1
|
Shaik RS, Yareeda S, Manne N. An Interesting Case of "Migratory" Complex Regional Pain Syndrome (CRPS)! Ann Indian Acad Neurol 2023; 26:803-806. [PMID: 38022441 PMCID: PMC10666875 DOI: 10.4103/aian.aian_540_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Reshma S. Shaik
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Sireesha Yareeda
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Narendhar Manne
- Department of Neurology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| |
Collapse
|
2
|
Kalia H, Trescot AM, Abd-Elsayed A. Peripheral Nerve Stimulation for Complex Regional Pain Syndrome. PERIPHERAL NERVE STIMULATION 2023:225-232. [DOI: 10.1016/b978-0-323-83007-2.00033-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
|
3
|
Glomus Tumor of the Lower Extremity Previously Misdiagnosed as Complex Regional Pain Syndrome in Close Proximity to a Myxofibrosarcoma: A Case Report. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202207000-00002. [PMID: 35797605 PMCID: PMC9263485 DOI: 10.5435/jaaosglobal-d-21-00311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 05/09/2022] [Indexed: 11/18/2022]
Abstract
Complex regional pain syndrome (CRPS) is a potentially devastating condition that can result in severe psychological and social morbidity. It is a diagnosis of exclusion, and other pathologic entities must be ruled out first. Glomus tumors are exquisitely painful benign vascular tumors that are most common in the hand and are rarely found in the lower extremity. Here, we present a case of a patient who developed a focus of severe anterior knee pain and tenderness a few months after a car accident that had been misdiagnosed as CRPS for 15 years. She coincidentally developed a sarcoma of her ipsilateral leg distal to this site. Magnetic resonance imaging of the sarcoma included the area of knee pain where, interestingly, it identified a separate small soft-tissue mass. A glomus tumor was diagnosed histologically in a needle biopsy specimen from this mass, which was resected along with the sarcoma. For the first time in 15 years, despite the additional sarcoma surgery, she reported relief of her pain and complete resolution of her “CRPS.”
Collapse
|
4
|
Fitterer JW, Picelli A, Winston P. A Novel Approach to New-Onset Hemiplegic Shoulder Pain With Decreased Range of Motion Using Targeted Diagnostic Nerve Blocks: The ViVe Algorithm. Front Neurol 2021; 12:668370. [PMID: 34122312 PMCID: PMC8194087 DOI: 10.3389/fneur.2021.668370] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/14/2021] [Indexed: 01/19/2023] Open
Abstract
Introduction: Hemiplegic shoulder pain (HSP) is the most common pain disorder after stroke with incidence estimates of 30–70% and associated with reductions in function, interference with rehabilitation, and a reduced quality of life. Onset may occur as soon as a week after stroke in 17% of patients. Management of HSP represents a complex treatment pathway with a lack of evidence to support one treatment. The pain has heterogeneous causes. In the acute setting, decreased range of motion in the shoulder can be due to early-onset spasticity, capsular pattern stiffness, glenohumeral pathology, or complex regional pain syndrome (CRPS). As contracture can form in up to 50% of patients after stroke, effective management of the painful shoulder and upper limb with decreased range of motion requires assessment of each possible contributor for effective treatment. The anesthetic diagnostic nerve block (DNB) is known to differentiate spasticity from contracture and other disorders of immobility and can be useful in determining an appropriate treatment pathway. Objective: To create a diagnostic algorithm to differentiate between the causes of HSP in the stiff, painful shoulder in the subacute setting using diagnostic techniques including the Budapest Criteria for CRPS and DNB for spasticity and pain generators. Results: Examination of each joint in the upper extremity with HSP may differentiate each diagnosis with the use of an algorithm. Pain and stiffness isolated to the shoulder may be differentiated as primary shoulder pathology; sensory suprascapular DNB or intra-articular/subacromial injection can assist in differentiating adhesive capsulitis, arthritis, or rotator cuff injury. CRPS may affect the shoulder, elbow, wrist, and hand and can be evaluated with the Budapest Criteria. Spasticity can be differentiated with the use of motor DNB. A combination of these disorders may cause HSP, and the proposed treatment algorithm may offer assistance in selecting a systematic treatment pathway.
