Baylor University Medical Center Proceedings July 2017 - 287

baclofen and/or calcium channel blockers, respectively, may
be of beneﬁt (12, 13).
For patients who fail to
obtain adequate symptom
relief with conser vative
management, interventional
pain procedures such as sympathetic (stellate ganglion and
lumbar sympathetic) blocks
and spinal or peripheral nerve
stimulation may be considered.
Stellate ganglion blocks for
upper extremities and lumbar
sympathetic blocks for lower
extremities have been shown in
Figure (a). Anteroposterior fluoroscopy of L2-L4 lumbar spine with injection of contrast to verify needle placement for trials to provide symptomatic
radiofrequency ablation of lumbar sympathetic chain. Sensory and motor stimulation were performed up to 1V and 2V, and functional benefits (14,
respectively, to ensure no involvement of the genitofemoral nerve, paresthesia, and motor stimulation of the lower extremity 15). In patients responsive to
at any level. Each level was treated with pulsed radiofrequency ablation at 42°C for 120 seconds. Each level was then treated
sympathetic blocks, RFA or
with thermal radiofrequency thermocoagulation at 80°C for 60 seconds. The thermocoagulation treatment was repeated
at each level after the needles were withdrawn approximately 1 cm. (b) Posterior fluoroscopy of L2-L4 lumbar spine with phenol neurolysis may provide
longer-term symptom control
injection of contrast to verify needle placement for radiofrequency ablation of lumbar sympathetic chain.
(16, 17). RFA may be preferred
to phenol based on reports of neuropathic pain symptoms
repeated every 3 months for the past 4 years with continued
secondary to phenol neurolysis (18). If patients fail to obtain
excellent control of symptoms.
adequate symptom control with the aforementioned treatment,
spinal cord/peripheral nerve stimulation or an implantable drug
DISCUSSION
delivery system may be considered (19-21).
CRPS is a chronic pain condition with uncertain
pathophysiology and variable clinical course. It is characterized
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by pain disproportionate to the inciting event with associated
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autonomic and inflammatory symptoms. Such symptoms
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tor (temperature and/or skin color changes), edema, sweating,
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J, Maihofner C, Lubenow T, Buvanendran A, Mackey S, Graciosa J,
phic (hair, nail, skin) changes. The condition is diagnosed based
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diagnostic criteria (the "Budapest criteria") for complex regional pain
exclusion in which no other conditions better account for the
syndrome. Pain 2010;150(2):268-274.
symptomology (5).
4. Rocco AG, Palombi D, Raeke D. Anatomy of the lumbar sympathetic
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on the absence and presence, respectively, of peripheral nerve
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7. Ezendam D, Bongers RM, Jannink MJ. Systematic review of the
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by fractures (44%) (1).
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The initial treatment of CRPS should include physical
8. Van de Vusse AC, Stomp-van den Berg SG, Kessels AH, Weber WE.
and occupational therapy (such as graded motor imagery
Randomised controlled trial of gabapentin in complex regional pain
[6] and mirror therapy [7]) in combination with symptomsyndrome type 1. BMC Neurol 2004;4(1):13.
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of gabapentin (8), tricyclic antidepressants (9), and/or carbaof neuropathic pain and pain in complex regional pain syndrome I to
mazepine (10). Inﬂammatory features/symptoms of CRPS may
carbamazepine and sustained-release morphine in patients pretreated with
be responsive to oral corticosteroids (11). However, prolonged
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tients with dystonia/myoclonus and/or vasomotor symptoms,
a

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Management of complex regional pain syndrome

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Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings July 2017