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CURRICULUM VITAENama : dr. Syafruddin Gaus, Ph.D, Sp.An-KMNTTL : Makassar /19 Oktober 1963Alamat rumah : Perumahan Dosen UNHAS Tamalanrea
Jl. Thomas Alfa Edison Blok AC Baru No. 14 Makassar-90245
Telp/HP/Fax/Email : 0411-4773189 /HP: Flexi: 0411-5764244 GSM: 081543058610
Email : [email protected]
Alamat kantor : Bagian Ilmu Anestesi, Perawatan Intensif & Manajemen Nyeri
Fakultas Kedokteran UNHAS / RS. Dr. Wahidin Sudirohusodo
Jl. Perintis Kemerdekaan Km.11 Tamalanrea Makassar-90245
Telp/HP/Fax/Email : 0411-582583 / Fax.0411-590290 / HP:081543058610
[email protected] / [email protected]
Riwayat Pendidikan : Lulus dokter umum FK Universitas Hasanuddin tahun 1991 Lulus dokter spesialis anestesi FK Universitas Hasanuddin tahun
2005 Lulus S3 Hiroshima University School of Medicine tahun 2003 Konsultan Manajemen Nyeri (KMN) tahun 2009
CURRICULUM VITAERiwayat Pekerjaan: Jabatan: - Staf Pengajar Bagian Anestesiologi: 1996-sekarang
- Sekeretaris Program Studi Bagian Anestesiologi: 2006-sekarang
- Institusi Kesehatan :1. Bagian Anestesiologi & ICU FK Universitas Hasanuddin – RS Dr. Wahidin Sudirohusodo Makassar2. Bagian Anestesi & ICU di RS. Polisi Bhayangkara mappa Oddang Makassar mulai tahun 2006 sampai sekarang3. Bagian Anestesi & ICU di RS. Ibnu Sina Makassar mulai tahun 2006 sampai sekarang 4. Bagian Anestesi di RSB. Siti Miriam Makassar mulai tahun 2006 sampai sekarang 5. Bagian Anestesi di RSIB Siti Khadijah I mulai tahun 2006 sampai sekarang
COMPLEX REGIONAL PAIN
SYNDROMESyafruddin Gaus
Dibawakan pada Simposium ISAPM 16-17 September 2011, Hotel Clarion - Makassar
Synonyms
Causalgia
Algodystrohy Algoneurodystrohy Shoulder-hand
syndrome Hyperpathic pain Traumatic
vasospasm Traumatic
angiospasm Peripheral acute
toponeurosis Postinfarctional
sclerodactyly
Also known as: Reflex Sympathetic
Dystrophy (RSD)
Sympathalgia Sympathetic
Maintained Pain Sudek’s
osteodystrophy Reflex Neurovascular
Dystrophy Reflex dystrophy Acute atrophy of
bone Post-traumatic
osteoporosis
History (1) Galen (1528):
Described nerve trunk along rib heads connecting to the spinal cord
Initiated concept of sympathy between different body parts
Potts (1700):“Atrophy and burning pain in an injured extremity”
Bernard (1853):“Role of sympathetic system in temperature control”
Colonel Weir Mitchell, MD (1864):“Severely painful dystrophic syndrome following
ballistic injuries” in US Civil War soldiersCausalgia
History (2) Leriche (1926):
“Sympathetic nerve root dysfunction as a cause of pain” First to use surgical sympathectomy to relieve pain of
causalgia Bonica (1953):
Popularized the term RSDStages I, II, and III of RSD: - Stage I (acute): immediately or within weeks, pain,
edema, allodynia, and hyperesthesia - Stage II (dystrophic): in 3-6 months, pain, cooling,
brawny discoloration, bone demineralization - Stage III (atrophic): thin skin, atrophy of muscles,
joints, and bones, some attenuation of pain, psychological issues
History (3) International Association for the Study
of Pain (1994):CRPS type I = RSDCRPS type II = Causalgia
Introduction (1) Complex Regional Pain Syndrome
(CRPS) is a disorder of the extremities.
A diagnosis of CRPS requires the presence of regional pain and sensory changes following a noxious event.
