CRPS

Division of Pain Medicine

Department of Anesthesiology
University Hospitals of
Cleveland

Salim Hayek, MD,

PhD
 Salim Hayek, MD, PhD

Division of Pain Medicine

Department of Anesthesiology
University Hospitals of Cleveland
CRPS and Surgery
 CRPS & Surgery
Spontaneous recurrence of CRPS
in 50–74% of cases
Prevalence early after surgery
may be higher than that at a later
time

Veldman PH et al., Pain 1996; 64:463–6

Sandroni P et al., Pain 2003; 103:199–207
CRPS and Timing of Surgery
Surgery on a limb with CRPS is generally
avoided
However, 6-10% of CRPS patients
require surgery
Surgery
Optimal timing
Remain Unclear
Prior intervention

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

Strategies
 Pre-op Strategies
Wait/Sympathectomy
Katz & Hungerford recommend
Wait until symptoms subside
PT + Analgesics + oral sympatholytics
Sympathetic blocks before any surgery
Using above criteria (2-17 mo; 5), 8 ot 17
(47%) patients had recurrence of CRPS after
knee surgery for mechanical derangement

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

 Perioperative Strategies
Wait/Sympathectomy
Veldman and Goris recommend
Wait until
signs and symptoms of RSD ↓ at rest
Perfusion of affected limb optimized
Rx: Vasodilators/sympathetic blocks
until skin temp. became normal
Recurrence rate of CRPS was only 13%

Veldman PH & Goris RJ, Unfallchirurg 1995; 98:45–8

Harden RN et al.; Pain 2003; 106:393–400
 Perioperative Strategies
Regional Blocks
Surgery under GA may rekindle CRPS
Regional anesthesia, by blocking the
sympathetics, may prevent recurrence
Epidural anesthesia for LE surgery
Brachial plexus blockade for UE surgery
Several reports: Patients with previous
CRPS had recurrence after surgery
during GA but not Regional Anesthesia
Rocco AG, ANESTHESIOLOGY 1993; 79:865
Viel EJ et al., ANESTHESIOLOGY 1994;81:265–6
 Perioperative Strategies
UE Surgeries
SGB immediately post-operatively in 100
patients who had UE CRPS in remission and
underwent 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 CRPS
undergoing hand surgery
Lidocaine: recurrence rate  74%
Lidocaine+Clonidine (1µg/kg):  10%
Reuben SS et al., J Hand Surg 2000:1147-51
Reuben SS et al., J Clin Anesth. 2004 Nov;16(7):517-22 Retracted
 Perioperative Strategies
LE Surgeries
Epidural anesthetic: Technique of
choice for patients with LE CRPS
Perioperative sympathetic block/epid
Blocks neuroendocrine stress
response
Experience comes only from
anecdotal case reports

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

 Tunneled Epidural Catheter (TEC)
260 TEC
10985 cath-days

230 Neuropathic 30 Somatic

10163 cath-days 822 cath-days

206 CRPS 24 Non-CRPS

9072 cath-days 1091 cath-days

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

 100%
2
90%
56
Number of Patients

80%

70%

60%

50%
28
40%
174
30%

20%

10%

0%

Neuropathic Somatic
Patients in the neuropathic pain group had significantly higher
chance of getting a TEC infection compared to patients in the
somatic pain group (p=0.029).
Hayek SM et al. 2006, Clin. J. Pain 22(1): 82-89
 TEC Infections
There were 24 epidural space infections, 23 of
which were in the neuropathic pain group--22
with CRPS
Staphylococcus was the most common organism
isolated from the epidural space (11/23)
Contrast-enhanced MRI findings
6 frank epidural abscesses
1 phlegmon
2 patients displayed mild epidural enhancement on
MRI suggestive of epidural inflammation
All occurred in CRPS patients
Hayek SM et al., 2006, Clin. J. Pain 22(1): 82-89
Perioperative Prevention
Free radical scavengers used based
on the assumption that CRPS is
induced by the inflammatory response
DMSO
N-acetylcysteine
Mannitol
Carnitine
Vitamin C
 Vitamin C for
prevention of CRPS
The only DBRPCT among scavengers
123 adults with 127 wrist fractures
Vit C 500 mg or placebo for 50 days
Conservative management/no surgery
CRPS incidence
Vitamin C 7%
Placebo 22 %

Zollinger PE et al., Lancet 1999; 354:2025-8

 Vitamin C
195 patients with isolated closed displaced
fractures of the distal radius which were
reduced by intrafocal pinning
100 patients: no Vitamin C
95 patients: 1 g daily of Vitamin C
Incidence of CRPS
Vitamin C: 2.1%
No Vitamin C: 10%

Cazeneuve JF, Acta Orthop Belg 2002; 68:481-4

 Summary
CRPS
Neuropathic
Inflammatory
Rehab is cornerstone of treatment
Perioperative Management
Regional/Sympathetic blocks
Antioxidants