Acute CRPS treatment and surgery timing

[MD87]

Patient with hand injury requiring surgery. On initial eval, exam/appearance of hand was straightforward. On day of surgery, hand had RSD-type picture. Surgery delayed. Has had symptoms for 72 hours.

I honestly have never seen someone this early on. Is SGB indicated this early on? High dose steroids? Dosing of bisphosphinates? I’ve read that surgery should be delayed at least 12 months… what are your thoughts? Thanks.

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[lobelsteve]

steroids now.
30mg bid for a month.
Do stellate and start desensitizing PT ASAP.
Stop it before it starts.

 

[drrosenrosen]

Wow, that is high dose steroids

 

[lobelsteve]

Wow, that is high dose steroids

A lot less than GCA.

 

[Orin]

I'm confused. Why are you diagnosing CRPS? Isn't it normal to have some CRPS like changes after a traumatic injury? That's a normal physiologic response to injury?

Is it just the delayed swelling after your evaluation?

 

[callmeanesthesia]

I’ve seen a lot of patients with underlying mechanical pain that seems to maintain the hypersensitization. High dose steroids will also delay surgical healing. I think delaying surgery for a year is crazy. I’d recommend starting vitamin C (500 mg TID), gabapentin or Lyrica, preop dose of gabapentinoid and oral Tylenol, preop nerve block with PNC for postop pain control (if permissible given the surgery), 10 mg dexamethasone IV at start of case, ketamine infusion during case, and early aggressive PT with desensitization postop.

 

[MD87]

I'm confused. Why are you diagnosing CRPS? Isn't it normal to have some CRPS like changes after a traumatic injury? That's a normal physiologic response to injury?

Is it just the delayed swelling after your evaluation?

I am seeing the patient this afternoon. Patient was diagnosed with presumed CRPS. By the hand surgeon who noted a significant change between the initial consult and the day of surgery. He is about 50 years old and he’s a very smart guy, lots of experience. It was not a typical “delayed swelling” type of thing according to him. I’ll report back after I eval the patient.

 

[soccrwz]

I’ve seen a lot of patients with underlying mechanical pain that seems to maintain the hypersensitization. High dose steroids will also delay surgical healing. I think delaying surgery for a year is crazy. I’d recommend starting vitamin C (500 mg TID), gabapentin or Lyrica, preop dose of gabapentinoid and oral Tylenol, preop nerve block with PNC for postop pain control (if permissible given the surgery), 10 mg dexamethasone IV at start of case, ketamine infusion during case, and early aggressive PT with desensitization postop.

I agree, I also wouldn't do steroids at this dose for this long, steroid induced diabetes, need to taper, dysfunction of HPA. Calcium, gabapentiods; topicals +/- ketamine compounding, and good PT person. SGB reasonable

 

[Orin]

I am seeing the patient this afternoon. Patient was diagnosed with presumed CRPS. By the hand surgeon who noted a significant change between the initial consult and the day of surgery. He is about 50 years old and he’s a very smart guy, lots of experience. It was not a typical “delayed swelling” type of thing according to him. I’ll report back after I eval the patient.

Smart people make mistakes too, but fair enough. I find the CRPS label gets applied quickly when you're not sure/afraid of it, but it's not clearly that in many of those cases. It does help grease the insurance wheels though.

I'm seeing at least one recent cohort and systematic review study in support of it:

Prednisone for Acute Complex Regional Pain Syndrome: A Retrospective Cohort Study

The objective of this study was to evaluate prednisone effectiveness on complex regional pain syndrome (CRPS) features in a community-based outpatient rehabilitation setting. A single-centre, retrospective inception cohort design was used. Inclusion ...

www.ncbi.nlm.nih.gov

Glucocorticoid treatment in patients with complex regional pain syndrome: A systematic review

The pathophysiology of complex regional pain syndrome (CRPS) is multifactorial, with an exaggerated inflammatory response being the most prominent. Treatment for CRPS is carried out according to the presenting pathophysiological mechanism. Anti‐inflammatory ...

www.ncbi.nlm.nih.gov

but I don't know if this meets Budapest criteria for CRPS as in acute injuries there are a lot more common issues that cause Budapest criteria to be positive

The key part to me is that "No other diagnosis can better explain the symptoms and signs"

Make sure you aren't missing a clot or something simpler.

 

[MD87]

Soooooo I saw the patient. Definitely NOT CRPS. Ha! Thanks for everyone’s help, though.

 

[Centurion38]

Soooooo I saw the patient. Definitely NOT CRPS. Ha! Thanks for everyone’s help, though.

"CRPS" in this context:

Ortho hand surgeon doesn't want to operate (hand looks RED!!!!)- send to pain guy

OR

Surgeon has operated (shouldn't have), patient needs opioid refills/work note/FMLA/disability/parking tag/assistive devices/electric bill excuse/child custody statement- send to pain guy

 

[MD87]

"CRPS" in this context:

Ortho hand surgeon doesn't want to operate (hand looks RED!!!!)- send to pain guy

OR

Surgeon has operated (shouldn't have), patient needs opioid refills/work note/FMLA/disability/parking tag/assistive devices/electric bill excuse/child custody statement- send to pain guy

Lol. Definitely # 1, and an overly cautious surgeon who didn’t want it to turn into #2