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CRPS

Division of Pain Medicine

Department of Anesthesiology

University Hospitals ofCleveland

Salim Hayek, MD,PhD

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Salim Hayek, MD, PhD

Division of Pain MedicineDepartment of AnesthesiologyUniversity Hospitals of Cleveland

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CRPS and Surgery

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Veldman PH et al., Pain 1996; 64:463–6Sandroni P et al., Pain 2003; 103:199–207

Spontaneous recurrence of CRPSin 50–74% of cases

Prevalence early after surgerymay be higher than that at a latertime

CRPS & Surgery

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Katz MM & Hungerford DS, J Bone Joint Surg 1987; 69:797–803

CRPS and Timing of Surgery

Surgery on a limb with CRPS is generallyavoided

However, 6-10% of CRPS patients

require surgerySurgeryOptimal timing

Prior interventionRemain Unclear

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Strategies

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Katz MM & Hungerford DS, J Bone Joint Surg 1987; 69:797–803

Pre-op StrategiesWait/Sympathectomy

Katz & Hungerford recommendWait until symptoms subside

PT + Analgesics + oral sympatholyticsSympathetic blocks before any surgery

Using above criteria (2-17 mo; 5), 8 ot 17

(47%) patients had recurrence of CRPS afterknee surgery for mechanical derangement

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Veldman PH & Goris RJ, Unfallchirurg 1995; 98:45–8Harden RN et al.; Pain 2003; 106:393–400

Veldman and Goris recommendWait untilsigns and symptoms of RSD ↓ at rest

Perfusion of affected limb optimized

Rx: Vasodilators/sympathetic blocks

until skin temp. became normalRecurrence rate of CRPS was only 13%

Perioperative StrategiesWait/Sympathectomy

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Rocco AG, ANESTHESIOLOGY 1993; 79:865Viel EJ et al., ANESTHESIOLOGY 1994;81:265–6

Surgery under GA may rekindle CRPS

Regional anesthesia, by blocking the

sympathetics, may prevent recurrenceEpidural anesthesia for LE surgery

Brachial plexus blockade for UE surgery

Several reports: Patients with previousCRPS had recurrence after surgeryduring GA but not Regional Anesthesia

Perioperative StrategiesRegional Blocks

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Reuben SS et al., J Hand Surg 2000:1147-51Reuben SS et al., J Clin Anesth. 2004 Nov;16(7):517-22

SGB immediately post-operatively in 100patients who had UE CRPS in remission andunderwent UE surgery

50: SGB recurrence rate: 5/50 or 10%50: no SGB recurrence rate: 36/50 or 72%

IVRA: limited supportive data

P R DB trial in 84 patients with UE CRPSundergoing hand surgeryLidocaine: recurrence rate 74%Lidocaine+Clonidine (1µg/kg): 10%

Perioperative StrategiesUE Surgeries

Retracted

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Cramer G et al., J Foot Ankle Surg 2000; 39:387-91

Epidural anesthetic: Technique ofchoice for patients with LE CRPS

Perioperative sympathetic block/epidBlocks neuroendocrine stressresponse

Experience comes only from

anecdotal case reports

Perioperative StrategiesLE Surgeries

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Hayek SM et al. 2006, Clin. J. Pain 22(1): 82-89

260 TEC10985 cath-days

230 Neuropathic10163 cath-days

30 Somatic822 cath-days

206 CRPS9072 cath-days

24 Non-CRPS1091 cath-days

Tunneled Epidural Catheter (TEC)

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Hayek SM et al. 2006, Clin. J. Pain 22(1): 82-89

174

56

28

2

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Neuropathic Somatic

   N  u  m

   b  e  r  o   f   P  a   t   i  e  n

   t  s

Patients in the neuropathic pain group had significantly higherchance of getting a TEC infection compared to patients in thesomatic pain group (p=0.029).

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Hayek SM et al., 2006, Clin. J. Pain 22(1): 82-89

TEC InfectionsThere were 24 epidural space infections, 23 of

which were in the neuropathic pain group--22with CRPS

Staphylococcus was the most common organism

isolated from the epidural space (11/23)Contrast-enhanced MRI findings6 frank epidural abscesses

1 phlegmon

2 patients displayed mild epidural enhancement onMRI suggestive of epidural inflammation

All occurred in CRPS patients

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Perioperative Prevention

Free radical scavengers used basedon the assumption that CRPS is

induced by the inflammatory responseDMSON-acetylcysteineMannitolCarnitineVitamin C

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SummaryCRPSNeuropathic

Inflammatory

Rehab is cornerstone of treatment

Perioperative ManagementRegional/Sympathetic blocks

Antioxidants