46. Complex regional pain syndromes : terminology and pathophysiology

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46. Complex regional pain syndromes terminology
and pathophysiology

• Dept. of anesthesiology and pain management
  kyung-hee medical center
• R2 hyunsuk Kim

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terminology
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history

• causalgia silas weir mitchell?? american civil
  war?? traumatic nerve injury? ?? ????? ???
  chronic pain syndrome? causalgia?? ??? ???.
• reflex sympathetic dystrophy (RSD) 20?? ??
  evans? ?? ?? ???.
• ?? RSD? causalgia? ???? ?? ???? ???.

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CRPS

• ??? RSD ?? causalgia-like syndrome?? ????? ??
  chronic pain state? CRPS ( complex regional pain
  syndrome )?? ????? IASP (International
  Association for the Study of Pain)?? ??.
• complex ??? ??? ?? ???? dynamic?.
• regional distribution of the symptom.
• pain ???? event? ??? ???? ??.
• syndrome ??? ??? ?????? symptom and sign? ????
  ??.

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CRPS type I (RSD)

• immobilization? ????? ???? noxious event?
  initiation?? ?? syndrome
• ?? hyperalgesia? allodynia? ???? continuous pain
• symptom? single peripheral nerve territory? ????
  ?? ?? ??? ???? ??.
• edema, skin blood flow abnormality, abnormal
  sudomotor activity?? ?? ? ??.
• CRPS type II (causalgia) ? peripheral nerve
  injury ? ??.

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SMP (sympathetic maintained pain) SIP
(sympathetic independent pain)

• SMP (sympathetic maintained pain) CRPS ????
  pain? affected area? sympathetic activity? ??.
  efferent sympathetic nervous system? block??
  pain? relieve?.
• SIP (sympathetic independent pain)
• CRPS??? pain syndrome? ??? SMP, ??? SIP? ???
  ????, symptom, sign, history?? ???? SMP? ????
  ???? ??? ???, sympathetic component? ???? ??
  selective sympahtetic blockade? ???? ????? ??? ??
  ??? ????.

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Clinical feature of CRPS

• CRPS? ????? ?? component? ?? ???? ?.
• ?? component? ???? ?? ? ??? ?? ??? ??? ??? pain?
  ??? ??, ? ??? ???? dynamic?? ???? ????.
• sensory symptom and sign spontaneous pain,
  hyperpathia, allodynia, hyperalgesia
• skin color, skin temperature, sweating, motor
  function, superficial and deep tissue? structure?
  ???? ???.
• psychological and psychiatric disturbance????
  ???, ????? ??? ???? ???.
• historically RSD? stage, grade? ???? ???, CRPS??
  ????? staging??, grading? ???? ???, stage? ?????
  ??? ??.

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Neural mechanisms underlying CRPS A hypothesis

• exact pathophysiology of CRPS is unclear
• ?? neuropathic pain? animal model? ????? ???,
  peripheral and central nervous system? persistent
  pain? mechanism? ???? ?? ??? ??.
• initial injury? nociceptitor?? -gt spinal cord??
  spinal modulation mechanism? ??? ?? -gt central
  pain signaling neuron? sensitization
• sensitized dorsal horn neuron? low threshold
  mechanoreceptor? ???? activated?? allodynia? ?? ?
  ??, ??? ????? excitation? neurogenic inflammation
  (vasodilation, increased capillary permeability,
  release of inflammatory mediator)
• central hyperexcitability? ??? continued input?
  ???. painful input? neuromas, dorsal root
  ganglia??? ectopic generator? ?? ??.

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• sympathetic-sensory interaction? nociceptive
  neuron? activity? ????
• sympathetic efferent fiber?? tonic activity? ??
  norepinephrine? release? ?? alpha-adrenergic
  receptor sensitivity? ???.
• ?? SMP? ??? ?? ?????,
• Skeptic?? sympathetic block, alpha-adrenoceptor
  antagonism, norepinephrine injection??
  pharmacologic treatment? ??? SMP? ?? ? ???.
• spontaneous pain and hyperalgesia?? sympathetic
  nervous system? natural stimulation? ???? ??? ??.
• Drummond?? CRPS I and II ??? affected extremity??
  sympathetic arousal ? pain, vasoconstriction?
  ???? ???.
• ??? ??? painful input? ?? ??? ???? central
  nervous system?? ???? signal? block?? ?? ?.
• ?? ??? central pain signaling neuron? reset??
  normal excitability ??? ??.

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Other mechanisms (inflammation)

• nerve injury animal model? CRPS II? ??? ?? ???
  ???.
• ??? ??? ??? CRPS ? acute phase??? inflammation?
  ??? ? ??, regional inflammatory response ?
  corticosteroid? ???.
• humorally mediated inflammation?? neurogenic
  inflammation? ?? clinical presentation? ???.
• neurogenic inflammation? activity-dependent,
  primary sensory afferent-mediated, central and
  peripheral neuropeptide release??? vasodilation,
  plasma extravasation? ???