Collapse
Affiliation(s)
- John W Fitterer
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada
| | - Alessandro Picelli
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada.,Section of Physical and Rehabilitation Medicine, Department of Neurosciences, Biomedicine and Movement Sciences, Neuromotor and Cognitive Rehabilitation Research Center, University of Verona, Verona, Italy
| | - Paul Winston
- Canadian Advances in Neuro-Orthopedics for Spasticity Congress, Victoria, BC, Canada.,Division of Physical Medicine and Rehabilitation, University of British Columbia, Victoria, BC, Canada
| |
Collapse
|
5
|
Abstract
Pain is common but often underrecognized after stroke. Poststroke pain (PSP) hinders recovery, impairs quality of life, and is associated with the psychological state of patients with stroke. The most common subtypes of PSP include central PSP, complex regional pain syndrome, shoulder pain, spasticity-related pain, and headache. The pathophysiologies of these PSP subtypes are not yet clearly understood, and PSP is refractory to conventional treatment in many patients. However, recent studies have proposed potential pathophysiologies of PSP subtypes, which may help prioritize therapies that target specific mechanisms.
Collapse
Affiliation(s)
- Seoyon Yang
- Department of Rehabilitation Medicine, Ewha Woman's University Seoul Hospital, Ewha Woman's University School of Medicine, Seoul, Korea
| | - Min Cheol Chang
- Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Republic of Korea
| |
Collapse
|
6
|
Kessler A, Yoo M, Calisoff R. Complex regional pain syndrome: An updated comprehensive review. NeuroRehabilitation 2020; 47:253-264. [PMID: 32986618 DOI: 10.3233/nre-208001] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Complex regional pain syndrome (CRPS) is a complex disorder that can have a significant impact on the quality of life of a person with this syndrome. The diagnosis and treatment of CRPS are often difficult as there is no one confirmatory test and no one definitive treatment. Currently, the most widely accepted clinical diagnostic criteria are the Budapest criteria, which were developed by expert consensus. Though no one single treatment has been found to be universally effective, early detection and an interdisciplinary approach to treatment appear to be key in treating CRPS. This review aims to present up-to-date clinical information regarding the diagnosis and management of CRPS and highlight the potential issues with diagnosis in the neurological population. Ultimately, more research is needed to identify the exact etiology of CRPS in order to help target appropriate therapies. In addition, more randomized controlled trials need to be performed in order to test new therapies or combinations of therapies, including pharmacological, interventional, and behavioral therapies, to determine the best treatment options for this potentially debilitating disorder.
Collapse
Affiliation(s)
- Allison Kessler
- Department of Physical Medicine and Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, IL, USA.,Shirley Ryan Abilitylab, Chicago, IL, USA
| | - Min Yoo
- Department of Physical Medicine and Rehabilitation, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Randy Calisoff
- Department of Physical Medicine and Rehabilitation, Northwestern Feinberg School of Medicine, Chicago, IL, USA.,Shirley Ryan Abilitylab, Chicago, IL, USA
| |
Collapse
|
7
|
Use of Oral Prednisolone and a 3-Phase Bone Scintigraphy in Patients with Complex Regional Pain Syndrome Type I. Healthcare (Basel) 2020; 8:healthcare8010016. [PMID: 31936474 PMCID: PMC7151022 DOI: 10.3390/healthcare8010016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/31/2019] [Accepted: 01/07/2020] [Indexed: 11/16/2022] Open
Abstract
To compare the treatment effects of a high-dose and low-dose oral steroid regimen based on changes in the radioisotope uptake ratio (RUR) observed from three-phase bone scintigraphy (TPBS) in patients with complex regional pain syndrome type I (CRPS I), we retrospectively analyzed data of 34 patients with CRPS I from traumatic brain injury and stroke. Depending on the dose of steroid administered, patients were divided into high-dose (n = 14) and low-dose steroid groups (n = 20). We compared the severity scores, Kozin's classification scores, and RUR observed from TPBS between the two groups. There were significant changes in the severity scores and Kozin's classification between the baseline and 2 weeks from baseline (p < 0.05), however, there were no significant differences in terms of changes in the scores, classification, or the RUR observed from TPBS at 2 weeks from baseline (p > 0.05). There were no treatment-emergent adverse events (TEAEs) such as blood pressure elevation, impaired glycemic control, or gastrointestinal disturbances. Our results indicate that the efficacy profile of a low-dose oral steroid regimen is comparable to that of a high-dose regimen in alleviating symptoms in CRPS I patients. However, additional prospective, large-scale, multi-center studies are warranted to confirm our results.
