Article Type : Case Report
Authors : Frank F
Keywords : Chronic pain syndrome; Spinal cord; Hyperalgesia; Allodynia
Background: Conservative treatment of patients with complex regional pain syndrome (CRPS) can be challenging and unsatisfactory due to a lack of pain reduction and dysfunction. CRPS can lead to serious mental health impairment with catastrophic pain perception. Spinal cord stimulation is a common treatment for mixed and chronic neuropathic pain syndromes that has been shown to be effective in early stages of CRPS type I.
Case Description: We present a case of a young woman with long-term CRPS of her left wrist. Under conservative therapy, she developed intolerable pain with catastrophizing pain perception and a desire for distal amputation of the upper extremity. Even after a prolonged course of disease, she was successfully treated with cervical spinal cord stimulation.
Conclusion: SCS is an effective treatment for patients with chronic upper extremity CRPS that is unresponsive to conventional therapy and should be considered at an early stage to prevent serious psychological and physical health effects. Even with long-term CRPS, SCS has positive effects on pain perception, mental health, and catastrophizing pain perception.
Complex regional pain syndrome (CRPS) is a chronic pain syndrome that affects the upper and lower extremities and occurs primarily after trauma or surgery. It is more common in middle-aged women [1, 2]. The pain intensity is disproportionate to the initial event and is associated with motor, sensory and autonomic deficits. Clinical diagnosis should be made early to avoid delayed treatment and is facilitated by the Budapest criteria . Pathophysiology is poorly understood and conventional therapy with pharmacological, physical and psychological aspects is challenging and applied in an interdisciplinary environment. Psychological factors and catastrophic perception can increase stress, aggravate pain and dysfunction . CRPS can lead to serious mental health impairment and can drastically affect the quality of life. Interventional methods should be considered if conservative therapy does not respond within 12 to 16 weeks. However, these surgical measures should be accumulated gradually in order to prevent further somatization of the complaints. SCS was first introduced in 1967 and has been shown to be highly effective in the treatment of CRPS type I with reduction of pain, allodynia, muscle dysfunction and improvement in quality of life . We present a case of a young woman with long-term distal upper extremity CRPS type I with catastrophic pain perception and a desire for an upper extremity amputation who was successfully treated with cervical spinal cord stimulation. The patient gave written informed consent.
The patient presented herself to our neurosurgical outpatient department for the first time in May 2019 with increased pain in her left wrist that did not respond to conservative treatment. In 2011, the patient worked as a paramedic and had an accident while working in medical service. The accident caused an avulsion fracture of her left wrist that resulted in several follow-up operations, i.e. 13 surgical procedures, including an arthrodesis of her left wrist, with no lasting effect on pain or function. As a result, neuropathic pain developed in 2015 and a complex regional pain syndrome was diagnosed in November 2016 (Figure 1). The pain symptoms started in her left wrist and spread over to the entire hand and forearm.
Figure 1: Left picture: Patient´s left upper extremity after several operations in 2015. The hand was swollen for weeks and burning pain began at the metacarpophalangeal joint including the thumb. Right picture: Decrease in swelling of the left hand after lymphatic drainage. Livid discoloration and marbling of the hand with difference in skin temperature with up to 4,5°C were present. The pain increased and became unbearable. The whole hand was affected and became more and more sensitive.
The pain intensity increased with exercises, cold weather, light touch, cold or warm water. An explanation based on other illnesses was excluded. Another surgical, i.e. causal, treatment could also be ruled out. The CRPS criteria were met for persisting pain and for the clinical categories’ hyperalgesia, allodynia, and asymmetry in skin temperature, change in skin colour, asymmetry in sweating, edema, and change in hair growth, decreased mobility, and weakness. In a side comparison, differences in skin temperature of a maximum of up to 4.5 °C were measured. Due to loss of function and persistent pain, she had to train her handedness by being originally left-handed. In professional terms, the patient lost her job in the ambulance service after the arthrodesis in 2015. She began studying in 2017, which she had to finish again due to exacerbated pain and psychological stress. In addition, she developed suicidal ideation in 2015, which took a certain form in 2017 due to a borderline personality disorder. During the presentation in our outpatient department, the pain intensity was rated with a maximum of 10/10 on the visual analog scale (VAS), a minimum of 5/10 on VAS and a pain average of 6/10 on VAS. On the intensity scale of the brief pain inventory 26 out of 40 points were achieved . The pain syndrome was refractory to comprehensive conservative treatment and only 30% of pain reduction could be achieved with previous therapy. A significant influence on mood (7/10), sleep (9/10) and enjoyment of life (7/10) with the brief pain inventory was described. On the pain interference scale, 39 out of a maximum of 70 points were achieved. A total value of 46 (max. 52) was achieved on the pain catastrophizing scale . Clinically, she showed marked allodynia of the distal forearm and the entire hand, accompanied by swelling and changes in skin colour (Figure 2).