Complex Regional Pain Syndrome and Carpal Tunnel Surgery

IASP criteria for CRPS

CRPS type 1

Two to four of the following criteria must be met, with two to four being mandatory

CRPS type 2

All of the following must be present

1. The presence of an initiating noxious event or a cause of immobilization

1. The presence of continuous pain, allodynia , or hyperalgesia after a nerve injury, not necessarily limited to the distribution of the nerve

2. Continuing pain, allodynia , or hyperalgesia where the pain is disproportionate to the inciting event

2. Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain

3. Evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of pain

3. This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction

4. This diagnosis is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction

Table 31.2

Budapest criteria

Budapest criteria for CRPS
All of the following must be satisfied: • The patient has continuing pain that is disproportionate to any inciting event • The patient has at least one sign in two or more of the categories below • The patient reports at least one symptom in three or more of the categories below • No other diagnosis can better explain the signs and symptoms
Category	Signs/symptoms
Sensory	Allodynia (pain to light touch and/or temperature sensation and/or deep somatic pressure and/or joint movement) and/or hyperalgesia (to pinprick)
Vasomotor	Temperature asymmetry and/or skin color changes and/or skin color asymmetry
Sudomotor/edema	Edema and/or sweating changes and/or sweating asymmetry
Motor/trophic	Decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/ or trophic changes (hair, nail, skin)

Clinical experience indicates that early diagnosis and treatment is vital and leads to improved outcomes. Postoperative pain and loss of function out of norm for a particular surgical procedure, especially if accompanied by autonomic dysfunction and hypersensitivity in the affected extremity, should trigger a referral to a pain specialist to aid in the diagnosis of CRPS type 1 or type 2.

Treatment

There is no cure for complex regional pain syndrome; treatment is palliative aimed at relieving symptoms and recovering motor and psychological function [12]. Multiple treatment modalities exist for both CRPS types with variable outcomes. These regimens include pharmacological, interventional, and psychological treatments.

Our pharmacological armamentarium includes membrane stabilizers (gabapentin, pregabalin), opioids (without escalation to high doses), tricyclic antidepressants (amitriptyline , desipramine ), and alpha-blockers (clonidine ) to name a few.

Different intravenous therapies have also been used. IV bisphosphonates seem to lessen the pain associated with the bone loss observed in CRPS. Other IV therapies include ketamine, glucocorticoids, local anesthetics (lidocaine ), immunoglobulins, and calcitonin [8].

Interventional options include sympathetic blockade, intrathecal therapy, spinal cord stimulators, and stellate ganglion blocks/radiofrequency neurolysis [13]. Unfortunately, sympathetic chain frequently regenerates, thus limiting long-term usefulness of ablative therapies.

Stellate ganglion blocks for the CRPS of the upper extremity have long been considered pivotal in the diagnosis, prognosis, and management [14]. Sympatholysis may reverse the vasoconstriction mediated hypoxia. Interestingly, many patients with either type of CRPS will respond to sympathetic blockade for a variable duration. Results of the sympathetic blockade could also serve as an indicator of success of the spinal cord stimulation.

Behavioral-cognitive therapy may also help reduce pain [15]. Addressing and managing any psychological features coupled with biomedical components has shown to improve outcome.

CRPS and Hand Surgery

Specific surgical interventions and injuries have a higher incidence in the development of CRPS. High-energy injuries, severe fractures, and the female gender contribute to the development of CRPS type I, especially after the surgical treatment of distal radius fractures [16].

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