Collapse
|
8
|
Krumme JW, Lauer MF, Stowell JT, Beteselassie NM, Kotwal SY. Bone Scintigraphy: A Review of Technical Aspects and Applications in Orthopedic Surgery. Orthopedics 2019; 42:e14-e24. [PMID: 30484853 DOI: 10.3928/01477447-20181120-05] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 04/23/2018] [Indexed: 02/03/2023]
Abstract
Due to its high sensitivity, low cost, accessibility, and ease of use, bone scintigraphy is used in orthopedic surgery for the diagnosis and management of varied pathology. It is commonly used for insufficiency fractures, metastatic neoplasia, staging and surveillance of sarcoma, and nonaccidental trauma. It augments diagnoses, including stress or occult fractures, musculoskeletal neoplasia or infection, and chronic regional pain syndrome, in patients presenting with normal results on radiographs. Bone scan images are resistant to metal-based implant artifact, allowing effective evaluation of failed total joint prostheses. Bone scintigraphy remains an underused tool in the evaluation and management of orthopedic patients. [Orthopedics. 2019; 42(1):e14-e24.].
Collapse
|
9
|
Abstract
OBJECTIVES The efficacy of ketamine in relieving complex regional pain syndrome (CRPS) lacks predictive factors. The value of three-phase bone scintigraphy (TPBS) was assessed for this purpose. MATERIALS AND METHODS TPBS was performed in 105 patients with unilateral, focal CRPS of type 1 before 5 days of ketamine infusions. Tracer uptake was measured in the region of interest concerned by CRPS and the contralateral homologous region. For the 3 scintigraphic phases (vascular, tissular, and bone phases), an asymmetry ratio of fixation was calculated between the affected and the unaffected sides (vascular phase [VPr], tissular phase [TPr], and bone phase [BPr]). Ketamine efficacy was assessed on pain intensity scores. RESULTS Ketamine-induced pain relief did not correlate with VPr, TPr, and BPr, but with the ratios of these ratios: BPr/TPr (r=0.32, P=0.009), BPr/VPr (r=0.34, P=0.005), and TPr/VPr (r=0.23, P=0.02). The optimum cut-off value for predicting the response to ketamine therapy was >1.125 for BPr/TPr, >1.075 for BPr/VPr, and >0.935 for TPr/VPr. The combination of increased values of BPr/TPr, BPr/VPr, and TPr/VPr was highly significantly associated with ketamine therapy outcome. CONCLUSIONS The relative hyperfixation of the radioactive tracer in the limb region concerned by CRPS in phases 2 and 3 versus phase 1 of TPBS correlated positively to the analgesic efficacy of ketamine. This study shows for the first time the potential predictive value of TPBS regarding ketamine therapy outcome. In addition, these results suggest that the analgesic action of ketamine is not restricted to "central" mechanisms, but may also involve "peripheral" mechanisms related to tissue inflammation and bone remodeling.
