Baylor University Medical Center Proceedings July 2017 - 286

Management of complex regional pain syndrome
Jason (Chung-Chieh) Lo, MD, Joel Cavazos, MD, and Christopher Burnett, MD

Complex regional pain syndrome (CRPS) is a relatively rare, chronic, and
debilitating condition that significantly impacts the patient's quality of
life. There is an overall paucity of literature addressing the management
of CRPS in immunocompromised patients. We define features of CRPS,
outline its treatment options, and describe a course of CRPS management for a 35-year-old patient who had heart transplantation requiring
immunosuppressive medications.

omplex regional pain syndrome (CRPS) is a relatively
rare (1), chronic, and debilitating condition that
signiﬁcantly decreases a patient's quality of life. In
this report, we describe the management of CRPS
in a patient who was initially on therapeutic anticoagulation
for an in situ ventricular assist device and was subsequently
immunosuppressed after heart transplantation. The estimated
10 million immunocompromised individuals in the United
States (2) deserve special consideration in various disease processes and their associated management options due to their
increased susceptibility to infection and complications.
CASE REPORT
A 35-year-old man had idiopathic dilated cardiomyopathy
with heart failure, cardiorenal syndrome, congestive
hepatopathy, hepatosplenomegaly, obesity, obstructive sleep
apnea, hypothyroidism, cholelithiasis, a left ventricular assist
device, and heart transplantation. The patient suﬀered viral
cardiomyopathy and congestive heart failure with multiple
associated admissions and interventions. During an intraaortic balloon pump placement, he suﬀered an injury to the
neurovascular structures supplying the right lower extremity,
necessitating vascular exploration and repair. The patient subsequently developed lateral ankle pain radiating to the foot,
as well as edema and decreased ankle range of motion. His
symptoms were not relieved by physical therapy, gabapentin
600 mg three times a day, and hydrocodone-acetaminophen
10-325 mg (Norco 10) four times a day.
The patient was seen by our pain clinic 6 months after
the onset of right lower extremity symptoms. He reported severe 10 out of 10 pain, now extending 2 inches proximal to
the lateral malleolus radiating distal to all toes. The pain was

286

exacerbated by light touch and weight bearing. On exam, he
had severe pain to light touch, leg edema, and decreased right
ankle range of motion compared to the contralateral ankle,
consistent with the diagnosis of CRPS by the Budapest criteria
(3). A lumbar sympathetic block was ruled out since the patient was on warfarin for his ventricular assist device. Instead,
an ankle ring block was performed with a 10 mL mixture of
80 mg triamcinolone with 8 mL 0.25% bupivacaine with 30
days of signiﬁcant pain relief. The gabapentin and Norco were
continued. The patient subsequently received two ankle ring
blocks prior to his heart transplantation, which provided 10
days and then 3 days of signiﬁcant pain relief, respectively.
The patient was oﬀ warfarin after his heart transplant. Due to
lack of symptom relief from extended conservative and medical
management, a lumbar sympathetic block was performed. With
ﬂuoroscopic guidance, contrast was injected with the nerve block
needle tip at the anterolateral edge of the L3 vertebral body. After
visualization of appropriate contrast spread to the anterolateral
aspect of the L2 to L4 vertebral bodies, where the sympathetic
ganglia are commonly located (4), a 20 mL mixture consisting of
10 mg dexamethasone, 9 mL 1% lidocaine, and 10 mL 0.25%
bupivacaine was injected in 3 mL aliquots. The block provided
near complete pain relief for 3 weeks with a gradual return of pain.
The patient had three subsequent lumbar sympathetic blocks performed at 1-month intervals with similar eﬃcacy before lumbar
sympathetic radiofrequency ablation (RFA) for longer duration
of symptom relief. The patient reported that RFA (Figure) provided better relief of his pain than other interventions, with a
90% reduction in symptoms that lasted for almost 3 months.
The gabapentin and Norco were continued. He reported taking
the Norco towards the end of the third month when the eﬀects
of the lumbar sympathetic RFA had waned. With initiation of
lumbar sympathetic blocks and RFA, the patient reported that
he was able to perform activities such as hiking, rock climbing,
and ﬁshing with his son. The lumbar sympathetic RFAs were
From the Department of Anesthesiology, Baylor Scott and White Health, Temple,
Texas.
Corresponding author: Jason (Chung-Chieh) Lo, MD, Department of
Anesthesiology, Baylor Scott and White Health, 2401 S. 31st Street, Temple, TX
76508 (e-mail: ChungChieh.Lo@BSWHealth.org).
Proc (Bayl Univ Med Cent) 2017;30(3):286-288

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