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47. Complex Regional Pain Syndrome Diagnosis
and Treatment

• Dept. of anesthesiology and pain management
  kyung-hee medical center
• R2 hyunsuk Kim

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Differntial Diagnosis

• CRPS? ?? ???? ?? ??? ??? ????, ???? ????? ??
  ????? ????? ?.
• unrecognized local pathology
• fracture
• strain
• sprain
• traumatic vasospasm
• cellulitis
• lymphedema
• Raynaud's disease
• thromboangitis obliterans
• erythromelalgia
• deep vein thrombosis
• entrapment syndrome
• occupational overuse syndrome
• diabetic neuropathy

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Diagnostic Algorithm

• in 1994, IASP(international association for the
  study of pain)?? ??? recommendation? ??? ??? ????
  ??.
• original diagnostic criteria? ?? ???? ????? ????
  ???? sensitivity? ???(0.98), ?? chronic pain
  syndrome?? ???? specificity? ???? ??.
• ??? ???? ????? ??? original criteria?
  modification? ?????.
• factor analysis ? ??? symptom? subgroup(sensory,
  vasomotor, sudomotor-edema, motor-trophic
  subgroup)?? ??? ???? ??? ???? ????.
• ?? ??? subgroup? original IASP diagnostic
  criteria? ???? ?????, ??? subgroup? ??? ????.

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Epidemiology

• epidemiology??? ??? peak incidence? 50? ??? ???
  ???.
• 80????? ???? ??? ?????? CRPS? ??? ?? ??? ????.
• ??? ?? ??? ??? ??? ?????? RSD? causalgia? ??? ?
  ??? ??.
• ? ?? predisposing factor? CRPS? ??? potential
  risk factor? ???.
• Genetic predisposition
• women with certain HLA profile? predisposing
  factor
• Disuse
• ?? ?? ??? ??? extremity? immobility? CRPS? ??
  sign and symptom? ???.
• Psychological factors
• ?? ???? ????? ??? CRPS ????? ??? ??? ??? ??.
• ??? stressful life event? symptom? ??? severity?
  ??? ?.
• ?? chronic pain patient? major depression,
  substance abuse disorder, somatoform disorder,
  anxiety disorder?? ?? comorbid psychiatric
  disease? ????? ?? negative impact? ? ? ??.

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Clinical characteristics of CRPS

• Spontaneous pain
• ?? extremity? tissue injury?? ???, severity,
  duration, extent? initial injury? clinical
  course?? ???.
• CNS injury ??? ?? ? ??.
• ?? ???? ???? pain?... burning pain, constant
  ache, throbbing, deep pressure, shooting pain ???
  ???.
• Blumberg ?? orthostatic component? ??? ?????,
  ???? affected extremity? ?? ????? ??? ???? ??.
• Allodynia and Hyperalgesia
• ???? ???? Allodynia and Hyperalgesia? ?? altered
  cutaneous sensation? ??.
• ?? ??? ??? ? ??? ?? ?? ???? ?.
• Tissue swelling and edema
• swelling ? ??? disuse? ?? dependent edema?? ????,
  skin? shiny appearance? ?? ??? ??.

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• Temperature and color change
• traditional??? early stage ?? warmer, later
  stage?? colder?? ??????, ???? mottled with dark,
  bluish, pale white discoloration, hot and red???
  ????.
• Sudomotor and vasomotor symptoms
• ?????? sweating? ??? ? ??. cold and warm limb?
  vascular regulation? ??? ?? ??? ??.
• Motor changes
• distal tremors, dystonia, weakness, reduced
  movement, joint stiffness
• ??? motor symptom? disease? clinical
  presentation??, painful limb? protection?????
  unclear?.
• Trophic changes
• alteration in skin, nail, hair growth are
  observed in patient who have severe allodynia to
  mechanical stimulation
• osteoporosis may be evident in patient with
  severe pain and guading
• Pattern and spread
• sensory impairment? affected area? ??? ???, body?
  hemilateral or quadratic region?? ?? extend ?.

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• Stages
• untreated CRPS? ? ??? ????? ?? historical
  understanding?.
• stage I - acute inflammation? ??. affected
  extremity? painful to touch, warm, vasodilated,
  edematous
• stage II - worsening pain, vasomotor
  dysfunction, motor abnormality, dystrophic change
• stage III - atrophy, continued motor impairment,
  diminution of sensory disturbance
• current understanding ? disease? progressively
  worsening stage? ??? ???.
• SMP and SIP ???? similar symptom and similar
  clinical presentation, clinical presentation? ???
  ???? ??? selective blockade? ??? ??? ?.