Collapse
|
10
|
Howard BA, Roy L, Kaye AD, Pyati S. Utility of Radionuclide Bone Scintigraphy in Complex Regional Pain Syndrome. Curr Pain Headache Rep 2018; 22:7. [PMID: 29388057 DOI: 10.1007/s11916-018-0659-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW To describe the current understanding of the role of three-phase bone scintigraphy (TPBS) in the diagnosis and management of complex regional pain syndrome (CRPS), discuss its advantages and limitations, and present three examples of TPBS patterns typically seen in CRPS patients. RECENT FINDINGS CRPS is a debilitating disorder frequently presenting with pain to ordinarily non-painful stimuli, redness, swelling, following fractures, stroke, myocardial infarction, surgery, or even minor trauma, and its diagnosis, based on clinical criteria and supportive imaging findings, is difficult. Of the available adjunctive diagnostic imaging modalities, radionuclide bone scintigraphy using a TPBS protocol is the most sensitive and specific for detecting abnormalities commonly seen with this condition-classically, increased periarticular uptake on delayed phase of TPBS, with variable increased uptake on perfusion phases, depending on chronicity. Recent studies have (1) demonstrated a more heterogeneous correlation of TPBS findings with CRPS diagnosis using the current Budapest criteria than in studies using older criteria, (2) pointed to the utility of novel quantitative scintigraphic techniques, and (3) highlighted the value of the early perfusion phases of TPBS in predicting treatment response. TPBS remains a valuable imaging adjunct to clinical diagnosis of CRPS. In combination with a multi-modal analgesic approach, TPBS can be used to follow disease course and potentially treatment response, although prospective trials are needed to further delineate its role.
Collapse
Affiliation(s)
- Brandon A Howard
- Division of Nuclear Medicine, Department of Radiology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Lance Roy
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Alan David Kaye
- Department of Anesthesiology, Louisiana State University, New Orleans, LA, 70112, USA
| | - Srinivas Pyati
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, 27710, USA. .,Department of Anesthesiology, Durham Veterans Affairs Medical Center, Durham, NC, 27710, USA.
| |
Collapse
|
11
|
Shin SH, Kim SJ. Bone scintigraphy in patients with pain. Korean J Pain 2017; 30:165-175. [PMID: 28757916 PMCID: PMC5532523 DOI: 10.3344/kjp.2017.30.3.165] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 06/26/2017] [Accepted: 06/26/2017] [Indexed: 11/24/2022] Open
Abstract
Nuclear medicine imaging is widely used in pain medicine. Low back pain is commonly encountered by physicians, with its prevalence from 49% to 70%. Computed tomography (CT) or magnetic resonance imaging (MRI) are usually used to evaluate the cause of low back pain, however, these findings from these scans could also be observed in asymptomatic patients. Bone scintigraphy has an additional value in patients with low back pain. Complex regional pain syndrome (CRPS) is defined as a painful disorder of the extremities, which is characterized by sensory, autonomic, vasomotor, and trophic disturbances. To assist the diagnosis of CRPS, three-phase bone scintigraphy is thought to be superior compared to other modalities, and could be used to rule out CRPS due to its high specificity. Studies regarding the effect of bone scintigraphy in patients with extremity pain have not been widely conducted. Ultrasound, CT and MRI are widely used imaging modalities for evaluating extremity pain. However, SPECT/CT has an additional role in assessing pain in the extremities.
