Have you ever wondered how patients interpret pain post-procedure?  We are all trained to "not interpret or judgementally determine a patient's pain level", but as a surgeon, how can you REALLY tell when that patient has gone beyond surgical pain mangement?

According to the Mayo Clinic, CPRS is defined as:

Complex regional pain syndrome (CRPS) is an uncommon, chronic condition that usually affects your arm or leg.

Rarely, complex regional pain syndrome can affect other parts of your body.

Complex regional pain syndrome is marked by intense burning or aching pain. You may also experience swelling, skin discoloration, altered temperature, abnormal sweating and hypersensitivity in the affected area.

Why am I bringing this up?  Recently, a patient was seen in the hospital for a non-union 1st metatarsal with an anklylosed 1st MPJ and associated AVN of the 2nd metatarsal.  While I did not perform the surgery, I was asked in consultation to see this patient.  The original surgery (performed by an ortho non-foot/ankle certified) in July of 2009.

Unfortunately, the pain management specialist NEVER completed the consultation.  Subsequently, the patient's current pain management specialist is now off his Cigna Network.  The patient comes to my office for follow-up, wondering why I won't do his surgery.

The nature of his pain, which in my opinion, is WAY beyond what one would reasonably expect post non-union and AVN, seems to be stratospheric.  I have explained to him in detail that if I were to perform any revisional surgery, that it might accelerate his pain receptors to a point that NO pain modalities/treatment would have any affect. 

I am not withholding doing a 1st MT fusion and/or 2nd MT osteotomy and revisional head work, if I truly think that performing it will resolve ALL of his pain issues, but I can't justify the surgical need in a patient that may have developed CPRS.

Eventually, he was admitted to another hospital and is receiving appropriate evaluations from pain management as well as my service follow-ups.

So has anyone been in this suituation where CPRS has been an issue and how have you delt with it?

Eric brings up a good point. Surgical revision with a patient where the patient has a diagnosis of Complex Regional Pain Syndrome/ Causalgia/ Reflex Sympathetic Dystrophy would probably exacerbate the patient's pain. Early intervention by a neurologist/pain management physician would be essential. I would tend to think of this if the patient is sustaining post-operative pain with a neurological component (paresthesias) out of proportion to the surgical procedure with no overt signs of bacterial infection (CBC w/ diff and sed rates), hematoma, post-surgical trauma/dislocation of surgical osteootomies, etc.  I have never experienced such a complication and hope to never experience it. Nerve blocks, use of anti-anxiety agents (since there is a correlation between the anxious patient and its development in this patient population,) oral corticosteroids and pain medications are best utilized early in the disease course. From what I remember of this, when you note on radiographs osteopenia (due to disuse/guarding/dimished weightbearing) and skin temperature dimishment as compared to the collateral limb, the condtion becomes more recalcitrant to treatment. Therefore, again, early intervention is essential to avoid a recalcitrant condition in the patient.

Complex regional pain syndrome or previously known as Reflex sympathetic dystrophy is a very interesting pain syndrome.  It is sympathetic mediated pain, in other words, the autonomic nervous system trying to interpret pain.  Subjective complaints of paresthesias, pain out of proportion, burning sensations, that are present all day all night not typical of musculoskeletal pain.  They may have temperature intolerance particularly with cold temperatures.  Clinically, they present with vasomotor cutaneous changes, swelling, livedo reticularis type appearance and allodynia.  This is a good call to suspect an entity like this, because if left unrecognized and you perform surgery on her...you have married yourself into endless disaster....well not endless...but definitely disaster.  Send her to pain management particularly anesthesia pain fellowship trained who would be willing to perform a paravertebral sympathetic nerve block which is considered to be diagnostic.  If the autonomic system is blocked and the patient has pain relief, then this confirms sympathetic mediated pain--this is complex regional pain syndrome.  

George,

Ironically, I readmitted the patient yesterday to the hospital for pain management.  Pain mangagement saw him today and scheduled for a sympathetic block.  The patient, even today, was SCREAMING at me to perform the surgery, still thinking that fixing the anklylosis and the non-union and the AVN would resolve the pain.....

I told him we will wait and see after tomorrow....story to continue! 

I have dealt with a few cases of CRPS and always involved someone from a pain management team.  This type of patient will come back to you for months and years if you are willing to help and they are difficult to satisfy because you can't heal them.  One particular case I had needed surgical intervention but for the same previously mentioned reasons, I would not take her to the OR, at least not right away.  The dilemma was knowing the surgery was warranted and would help her.  However, it would likely aggravate the CRPS and certainly not seem like improvement when the "whole" patient was evaluated.   What worked for this case was sending her to a neurologist for treatment of the CRPS with an implanted permanent spine stimulating device which controlled the CRPS very well.  However, the neurologist would not put the device in her back until after I did the foot surgery, which I think allowed pain management to achieve a baseline for their treatment.  Although surgical intervention when CRPS is involved is risky and not highly recommended, it can be done.  However, make sure you have documentation from all medical parties involved indicating that you are doing such a procedure in accordance to other professionals recommendations and involving a thorough pre- and post-surgical plan that involves the management of the CRPS.  Keep in touch with the pain management team in monitoring this patient type.

I'm proud of my colleagues for not citing  that old wives' tale of CRPS (RSD) being limited to hysteric women with psychiatr ic disorders. After the original MRI studies that showed brainwave changes, that were done in the 90's, we learned that those old wives' tales were just that. Bunk.

So now on to the science. There are a host of modalities and pharmaceuticals that can take hold of CRPS now that we have taken out the Voodoo and introduced the science. Spinal Stimulators, pharmaceuticals, behavioral modalities. The sky is the limit.

I just did a rewrite on an abstract that is being presented at a Toronto pain symposium next month that will introduce a completely new modality for treating CRPS, a combination therapy of electro-therapy and injection therapy that is highly effective. The sky is truly the limit.

We were truly our own worst enemies when it came to the old CRPS because we thought of it as an old woman's hysterical disease. When we relegated that belief to the trash heap, we decided to take ourselves into the 21st century of medicine. (Although I did notice that some of my colleagues did refer to "she" in their descriptions of the condition.)

Kathleen is indeed correct in that I noted the patient to be mistakenly identified as a female by referring to "her." My apologies since this was in no way to insinuate that the condition is linked to women of a "hysteric" state. Thank you for pointing out my error in identification of the "patient" as "her" rather than a "him." No slight was intended nor was any intent to link a female-prevalence trait associated with CRPS. Best regards.

I hadn't even noticed that you had said "her," so please don't think I was pointing to anyone in particular!

No harm, no foul!

I often, when writing, will refer to a patient as "she" or "he" as a generic matter as well.