Nerve resection, crush and re-location relieve complex regional pain syndrome type II: A case report

Complex regional pain syndrome type II localized to the index finger. A case report translating scientific evidence into clinical practice

BACKGROUND

Complex regional pain syndrome type II (CRPS-II) is a rare condition associated with peripheral nervous system lesions. Its localized distribution in the fingers is unique, and its treatment is unclear.

CASE DESCRIPTION

A 56-year-old male presented to the emergency department with a saw-cut index finger injury with associated tendon and nerve injuries. After surgery, he was admitted to physical therapy (PT) with persistent pain, joint stiffness, allodynia, and trophic changes compatible with CRPS-II localized in the index finger. The diagnosis was confirmed after applying the Budapest Criteria, and PT was progressive and individualized according to the patient's needs, including graded motor imagery, mobilizations, exercises, and education.

OUTCOMES

After 12 weeks of PT, a clinically significant decrease in pain intensity and improvements in mobility and index finger and upper limb functionality was observed, reducing CRPS symptomatology.

DISCUSSION

This report provides information about a unique case of a localized form of CRPS-II. After reviewing the literature on clinical cases of both CRPS-II and localized forms of CRPS, we highlight that the clinical features of this patient and his positive therapeutic response support the importance of translating the scientific evidence on CRPS into clinical practice.

Causalgia: A Review of Nerve Resection, Amputation, Immunotherapy, and Amputated Limb CRPS II Pathology

BACKGROUND

Causalgia and complex regional pain syndrome (CRPS) type II with nerve injury can be difficult to treat. Surgical peripheral nerve denervation for causalgia has been largely abandoned by pain clinicians because of a perception that this may aggravate a central component (anesthesia dolorosa).

METHODS

We selectively searched Pubmed, Cochrane, MEDLINE, EMBASE, CINAHL Plus, and Scopus from 1947 for articles, books, and book chapters for evidence of surgical treatments (nerve resection and amputation) and treatment related to autoimmunity and immune deficiency with CRPS.

RESULTS

Reviews were found for the treatment of causalgia or CRPS type II (n = 6), causalgia relieved by nerve resection (n = 6), and causalgia and CRPS II treated by amputation (n = 8). Twelve reports were found of autoimmunity with CRPS, one paper of these on associated immune deficiency and autoimmunity, and two were chosen for discussion regarding treatment with immunoglobulin and one by plasma exchange. We document a report of a detailed and unique pathological examination of a CRPS type II affected amputated limb and related successful treatment with immunoglobulin.

CONCLUSIONS

Nerve resection, with grafting, and relocation may relieve uncomplicated causalgia and CRPS type II in some patients in the long term. However, an unrecognized and treatable immunological condition may underly some CRPS II cases and can lead to the ultimate failure of surgical treatments.

Resurgent neuropathic discharge: an obstacle to the therapeutic use of neuroma resection?

ABSTRACT

Ectopic discharge ("ectopia") in damaged afferent axons is a major contributor to chronic neuropathic pain. Clinical opinion discourages surgical resection of nerves proximal to the original injury site for fear of resurgence of ectopia and exacerbated pain. We tested this concept in a well-established animal neuroma model. Teased-fiber recordings were made of ectopic spontaneous discharge originating in the experimental nerve-end neuroma and associated dorsal root ganglia in rats that underwent either a single transection (with ligation) of the sciatic nerve or 2 consecutive transections separated by 7, 14, 21, or 30 days. Ectopia emerged in afferent A and C fibers after a single cut with kinetics anticipated from previous studies. When resection was performed during the early period of intense A-fiber activity, a brief period of resurgence was observed. However, resection of neuromas of more than 14 days was followed by low levels of activity with no indication of resurgence. This remained the case in trials out to 60 days after the first cut. Similarly, we saw no indication of resurgent ectopia originating in axotomized dorsal root ganglion neuronal somata and no behavioral reflection of resurgence. In summary, we failed to validate the concern that proximal resection of a problematic nerve would lead to intense resurgent ectopic discharge and pain. As the well-entrenched concept of resurgence is based more on case reports and anecdotes than on solid evidence, it may be justified to relax the stricture against resecting neuromas as a therapeutic strategy, at least within the framework of controlled clinical trials.

Deep Peroneal Neurectomy for Midfoot Arthritis

Osteoarthrosis of the tarsometatarsal joint (TMTJ) and naviculocuneiform joint (NCJ) is a common pathology treated by foot and ankle specialists. Arthrodesis is the most widely accepted surgical treatment. Patients that are not candidates for arthrodesis are often left without surgical treatment options. Neurectomy has been described for treatment of upper extremity joint arthrosis but has not been well described in the foot. The deep peroneal nerve innervates the first, second, third TMTJs and NCJ. We present a retrospective case series on the outcomes of patients treated with deep peroneal neurectomy for TMTJ and NCJ arthrosis (N = 34 feet in 26 patients). The median postoperative American Orthopedic Foot and Ankle Society midfoot score was 53 (range 16-75) points. Twenty two (85%) of 26 patients stated that their expectations were met as a result of the deep peroneal neurectomy procedure, and 20 (77%) of 26 patients stated that they would have deep peroneal neurectomy for their symptoms again. There were recurrent symptoms prompting patients to seek additional treatment in 7 (21%) of 34 feet. Recurrent pain is also documented in hand denervation studies and the physiologic explanation remains unclear. Our results suggest that deep peroneal neurectomy is an effective treatment option for TMTJ and NCJ arthritis and may be particularly helpful in patients that are poor candidates for arthrodesis.