Collapse
Affiliation(s)
- Seung Hyeon Shin
- Department of Nuclear Medicine, Pusan National University Hospital, Busan, Korea
| | - Seong Jang Kim
- Department of Nuclear Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,BioMedical Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| |
Collapse
|
12
|
Wertli MM, Brunner F, Steurer J, Held U. Usefulness of bone scintigraphy for the diagnosis of Complex Regional Pain Syndrome 1: A systematic review and Bayesian meta-analysis. PLoS One 2017; 12:e0173688. [PMID: 28301606 PMCID: PMC5354289 DOI: 10.1371/journal.pone.0173688] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 02/24/2017] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Since 2007, the Budapest criteria are recommended for the diagnosis of Complex Regional Pain Syndrome (CRPS) 1. The usefulness of bone scintigraphy (BS, index test) for the diagnosis of CRPS 1 remains controversial. Imperfect reference tests (RT) result in underestimation of the diagnostic accuracy of BS. Further, biased results can occur when a dependency between the RT and BS exists. The objective was to assess the impact of different RTs, specifically the Budapest criteria, and the assumed imperfect nature of the RT on the diagnostic accuracy of BS. Further, we analyzed the association between baseline characteristics and positive BS in patients with CRPS 1. METHODS Systematic literature review and Bayesian meta-analysis to assess the test accuracy of BS with and without accounting for the imperfect nature of the RT. We examined correlations (Spearman correlation coefficients / Wilcoxon tests) between baseline characteristics and the proportion of positive BS in patients with CRPS 1. RESULTS The pooled sensitivity was 0.804 (95% credible interval (CI) 0.225-1.0, 21 studies) and specificity 0.853 (95%CI 0.278-1.00). Sensitivity and specificity of BS increased when accounting for the imperfect nature of the RT. However, in studies using Budapest criteria as reference, the sensitivity decreased (0.551; 95% CI 0.046-1) and the specificity increased (0.935; 95% CI 0.306-1). Shorter disease duration and a higher proportion of males were associated with a higher proportion of positive BS (27 studies, disease duration <52 weeks Wilcoxon test p = 0.047, female proportion Spearman correlation -0.63, p = 0.009). CONCLUSION Compared to the accepted Budapest diagnostic criteria BS cannot be used to rule-in the diagnosis of CRPS 1. In patients with negative BS CRPS 1 is less likely the underlying illness. Studies using older or no diagnostic criteria should not be used to evaluate the diagnostic accuracy of BS in CRPS 1.
Collapse
Affiliation(s)
- Maria M. Wertli
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, Zurich, Switzerland
- Division of General Internal Medicine, Bern University Hospital, Bern University, Freiburgstrasse 8, Bern, Switzerland
| | - Florian Brunner
- Department of Physical Medicine and Rheumatology, Balgrist University Hospital, Forchstrasse 340, Zurich, Switzerland
| | - Johann Steurer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, Zurich, Switzerland
| | - Ulrike Held
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, Zurich, Switzerland
| |
Collapse
|
13
|
Wilmot AS, Ruutiainen AT, Bakhru PT, Schweitzer ME, Shabshin N. Subchondral insufficiency fracture of the knee: A recognizable associated soft tissue edema pattern and a similar distribution among men and women. Eur J Radiol 2016; 85:2096-2103. [PMID: 27776664 DOI: 10.1016/j.ejrad.2016.08.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Revised: 08/15/2016] [Accepted: 08/24/2016] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Primary: to describe the presence and pattern of soft tissue edema in subchondral insufficiency fractures of the knee (SIFK). Secondary: to investigate the gender distribution and identify factors associated with disease progression. METHODS MR images of 74 SIFKs in 74 patients were retrospectively reviewed for soft tissue edema presence and location, meniscal tears and extrusion and synovitis. The clinical records were reviewed for age, gender, and BMI. Follow up examinations were reviewed to assess for progression. Data were analyzed for gender distribution and for association between each imaging finding as a predictor of SIFK location and progression. RESULTS Soft tissue edema was present in 89% (66/74) of SIFK. It was located around the MCL in 78% (58/74), posterior to and abutting on the posterior distal femur in 68% (50/74), around to the tibia in only 18% (13/74), but when present it strongly predicted the presence of a medial tibial plateau SIFK (p=5.6×10^-12). Edema extended to the vastus medialis fascia in 51% (38/74) and vastus lateralis fascia in 24% (18/74). Gender distribution was 1:1 (males=38, females=36), most common in the 6th decade (29/74, 39%). Lesion progression showed a trend towards being more common in females (8/9, 89%) compared to males (9/16, 56%), and in patients with meniscal extrusion (≥3mm) (13/14, 93%) compared to those with no extrusion (2/7, 29%). CONCLUSION A recognizable soft tissue edema pattern is seen in SIFK and may have an important role in early diagnosis. Also, SIFK may affect equally males and females in the 6th decade and may progress more in females. Meniscal extrusion may predispose to disease progression.
