CRPS: A surgeon's perspective

CRPS: A surgical view….

Dominic Power

CRPS: Historical Perspective• 1864 – Silas Weir Mitchell described “causalgia” in American Civil War

veterans• 1946– Evans popularised term “RSD” following successful treatment

of patients using sympathetic blockade• 1986– IASP Working Party redefined RSD as CRPS I and II

• 1999– Harden proposed modified diagnostic criteria including trophic

and motor signs

CRPS: Associations

• Distal radius fractures• Limb fractures• Vascular injury• Nerve injury (CRPS II)• MI• CVA

CRPS: Pathophysiology

• Trauma– Activation of inflammatory cascade

• Ischaemia-reperfusion– Reactive Oxygen Species & Free Radicals

• Immobilisation– Free radicals– Mast cell activation– Osteoclast differentiation

CRPS: Pathophysiology in Trauma

• Trauma• Ischaemia-reperfusion• Immobilisation

“Plaster disease”Trophism, pain, stiffness & loss of function in immobilized limb Tight cast – cause or effect?Incidence declining with ORIF radius fractures?

CRPS: Physiological Theories

• Neuroinflammatory factors• Abnormal sympathetic nervous system - SMP• Central sensitization in dorsal horn cells• Spinal cord microglia• Cortical re-organization

CRPS: A Simple Surgeon’s View

Traumatic Event

Inflammatory Response Resolution Functional

Recovery

CRPS: A Simple Surgeon’s View

Traumatic Event

Inflammatory Response Resolution Functional

Recovery

Exaggerated Response

CRPS: A Simple Surgeon’s View

Traumatic Event

Inflammatory Response Resolution Functional

Recovery

Exaggerated Response

Further Injury

CRPS: A Simple Surgeon’s View

Traumatic Event

Inflammatory Response Resolution Functional

Recovery

Exaggerated Response

Further Injury

CRPS: A Simple Surgeon’s View

Traumatic Event

Inflammatory Response Resolution Functional

Recovery

Exaggerated Response

Further Injury

Chronicity & Memory

CRPS: A Simple Surgeon’s View

Traumatic Event

Inflammatory Response Resolution Functional

Recovery

Exaggerated Response

Further Injury

Chronicity& Memory

Functional Deficit

CRPS: A Simple Surgeon’s View

Traumatic Event

Inflammatory Response Resolution Functional

Recovery

Exaggerated Response

Further Injury

Chronicity& Memory

CRPS Treatment

CRPS: “An allergic reaction to trauma”

Traumatic Event

Inflammatory Response Resolution Functional

Recovery

Exaggerated Response

Further Injury

Chronicity& Memory

CRPS Treatment

CRPS: Clinical Syndrome• Disproportionate pain• Sensory

– Hyperaesthesia, hyperalgesia, allodynia, hyperpathia• Vasomotor

– Skin temperature and colour asymmetry• Motor

– Reduced ROM, weakness, tremor, dydtonia• Sudomotor

– Oedema, sweating dysfunction and asymmetry• Trophic changes

– Neglect– Hair, nail and skin trophic changes

CRPS: The Typical T&O Patient

• Female (3:1)• Age 40-50• Upper limb injury• Psychosocial issues– No evidence of CRPS preconditioned personality– Definite evidence that psychological stress and

prolonged pain may lead to behavioural changes and may influence the perception and response to pain

The Problems

• Patient dysfunctional behaviour?• Loss of confidence– Difficult to diagnose in first 3 months– High index of suspicion– Pain and stiffness greater than expected– Symptoms often dismissed in early phase

• Poor understanding• Loss of function• Fear regarding permanency• Pain

My approach

• Listen• Explain the underlying problem• Honesty regarding timeframe for recovery• Develop a strategy for treatment• Treat underlying disorder (eg CTS)• Review medications• Access appropriate services• Provide resources• Review regularly

CRPS: My Explanation • The nerves carry signals to the brain and retuen signals to the

muscles, skin and blood vessels• Sensitivity is tightly controlled• In CRPS the sensitivity mechanism is dysfunctioning• Compare to a faulty movement sensor in a burglar alarm system• Alarm triggers with normally non-injurious stimulus• Alarm may not trigger when it should• Strategy is to deal with sequelae and allow the sensitivity

settings to return to normal• Delay in treatment may produce permanency• Early treatment may allow resolution in 12-24 months

Surgery is more art than science…

• There are some patients that shouldn’t be treated with surgery

• …. But there are some surgeons who shouldn’t treat patients

CRPS: My Treatment Strategy• Look for reversible causes

– Eg treat CTS• Pain relief

– Neuromodulators, Nsaids, Opioids• Other agents

– Alpha Blockade, Vitamin C, Bisphosphonates, Capsaicin• Therapy

– Splints, Active ROM, education• Encourage hand use

– Normalisation of function• Mirror therapy

– Use of mirror neurons to suppress cortical re-organisation• Pain clinic support

– Sympathetic blockade, Spinal cord stimulation