The Role of the Peripheral Nerve Surgeon in the Treatment of Pain

Pain is a frequent cause of physician visits. Many physicians find these patients challenging because they often have complicated histories, emotional comorbidities, confusing examinations, difficult problems to fix, and the possibility of factitious complaints for attention or narcotic pain medications. As a result, many patients are lumped into the category of chronic, centralized pain and relegated to pain management. However, recent literature suggests that surgical management of carefully diagnosed generators of pain can greatly reduce patients' pain and narcotic requirements. This article reviews recent literature on surgical management of pain and four specific sources of chronic pain amenable to surgical treatment: painful neuroma, nerve compression, myofascial/musculoskeletal pain, and complex regional pain syndrome type II.

The clinical relevance of complex regional pain syndrome type I: The Emperor's New Clothes

The management of patients with chronic pain is a nearly daily challenge to rheumatologists, neurologists, orthopedic surgeons, pain specialists and indeed a issue in nearly every clinical practice. Among the myriad of causes of pain are often included a unique syndrome, generally referred to as complex regional pain syndrome type I (CRPS). Unfortunately CRPS I has become a catch all phase and there are serious questions on whether it exists at all; this has led to an extraordinary number of poorly defined diagnostic criteria. It has also led to an etiologic quagmire that includes features as diverse as autoimmunity to simple trauma. These, in turn, have led to overdiagnosis and often overzealous use of pain medications, including narcotics. In a previous paper, we raised the issue of whether CRPS type I reflected a valid diagnosis. Indeed, the diagnostic criteria for CRPS I, and therefore the diagnosis itself, is unreliable for a number of reasons: 1) the underlying pathophysiology of the signs and symptoms of CPRS I are not biologically plausible; 2) there are no consistent laboratory or imaging testing available; 3) the signs and symptoms fluctuate over time without a medical explanation; 4) the definitions of most studies are derived from statistical analysis with little consideration to required sample size, i.e. power calculations; 5) interobserver reliability in the assessment of the signs and symptoms are often only fair to moderate, and agreement on the diagnosis of "CRPS I" is poor. Even physicians who still believe in the concept of "CRPS I" admit that it is vastly overdiagnosed and has become a diagnosis of last resort, often without a complete differential diagnosis and an alternative explanation. Finally, one of the most convincing arguments that there is no clinical entity as "CRPS I" comes from the enormous heterogeneity in sign and symptom profiles and the heterogeneity of pathophysiological mechanisms postulated. This observation is underscored by the diversity of responses among "CRPS I" patients to essentially all treatment modalities. It has even led to the concept that the signs and symptoms of CRPS can spread throughout the body, as if it is an infectious disease, without any medical plausible explanation. If true progress is to be made in helping patients with pain, it will require entirely new and different concepts and abandoning CRPS I as a legitimate diagnosis.

Donor Distal, Recipient Proximal and Other Personal Perspectives on Nerve Transfers

This article presents a personal overview of nerve transfers and emphasizes the various factors that contribute to outcome following these surgeries. There is no "one result" for all nerve transfers. The results will vary depending on factors relating to the donor nerve and the recipient nerve, the degree of the surgical difficulty of the specific procedure, and issues relating to preoperative and postoperative rehabilitation. The general issues that influence all nerve injury and recovery, such as age of the patient, comorbidities, and time since injury, pertain to nerve transfers as well.

The complex regional pain syndrome

Complex regional pain syndrome (CRPS) is the current consensus-derived name for a syndrome usually triggered by limb trauma. Required elements include prolonged, disproportionate distal-limb pain and microvascular dysregulation (e.g., edema or color changes) or altered sweating. CRPS-II (formerly "causalgia") describes patients with identified nerve injuries. CRPS-I (formerly "reflex sympathetic dystrophy") describes most patients who lack evidence of specific nerve injuries. Diagnosis is clinical and the pathophysiology involves combinations of small-fiber axonopathy, microvasculopathy, inflammation, and brain plasticity/sensitization. Females have much higher risk and workplace accidents are a well-recognized cause. Inflammation and dysimmunity, perhaps facilitated by injury to the blood-nerve barrier, may contribute. Most patients, particularly the young, recover gradually, but treatment can speed healing. Evidence of efficacy is strongest for rehabilitation therapies (e.g., graded-motor imagery), neuropathic pain medications, and electric stimulation of the spinal cord, injured nerve, or motor cortex. Investigational treatments include ketamine, botulinum toxin, immunoglobulins, and transcranial neuromodulation. Nonrecovering patients should be re-evaluated for neurosurgically treatable causal lesions (nerve entrapment, impingement, infections, or tumors) and treatable potentiating medical conditions, including polyneuropathy and circulatory insufficiency. Earlier impressions that CRPS represents malingering or psychosomatic illness have been replaced by evidence that CRPS is a rare complication of limb injury in biologically susceptible individuals.