Collapse
Affiliation(s)
- Andrew S Wilmot
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States; Department of Radiology, UPMC Department of Radiology, 200 Lothrop Street, UPMC Montefiore, Room NE 595, Pittsburgh, PA 15213, United States.
| | - Alexander T Ruutiainen
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States; Michael J. Crescenz VA Medical Center in Philadelphia, 3900 Woodland Avenue, Philadelphia, PA 19104, United States.
| | - Prashant T Bakhru
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States; Princeton Radiology Associates, Kendall Park, NJ 08824, United States.
| | - Mark E Schweitzer
- Stonybrook "University Medical Center, Stonybrook, NY, United States.
| | - Nogah Shabshin
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States; Department of Radiology, HaEmek Medical Center, Afula, Israel.
| |
Collapse
|
14
|
Held U, Brunner F, Steurer J, Wertli MM. Bayesian meta-analysis of test accuracy in the absence of a perfect reference test applied to bone scintigraphy for the diagnosis of complex regional pain syndrome. Biom J 2016; 57:1020-37. [PMID: 26479506 DOI: 10.1002/bimj.201400155] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 05/26/2015] [Accepted: 06/07/2015] [Indexed: 11/06/2022]
Abstract
There is conflicting evidence about the accuracy of bone scintigraphy (BS) for the diagnosis of complex regional pain syndrome 1 (CRPS 1). In a meta-analysis of diagnostic studies, the evaluation of test accuracy is impeded by the use of different imperfect reference tests. The aim of our study is to summarize sensitivity and specificity of BS for CRPS 1 and to identify factors to explain heterogeneity. We use a hierarchical Bayesian approach to model test accuracy and threshold, and we present different models accounting for the imperfect nature of the reference tests, and assuming conditional dependence between BS and the reference test results. Further, we include disease duration as explanatory variable in the model. The models are compared using summary ROC curves and the deviance information criterion (DIC). Our results show that those models which account for different imperfect reference tests with conditional dependence and inclusion of the covariate are the ones with the smallest DIC. The sensitivity of BS was 0.87 (95% credible interval 0.73-0.97) and the overall specificity was 0.87 (0.73-0.95) in the model with the smallest DIC, in which missing values of the covariate are imputed within the Bayesian framework. The estimated effect of duration of symptoms on the threshold parameter was 0.17 (-0.25 to 0.57). We demonstrate that the Bayesian models presented in this paper are useful to address typical problems occurring in meta-analysis of diagnostic studies, including conditional dependence between index test and reference test, as well as missing values in the study-specific covariates.
Collapse
Affiliation(s)
- Ulrike Held
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland
| | - Florian Brunner
- Department of Rheumatology, University Hospital Balgrist, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Johann Steurer
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland
| | - Maria M Wertli
- Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, 8032, Zurich, Switzerland
| |
Collapse
|
15
|
Early Treatment of Acute Complex Regional Pain Syndrome after Fracture or Injury with Prednisone: Why Is There a Failure to Treat? A Case Series. Pain Res Manag 2016; 2016:7019196. [PMID: 27445622 PMCID: PMC4904610 DOI: 10.1155/2016/7019196] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 12/02/2015] [Indexed: 11/24/2022]
Abstract
Background. Complex regional pain syndrome (CRPS) after fracture is a cause of pain, dysfunction, and potentially permanent disability. The evidence for treatment with oral corticosteroids is growing and supported by several international guidelines; however, treatment is not widely offered. Objective. Rapid recognition and treatment of complex regional pain in the upper extremity after acute injury as a disease modifying and potentially curative treatment. Methods. The present study was a case series involving three patients who developed CRPS after a trauma to the neck and/or upper limb. Patients were screened by clinical examination and bone scan and met the Budapest criteria. Results. Resolution of pain, swelling, and disability in all three patients. Discussion. There is increasing support, based on the existing evidence and clinical outcomes, for the use of prednisone to treat the acute phase of CRPS and as a promising treatment to halt the progression of the phenomenon and potentially cure the condition; however, widespread use of prednisone likely remains low, potentially resulting in long-term pain, joint contracture, and disability. A large-scale randomized control trial has not been performed. Conclusion. Corticosteroids can be an effective treatment option for CRPS after fracture.
Collapse
|