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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