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Diagnostic Tests

• SMP? ??? ???, painful area? sympathetic effent
  innervation blockade? ???.
• pain area? supplying?? sympathetic ganglia
  blocking ???? sympathetic component? assessing ?
  ? ??.
• Local anesthetic sympathetic blocks
• traditional sympatholytic test is local
  anesthetic sympathetic ganglion block.
• pain ?? upper and lower extremity? stellate
  ganglion or the lumbar paravertebral sympathetic
  ganglia? local anesthetics administration.
• interpretation? ??? ? - sympathetic blockade?
  complete?? ??? ?. pain relif? ??? ???? careful
  sensory examination?? ?? ????. ??? local
  anesthetics? directly nerve root??? spread??
  somatic nerve block? ?? pain? effect? ? ? ????.
  total dose? ?? systemic uptake? ?? pain relief ??
  ? ??. invasive procedure??? placebo effect,
  local anesthetic? sympathetic effenrent fiber?
  block?? ?? ???, sympathetic chain??? ????
  visceral sensory afferent fiber? ???.

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• Regional intravenous blockade
• SMP? ??? ?? guanethidine ? ??? regional
  intravenous blockade? ? ? ??.
• guanethidine? postganglionic sympathetic axon?
  noradenergic varicosites? ?? take up??,
  norepinephrine? depletion???.
• ??? nociceptor? short-term excitiation?? test??
  ?? pain? ???? ??.
• guanethidine? ? ?? postganglionic axon?
  depletion?? 1 or 2 days?? noradrenaline? release?
  ???.
• ???, review of randomized controlled
  trial(RCT)??? CRPS???? guanethidine? ??? ????
  ???.
• Quatitative sensory testing and autonomic testing
• SMP?? cooling stimuli? ?? pain? ??? ?? ???? ?????
  SMP? ???? quantitative sensory testing? ??? ??.
• quantitative sensory testing? CRPS I, II?? warm
  perception threshold? ??? cold pain threshold?
  ??? ???.
• Skin temperature measurements
• CRPS? ?? extremity pain?? disease?
  thermoregulatory cycle??? maximal skin
  temperature difference? ??? ? ??.
• ??? ?? CRPS??? temperature difference? dynamic??
  ????? ??? ?? ??? ???.

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• Skin blood flow measurements
• acute CRPS?? neurogenic inflammation? sympathetic
  vasoconstrictor activity? ??? ?? affected
  extremity?? total skin blood flow? ??????.
• chronic CRPS??? total skin blood flow? ???? ??.
  sympathetic activity? ??? ???? ???, ??? ??????
  vasoconstiction? ???.
• X-ray and bone scan
• subacute and chronic stage?? three-phase bone
  scan?? periarticular uptake??? fine-detail
  radiography?? demineralization? ??? ??? ??? ? ??.
• ??? ?? post-traumatic syndrome? CRPS? ???? ?? ???
  ?? ??.
• Phetolamine infusion test
• SMP? ???? placebo response? expectation bias? ???
  ? ? ??.
• phentolamine? IV injection? ? SMP? ??? ??? ??

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Treatment of CRPS

• ????? ??? CRPS? ????? ??.
• disease? sign? symptom? manage?? ???? ???? ????
  ???, ?? ????? pharmaco-, physio-,
  psychotherapeutic ? ???? modality? ??? ??? ??
  ???? ??.
• Pharmacological strategies
• CRPS ??? ??? action mechanism? ?? pharmacological
  therapy? ??.
• ???? ????? CRPS? neuropathic or inflammatory
  process? ????.

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• ?? therapy? ??? ???? clinician? neuropathic pain?
  treat? ??? ??? ??. anticonvulsant, TCA,. ? ????,
  opioid? ?? ???.
• Physical therapy
• CRPS ??? functional restoration and
  rehabilitation? ??? physical therapy? ???.

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• Psychological approach
• CBT(cognitive behavioral therapy)? chronic pain
  disorder? ????? ???.
• CBT? specific use? ?? ??? ???, ???? clinician?
  3?? ??? CRPS???? CBT? ???? ?? formal psychiatric
  evaluation? recommend?? ??.
• CRPS???? psychological dysfunction? ?? ??? ???,
  predisposing?? personality trait? ??.
• Spinal cord stimulation
• PT? ?? ???? ?? PT? SCS? ?? ?? ???? pain relief? ?
  ?? ??? ???.
• SCS? mechanism? ??? ?? ???, ?? sympathectomy?
  ????? SCS? ?????.

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• Neuraxial infusion therapy
• epidural clonidine, intrathecal baclofen ??
  dystonia? ??? ? ???? ??? ???.
• Neuroablation strategies
• sympathetically mediated pain? treatment?
  surgical sympathectomy, chemical sympathectomy,
  radiofrequency ablation?? ????? ???,
  postsympathectomy neuralgia ???? ???, ??
  peripheral alpha adrenergic receptor? denervation
  supersensitivity? ??? ??? ??.

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CRPS and Pediatrics

• ??? ????? CRPS? ????? ??? ??? ??.
• ???? ????? CRPS? upper extremity?? lower
  extremity? ? ? ????, sensory, motor, automatic
  disturbance? main feature??.
• trophic change? ? ?? ???, trauma history? ? ????
  ??.
• recurrence rate? ??? 10? ?? 30? ?? ?????,
  prognosis? ?? ??? ????.
• refractory case?? disability??? ??? ???? ???,
  sympathetic block, epidural catheter, spinal cord
  stimulationk, surgical sympathectomy??
  interventional approach? ?? ???? ??.