The pain is more severe than expected from the injury which caused it.
Unclear pathophysiology.
Introduction (2)CRPS is characterized
by: - Pain - Swelling/edema - Limited range of motion (ROM)
- Vasomotor instability - Skin changes/abnormal skin
color - Patchy bone demineralization - Temperature changes - Atrophy
Fig. 1. Clinical features of Complex Regional Pain Syndrome type I (Reflex Sympathetic Dystrophy)
A consensus development conference in 1994 grouped these disorders under the single heading CRPS.
Two types of CRPS have been recognized:CRPS Type I:
○ No definable nerve lesion is present.○ Represents about 90% of clinical cases.○ Formerly termed Reflex Sympathetic Dystrophy
(RSD).CRPS Type II:
○ A definable nerve lesion is present.○ Formerly termed Causalgia.
Introduction (3)
Merskey H, Bogduk N. Classification of Chronic Pain: Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, 2nd ed. Seattle: IASP Press; 1994.
Harden R.N, Bruehl SP. Diagnosis Criteria: The Statistical Derivation of the Four Criterion Factors. Progress in Pain Research and Management, Vol. 32. Seattle: IASP Press; 2005:45-58
(1) (2) (3) (4)Positive sensory
abnormalities
Vascular abnormalitie
s
Edema, sweating
abnormalities
Motor, trophic changes
Spontaneous pain
Mechanical hyperalgesia
Thermal hyperalgesia
Deep somatic hyperalgesia
Vasodilatation Vasoconstricti
on Skin
temperature asymemetries
Skin color changes
Swelling Hyperhidrosis hypohidrosis
Motor weakness Tremor Dystonia Coordination
deficits Nail, hair
changes Skin atrophy Joint stiffness Soft tissue
changesInterpretation for Clinical Use:> 1 symptom of > 3 categories each AND > 1 sign of > 2
categories eachSenstivity 0.85; Specifity 0.60Interpretation for Research Use::> 1 symptom of > 4 categories each AND > 1 sign of > 2 categories eachSenstivity 0.70; Specifity 0.96
Revised Diagnostic Criteria for CRPSCategories of Clinical Signs/Symptoms
Baron R et al. CRPS: a neuropathic disorder?. Pain 2010, An Updated Review.
Epidemiology Age - common in younger adults:
• Mean: 41.8 years• Mean age at time of injury: 37.7 years
Mean duration of symptoms before pain center evaluation: 30 months
2.3 to 3 times more frequent in females than males.1
Usually involves a single limb in the early stage.2
1. Raja SN et al. Anesthesiology. 2002;96:1254-1260. 2. Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001, 388-411.
Epidemiology USA: Incidence: 5.5 per 100,000
person-years Prevalence: 2.1 per 100,000
Europe: Incidence: 26.2 per 100,000
person-years1. Raja SN et al. Anesthesiology. 2002;96:1254-1260.
2. Galer BS et al. In: Loeser, ed. Bonica’s Management of Pain. 2001, 388-411.
Natural History of CRPS Triggered by a variety of events:
An injury or trauma (often minor) ranks as the leading provocative event
Ischemic heart disease and myocardial infarction Cervical spine or spinal cord disorders Cerebral lesions (stroke)Infections Surgery Repetitive motion disorder or cumulative trauma,
causing conditions such as carpal tunnel In approximately 10% of patients, no
precipitant can be identified
Etiology (1) The pathogenesis of CRPS is
unclear. It is thought to involve the
formation of a reflex arc after an inciting event.
The reflex arc follows the routes of the sympathetic nervous system.
It is modulated by cortical centers which produce peripheral vascular changes.
Etiology (2) Autonomic features are thought
to be due to catecholamine hypersensitivity and include:Cyanosis MottlingIncreased sweatingAbnormal growth of hair Diffuse swellingColdness
Etiology (3) A proposed mechanism for the
persistent pain & allodynia is the release of inflammatory mediators & pain producing peptides by peripheral nerves, including:Substance PNeuropeptide YCalcitonin gene related peptide
(CGRP)IL-6, IL-8, IL-1βTNF-α
Normal terminations of primary afferents in the dorsal horn
After Nerve Injury
Allodynia: Nerve injury leads to central reorganization in the spinal dorsal horn
Clinical Manifestations CRPS may occur in either the
upper or lower extremities. Involvement of both upper and
lower extremities in the same patient is unusual.
