characterized by marked changes including immobility, paleness, hair loss, and coldness. At this point the syndrome is almost irreversible and even surgical interruption of the sympathetic nerves may fail to provide any benefit, presumably because the process has become "central".
Clearly, the primary treatment is a series of sympathetic nerve blocks. It is important to realize that the response to nerve blocks will vary with each case, depending on the length of the symptoms, and the severity of the syndrome. If sympathetic blocks are carried out early in the process, fewer may be needed for treatment. Typically, each nerve block may provide longer and longer relief. Several other appoaches to blocking, still considered experimental, have been tried with limited success. Some have used "anticonvulsant drugs" or antidepressants also with limited success. Most important to remember: (1)This syndrome can be devastating.(2)Early and frequent sympathetic nerve blocks have shown the most success.(3)Treatment should begin as soon as the syndrome is diagnosed, at a pain clinic.(4)Even with treatment the process may become irreversible.
If you or someone you know has CRPS call us immediately for an appointment. Early treatment is absolutely essential!
Appointments can be made by calling: 931.840.4333
Thank you. By Dr. Bowers, at the Pain Institute of Tennessee.
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