Invasive intervention for “intractable” Complex Regional Pain Syndromes (CRPS)?

Invasive intervention for “intractable” Complex Regional Pain Syndromes (CRPS)? In this issue of the Scandinavian Journal of Pain Hagerdorn and Atallah publish an educational case report on their experience treating highly selected patients suffering from longstanding apparently intractable CRPS with intrathecal pump-administration of morphine and bupivacaine [1]. The patient had failed to obtain pain relief or had intolerable side effects during trial of several oral drugs that are often tried, but are only occasionally effective [2]. She also had a failed spinal cord stimulator trial.Multimodal, multidisciplinary approach with cognitive behavioural techniques may help some patients cope better. Children with CRPS appear to benefit more often from such approaches, at least compared with adult patients with longstanding CRPS with complicating comorbidities. However, it is increasingly apparent that children, who apparently were cured of their CRPS during multidisciplinary psychosocial care, have recurrent CRPS episodes later in life [3,4,5]. Case-histories of such patients indicate that CRPS patients have lasting changes in their central pain modulating systems. Such pathological changes in the fundamental regulations of the ability to sense and modulate nociceptive impulses appear to be important in the conundrum that intractable CRPS is. These mechanisms, that make most of us benefit from the nociceptive alarm and defence mechanisms of our nervous system, they ensure that we are not left with chronic pain after an acute pain-event.These defence systems likely depend on multiple mechanisms in our central nervous system. It is a bit naïve to believe that multidisciplinary psychosocial and behavioural approaches can help all patients with CRPS. It is a problem that most invasive interventions, except maybe spinal cord stimulation, have been considered by some authorities to be more or less mal-practice. Striking educational case reports [1,3,4,5] remind us that there still is a place for invasive techniques, and not only for intractable cancer pain in palliative medicine [6,7].Although a variety of drugs can be effective in intrathecal infusions [1], the local anaesthetic and opioid receptor agonist components appear to be essential [1,4,6].References[1]Hagedorn JM, Atallah G. Intrathecal management of complex regional pain syndrome: a case report and literature. Scand J Pain 2017;14:110–2.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000391262000024&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f328850424HagedornJMAtallahG.Intrathecal management of complex regional pain syndrome: a case report and literatureScand J Pain2017141102[2]Bruehl S. Complex regional pain syndrome. BMJ 2015;350:h2730.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000359010900001&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3BruehlS.Complex regional pain syndromeBMJ2015350h2730[3]Satteson ES, Jarbpur PW, Koman LA, Smith BP, Li Z. The risk of pain syndrome affecting a previously non-painful limb following trauma or surgery in patients with a history of complex regional pain syndrome. Scand J Pain 2017;14:84–8.28850441http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000391262000018&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3SattesonESJarbpurPWKomanLASmithBPLiZ.The risk of pain syndrome affecting a previously non-painful limb following trauma or surgery in patients with a history of complex regional pain syndromeScand J Pain201714848[4]Rodriguez-Lopez MJ, Fernandez-Baena M, Barroso A, Yánez-Santos JA. Complex regional pain syndrome in children: a multidisciplinary approach and invasive techniques for the management of nonresponders. Pain Pract 2015;15:E81–9.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000364712600001&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f310.1111/papr.1231726095620Rodriguez-LopezMJFernandez-BaenaMBarrosoAYánez-SantosJA.Complex regional pain syndrome in children: a multidisciplinary approach and invasive techniques for the management of nonrespondersPain Pract201515E819[5]Breivik H. Complex Regional Pain Syndrome (CRPS): high risk of CRPS after trauma in another limb in patients who already have CRPS in one hand or foot: lasting changes in neural pain modulating systems? Scand J Pain 2017;14:82–3.28850440http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000391262000017&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3BreivikH.Complex Regional Pain Syndrome (CRPS): high risk of CRPS after trauma in another limb in patients who already have CRPS in one hand or foot: lasting changes in neural pain modulating systems?Scand J Pain201714823[6]Breivik H. Terminal cancer pain intractable by conventional pain management can be effectively relieved by intrathecal administration of a local anaesthetic plus an opioid and an alfa2-agonist into the cerebro-spinal-fluid. Scand J Pain 2017;14:71–3.28850434BreivikH.Terminal cancer pain intractable by conventional pain management can be effectively relieved by intrathecal administration of a local anaesthetic plus an opioid and an alfa2-agonist into the cerebro-spinal-fluidScand J Pain201714713[7]Mastenbroek TC, Kramp-Henriks BJ, Kallewaard JW, Vonk JM. Multimodal intrathecal analgesia in refractory cancer pain. Scand J Pain 2017;14:39–43.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000391262000005&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f328850428MastenbroekTCKramp-HenriksBJKallewaardJWVonkJM.Multimodal intrathecal analgesia in refractory cancer painScand J Pain2017143943 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Scandinavian Journal of Pain de Gruyter

Invasive intervention for “intractable” Complex Regional Pain Syndromes (CRPS)?