It may be recurrent. Three clinical stages can occur
during the course of illness.
Stage I (Acute Stage) The patient develops pain in a limb
following an event or without apparent cause.
Symptoms: burning or throbbing pain, diffuse aching, sensitivity to touch or cold, and localized edema.
Vasomotor disturbances occur with variable intensity, producing altered color and temperature.
Radiographs are usually normal but may show patchy demineralization of the involved bones.
Stage I (Acute Stage)
Stage II (Dystropic Stage) Is characterized by:
Progression of soft tissue edema Thickening of the skin and articular soft
tissues Muscle wasting Development of brawny skin
Symptoms typically last for three to 6 months.
Stage II (Dystropic Stage)
Stage III (Atrophic Stage) The most severe stage. It is characterized by:
Limitation of movement Shoulder-hand syndrome Contractures of digitsWaxy trophic skin changesBrittle ridged nails
Radiographs reveal severe bone demineralization.
Stage III (Atrophic Stage)
Diagnostic Test (1)
The diagnosis of CRPS is a clinical diagnosis, predominantly based on signs and symptoms
Majority of tests, sensitivity and specificity have not been determined
The diagnostic value of laboratory test can only be established in patients who have received a reliable clinical diagnosis
No gold-standard laboratory test Useful in early stages of the disease may
fail later onRommel O, Habler H-J, Schurmann M. Laboratory Test for Complex Regional Pain Syndrome. Progress in Pain Research and Management, Vol. 32. Seattle: IASP Press; 2005:139-159.
Diagnostic Test (2) Test to verify clinical findings: - Edema, impaired joint movement and
pain - Bilateral differences in skin
temperature - Evaluation of sensory dysfunction:
quantitative sensory testing
Sympathetic function tests: - Peripheral vasoconstrictor reflex - Sudomotor function test - Sympathetic skin response
Bilateral differences in skin temperature
Thermography: warmer early, cooler late
Temperature measurement: 2°C difference is significant
Diagnostic Test (3) Neurophysiological procedures: - Nerve conduction velocity - Somatosensory evoked potentials - Electromyography Psychological assessment Imaging method: - Radiograpy - Three-phase of bone scan - MRI
Radiography:
Patchy osteoporosis (late in the course)
Sudek’s atrophy- periarticular osteoporosis
Cortical thinning and cortical bone loss secondary to an increase in osteoclastic activity (2-3weeks.)
Abnormal third phase that is characterized by a diffusely increased uptake (very low sensitivity & specificity)
Three-phase bone scintigraphy:
Management of CRPS (1) Multidisciplinary Early intervention: delay in
diagnosis and treatment leads to poor outcomes (Stanton-Hicks, 2001)
Primary aim: return to normal function via gradual progression from gentle movements to load-bearing activities (Harden, 2001)
Desensitization (Stanton-Hicks et al, 2001)
Management of CRPS (2) Physical and occupational
therapies Pharmacologic management Psychological interventions Traditional interventional
therapies Implanted therapies Miscellaneous and experimental
therapies
Pharmacologic Management Must be secondary & supportive of
effort to mobilize the affected limb & to restore its function.
Major treatment for the patients whose symptoms do not improve substantially despite aggressive rehabilitation efforts within the first year after onset.
