Hayek_CRPS
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CRPS Division of Pain Medicine Department of Anesthesiology University Hospitals of Cleveland Salim Ha yek, MD, PhD
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Transcript of Hayek_CRPS
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CRPS
Division of Pain Medicine
Department of Anesthesiology
University Hospitals ofCleveland
Salim Hayek, MD,PhD
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Salim Hayek, MD, PhD
Division of Pain MedicineDepartment of AnesthesiologyUniversity Hospitals of Cleveland
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CRPS and Surgery
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Veldman PH et al., Pain 1996; 64:463–6Sandroni P et al., Pain 2003; 103:199–207
Spontaneous recurrence of CRPSin 50–74% of cases
Prevalence early after surgerymay be higher than that at a latertime
CRPS & Surgery
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Katz MM & Hungerford DS, J Bone Joint Surg 1987; 69:797–803
CRPS and Timing of Surgery
Surgery on a limb with CRPS is generallyavoided
However, 6-10% of CRPS patients
require surgerySurgeryOptimal timing
Prior interventionRemain Unclear
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Strategies
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Katz MM & Hungerford DS, J Bone Joint Surg 1987; 69:797–803
Pre-op StrategiesWait/Sympathectomy
Katz & Hungerford recommendWait until symptoms subside
PT + Analgesics + oral sympatholyticsSympathetic blocks before any surgery
Using above criteria (2-17 mo; 5), 8 ot 17
(47%) patients had recurrence of CRPS afterknee surgery for mechanical derangement
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Veldman PH & Goris RJ, Unfallchirurg 1995; 98:45–8Harden RN et al.; Pain 2003; 106:393–400
Veldman and Goris recommendWait untilsigns and symptoms of RSD ↓ at rest
Perfusion of affected limb optimized
Rx: Vasodilators/sympathetic blocks
until skin temp. became normalRecurrence rate of CRPS was only 13%
Perioperative StrategiesWait/Sympathectomy
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Rocco AG, ANESTHESIOLOGY 1993; 79:865Viel EJ et al., ANESTHESIOLOGY 1994;81:265–6
Surgery under GA may rekindle CRPS
Regional anesthesia, by blocking the
sympathetics, may prevent recurrenceEpidural anesthesia for LE surgery
Brachial plexus blockade for UE surgery
Several reports: Patients with previousCRPS had recurrence after surgeryduring GA but not Regional Anesthesia
Perioperative StrategiesRegional Blocks
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Reuben SS et al., J Hand Surg 2000:1147-51Reuben SS et al., J Clin Anesth. 2004 Nov;16(7):517-22
SGB immediately post-operatively in 100patients who had UE CRPS in remission andunderwent UE surgery
50: SGB recurrence rate: 5/50 or 10%50: no SGB recurrence rate: 36/50 or 72%
IVRA: limited supportive data
P R DB trial in 84 patients with UE CRPSundergoing hand surgeryLidocaine: recurrence rate 74%Lidocaine+Clonidine (1µg/kg): 10%
Perioperative StrategiesUE Surgeries
Retracted
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Cramer G et al., J Foot Ankle Surg 2000; 39:387-91
Epidural anesthetic: Technique ofchoice for patients with LE CRPS
Perioperative sympathetic block/epidBlocks neuroendocrine stressresponse
Experience comes only from
anecdotal case reports
Perioperative StrategiesLE Surgeries
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Hayek SM et al. 2006, Clin. J. Pain 22(1): 82-89
260 TEC10985 cath-days
230 Neuropathic10163 cath-days
30 Somatic822 cath-days
206 CRPS9072 cath-days
24 Non-CRPS1091 cath-days
Tunneled Epidural Catheter (TEC)
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Hayek SM et al. 2006, Clin. J. Pain 22(1): 82-89
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Neuropathic Somatic
N u m
b e r o f P a t i e n
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Patients in the neuropathic pain group had significantly higherchance of getting a TEC infection compared to patients in thesomatic pain group (p=0.029).
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Hayek SM et al., 2006, Clin. J. Pain 22(1): 82-89
TEC InfectionsThere were 24 epidural space infections, 23 of
which were in the neuropathic pain group--22with CRPS
Staphylococcus was the most common organism
isolated from the epidural space (11/23)Contrast-enhanced MRI findings6 frank epidural abscesses
1 phlegmon
2 patients displayed mild epidural enhancement onMRI suggestive of epidural inflammation
All occurred in CRPS patients
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Perioperative Prevention
Free radical scavengers used basedon the assumption that CRPS is
induced by the inflammatory responseDMSON-acetylcysteineMannitolCarnitineVitamin C
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SummaryCRPSNeuropathic
Inflammatory
Rehab is cornerstone of treatment
Perioperative ManagementRegional/Sympathetic blocks
Antioxidants