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Publisher
De Gruyter
Copyright
© 2016 Scandinavian Association for the Study of Pain
ISSN
1877-8860
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1877-8879
D.O.I.
10.1016/j.sjpain.2016.12.006
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Abstract

In this issue of the Scandinavian Journal of Pain Hagerdorn and Atallah publish an educational case report on their experience treating highly selected patients suffering from longstanding apparently intractable CRPS with intrathecal pump-administration of morphine and bupivacaine [1]. The patient had failed to obtain pain relief or had intolerable side effects during trial of several oral drugs that are often tried, but are only occasionally effective [2]. She also had a failed spinal cord stimulator trial.Multimodal, multidisciplinary approach with cognitive behavioural techniques may help some patients cope better. Children with CRPS appear to benefit more often from such approaches, at least compared with adult patients with longstanding CRPS with complicating comorbidities. However, it is increasingly apparent that children, who apparently were cured of their CRPS during multidisciplinary psychosocial care, have recurrent CRPS episodes later in life [3,4,5]. Case-histories of such patients indicate that CRPS patients have lasting changes in their central pain modulating systems. Such pathological changes in the fundamental regulations of the ability to sense and modulate nociceptive impulses appear to be important in the conundrum that intractable CRPS is. These mechanisms, that make most of us benefit from the nociceptive alarm and defence mechanisms of our nervous system, they ensure that we are not left with chronic pain after an acute pain-event.These defence systems likely depend on multiple mechanisms in our central nervous system. It is a bit naïve to believe that multidisciplinary psychosocial and behavioural approaches can help all patients with CRPS. It is a problem that most invasive interventions, except maybe spinal cord stimulation, have been considered by some authorities to be more or less mal-practice. Striking educational case reports [1,3,4,5] remind us that there still is a place for invasive techniques, and not only for intractable cancer pain in palliative medicine [6,7].Although a variety of drugs can be effective in intrathecal infusions [1], the local anaesthetic and opioid receptor agonist components appear to be essential [1,4,6].References[1]Hagedorn JM, Atallah G. Intrathecal management of complex regional pain syndrome: a case report and literature. Scand J Pain 2017;14:110–2.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000391262000024&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f328850424HagedornJMAtallahG.Intrathecal management of complex regional pain syndrome: a case report and literatureScand J Pain2017141102[2]Bruehl S. Complex regional pain syndrome. BMJ 2015;350:h2730.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000359010900001&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3BruehlS.Complex regional pain syndromeBMJ2015350h2730[3]Satteson ES, Jarbpur PW, Koman LA, Smith BP, Li Z. The risk of pain syndrome affecting a previously non-painful limb following trauma or surgery in patients with a history of complex regional pain syndrome. Scand J Pain 2017;14:84–8.28850441http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000391262000018&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3SattesonESJarbpurPWKomanLASmithBPLiZ.The risk of pain syndrome affecting a previously non-painful limb following trauma or surgery in patients with a history of complex regional pain syndromeScand J Pain201714848[4]Rodriguez-Lopez MJ, Fernandez-Baena M, Barroso A, Yánez-Santos JA. Complex regional pain syndrome in children: a multidisciplinary approach and invasive techniques for the management of nonresponders. Pain Pract 2015;15:E81–9.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000364712600001&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f310.1111/papr.1231726095620Rodriguez-LopezMJFernandez-BaenaMBarrosoAYánez-SantosJA.Complex regional pain syndrome in children: a multidisciplinary approach and invasive techniques for the management of nonrespondersPain Pract201515E819[5]Breivik H. Complex Regional Pain Syndrome (CRPS): high risk of CRPS after trauma in another limb in patients who already have CRPS in one hand or foot: lasting changes in neural pain modulating systems? Scand J Pain 2017;14:82–3.28850440http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000391262000017&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f3BreivikH.Complex Regional Pain Syndrome (CRPS): high risk of CRPS after trauma in another limb in patients who already have CRPS in one hand or foot: lasting changes in neural pain modulating systems?Scand J Pain201714823[6]Breivik H. Terminal cancer pain intractable by conventional pain management can be effectively relieved by intrathecal administration of a local anaesthetic plus an opioid and an alfa2-agonist into the cerebro-spinal-fluid. Scand J Pain 2017;14:71–3.28850434BreivikH.Terminal cancer pain intractable by conventional pain management can be effectively relieved by intrathecal administration of a local anaesthetic plus an opioid and an alfa2-agonist into the cerebro-spinal-fluidScand J Pain201714713[7]Mastenbroek TC, Kramp-Henriks BJ, Kallewaard JW, Vonk JM. Multimodal intrathecal analgesia in refractory cancer pain. Scand J Pain 2017;14:39–43.http://gateway.webofknowledge.com/gateway/Gateway.cgi?GWVersion=2&SrcApp=PARTNER_APP&SrcAuth=LinksAMR&KeyUT=WOS:000391262000005&DestLinkType=FullRecord&DestApp=ALL_WOS&UsrCustomerID=b7bc2757938ac7a7a821505f8243d9f328850428MastenbroekTCKramp-HenriksBJKallewaardJWVonkJM.Multimodal intrathecal analgesia in refractory cancer painScand J Pain2017143943

Journal

Scandinavian Journal of Painde Gruyter

Published: Dec 29, 2017

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