Most drugs used for neuropathic pain are used to treat CRPS
Evidence-Based Pharmacotherapy for
CRPS
Pharmacotherapy for early CRPSPharmacotherapy for chronic
CRPS
Pharmacotherapy for Early CRPS
Modes of action: Decreasing inflammation & minimizing ectopic electrical activity after nerve injury through neuronal membrane stabilization (Devor et al. 1985)
Oral prednisone 30 mg/day, methylprednisolone 32 mg/day (Christensen et al. 1982, Braus et al. 1994)
Corticosteroid:
Level 3
Pharmacotherapy for Early CRPS
Modes of action: Inhibit bone resorption by osteoclast
and direct antihyperalgesic effects independent of its effect on bone (Braga 1994)
Calcitonin 100-400 IU intranasally (Bickerstaff & Kanis 1991; Gobelet et al. 1992; Hamamci et al. 1996; Zyluk 1998)
Calcitonin:
Level 1
Pharmacotherapy for Early CRPS
Modes of action: Inhibitors of osteoclast-mediated bone
resorption, prostaglandin E2, proteolytic enzyme, lactid acid, and proinflammatory cytokines (Ohya et al.1985; Van Offel et al. 2001)
Pamidronate 30 mg/day for 3 days (acute and chronic CRPS) (Maillefert et al. 1999)
Bisphosphonate:
Level 2
Pharmacotherapy for Early CRPS
Modes of action: Hypothesis that CRPS is caused by
oxygen-derived free radical damage that initiates or potentiates inflammation and microangiopathy.
Benefit for topical dimethylsulfoxide (DMSO) in fatty cream (Zuurmond et al.1996)
500 mg of vitamin C in reducing prevalence of CRPS (Zollinger et al..1999)
Antioxidants & Free-radical Scavengers:
Pharmacotherapy for Early CRPS
Phenoxybenzamine in early CRPS type I (Muizelaar et al.1997) & chronic CRPS type II (Ghostine et al..1984) were helpful
Ca channel blocker: nifedifine (Prough et al..1985; Muizelaar et al. 1997)
Alpha-adrenergic antagonist & vasodilators:
Level 4
Pharmacotherapy for Chronic CRPS
Available in several forms: viscous lidocaine, gel, creams, sprays, and patch.
5% lidocaine patch is currently the most popular route of administration because protect allodynic skin from contact.
Meier et al. 2003; found efficacy of lidocaine for patients with focal neuropathic pain including CRPS.
Topical local anesthetics:
Level 2
Pharmacotherapy for Chronic CRPS Modes of action: Potentiation of serotonergic and especially
noradrenergic descending inhibitory pathway to decrease dorsal horn hyperactivity, μ-opioid activity, and cation channel blockade (Jensen 2002)
Nortriptyline or desipramine 50-75 mg once/day are the best choise for most patient with CRPS (Max et al. 1992)
May be the single medication for CRPS available today (Oaklander 2005)
Tricyclic antidepressants (TCAs):
Level 2
Pharmacotherapy for Chronic CRPS
Mode of action: Decreasing central neuronal
hyperexcitability and decreasing calcium-mediated synthesis and release of excitatory neurotransmitter (Gee et al. 1996)
Gabapentin 600 mg/day is efficacious and safe in CRPS patient (Mellick and Mellick 1997)
Pregabalin, an analoque of gabapentin is useful for CRPS (Dworkin et al. 2003)
Antiepileptic drugs:
Level 1 & 2
Pharmacotherapy for Chronic CRPS
Controlled-release oxycodone 60 mg/day reported about 30% reduction in pain (Gimbel et al. 2003; Watson et al. 2003)
Tramadol was effective at doses up to 400 mg/day (Harati et al. 1998)
Well-designed study found 27% pain relief attributed to use of controlled-release morphine 30 mg/day or methadone 15 mg/day (Raja et al. 2002)
Opioids:
Level 2
Challenges of CRPS Natural course and pathophysiology
remain elusive1
Therapies remain controversial2
Underdiagnosed and undertreated3
Significant morbidity and loss of quality of life
1. Jänig W. In: Harden , Baron Janig, eds. Complex regional Pain Syndrome, Progress in Pain Research and Management. 2001: 3-15.2. Bogduk N. Current Opinions in Anesthesiology. 2000;14:541-546.3. Raja SN et al. Anesthesiology. 2002;96:1254-1260.
Prognosis Difficult to predict Earlier intervention may be more
likely to be successful Some patients experience reduced
symptoms or apparently full recovery
Some patients continue to experience significant disability
Raja SN et al. Anesthesiology. 2002;96:1254-1260.
Summary: Early diagnosis, appropriate
treatment, and intervention is essential
Ideal treatment should be multidisciplinary
THANKS FOR YOUR ATTENTION!