Complex Regional Pain Syndrome To Amputate Or Not Nursing Essay

Complex Regional Pain Syndrome To Amputate Or Not Nursing Essay Abstract Complex Regional Pain Syndrome is pain syndrome confined to one or more limbs, usually occurring after trauma. The cause of CRPS remains unknown and its diagnosis is based upon a set of clinical signs and symptoms: the Budapest Criteria (figure 1). CRPS is characterised by the presence of limb pain associated with sensory, motor, autonomic, skin and bone changes. It is often resistant to treatment and its clinic course is difficult to predict. Early diagnosis and treatment from a multidisciplinary team is associated with the best outcome. In the UK there has been recent guidelines published to aid the diagnosis and treatment of CRPS. The mainstay of this treatment is physiotherapy, patient education and the medical management of pain. The patient in this case was scheduled to undergo an amputation of the affected limb prior to trying any of the above management, indeed prior to even being diagnosed with CRPS. Amputation for the treatment of CRPS is controversial. Evidence based guide lines regarding CRPS currently state that there is insufficient evidence to prove that amputation positively contributes to the treatment of the patient. It also runs the risk of the patient suffering from phantom limb pain or CRPS recurring in the stump or contralateral limb. If indeed CRPS is a sympathetically mediated neuropathic pain, as proposed, surgery to the area is likely to aggravate the condition. Tissue damage locally will result in the release of inflammatory neurokines leading to up regulation of the immune and nervous system. Amputation in the presence of CRPS can only therefore be justified in the treatment of therapy-resistant infection after other treatment options have been explored. Even more pertinent to this case was that the patient had never tried more conventional treatment options before an amputation was decided upon. Case Presentation Referral Information Patient JM was referred by Dr FJ, consultant in rehabilitation medicine as a query diagnosis of CRPS of his right lower limb. JM was scheduled to have a Symmes amputation, under a Professor MS a consultant orthopaedic surgeon, two weeks after this referral was made. Questionaire Scores MPSQ 8 Mod Zung 21 Current Problem JM complained of gradually worsening pain in right ankle and foot over a twenty-four month period. He scored his pain from 2-8/10 worse on light touch, cold weather and at the end of the day. The pain was accompanied by decreased motor function, oedema, an increase in sweating and skin colour changes in the limb. He described his pain as like a really bad tooth ache especially worse when the limb was swollen and only decreased by rest and elevation. He described a dropping sensation in the foot despite it being fused at the ankle which causes such severe pain it has at times caused him to vomit. Background History JM was born with a congenitally abnormal right tibia. As a child he underwent multiple operations on his right ankle. He has had two osteotomies, a bone graft and Lizorov frame and a triple arthrodesis at this ankle joint. Past Medical History JM has no other medical problems. Drug History Dihydrocodine 30mg four times a day. No other medication tried. Family History No family medical history of note. Mum and Dad alive and well. Social History JM lives with his parents and works in IT full time from an office at home. He feels that his career progression has been halted over the last few years as his pain has increased and his function worsened. He has an active social life and close family support. He played regular tennis until the pain in his ankle increased a few years ago but hasnt been able to play since 2010. He denies any depression or anxiety although finds his functional limitations frustrating. His mother attended his first clinic appointment and was extremely upset and anxious when it was suggested that her son try medical treatment options before resorting to a Symmes amputation. She felt that JM had gone through a lot of psychological distress coming to terms with the prospect of having his leg amputated at the foot and was fully decided this was the best course of action only for that decision to be questioned. JM didnt have any expectations of the pain clinic other than to help him reduce his pain to a liva ble level. The main reasons given by the Orthopeadic team for amputation was functional: to improve his gait and in the long run reduce possible arthritic changes developing due to his poor posture. Examination Findings JMs right lower limb on inspection was swollen from below the knee, with a pale discolouration and multiple operation scars at the ankle. There were noticeable trophic changes in the nails of the right foot but no hair or skin changes locally. His right ankle is fused in fixed dorsi flexion. On palpation it is cooler to touch and clammy when compared to the left lower leg and ankle. JM is tender to light touch over the medial aspect of the right ankle. The right knee has normal and has a good range of movement. Diagnostic Formulation JMs right ankle is positive for the Budapest Diagnostic Criteria for Complex Regional Pain Syndrome. Sensory Allodynia Hyperalgesia Vasomotor Temperature asymmetry Skin colour changes Skin colour asymmetry Sudomoter / Oedema Oedema Sweating changes Sweating asymmetry Motor / Trophic Decreased range of movement Motor dysfunction Trophic changes (hair/skin/nails) For the patient to be positive for CRPS with the Budapest criteria they must have continuing pain which is disproportionate to the eliciting event and have: More than one sign in two or more of the categories above AND More than one symptom in three or more of the categories above AND No other diagnosis that could better explain their signs and symptoms. JM has all of the italic signs and symptoms above and no other diagnosis that could better explain his symptoms. JM had also undergone a bone density scan of the right leg showing osteopenia and an xray showing arthritic changes to the deformed and fused ankle joint. Therefore a diagnosis of CRPS of his right lower limb was made. Subsequent Management JM was started on lignocaine 5% patches. Communications were also made with the other consultants involved in JMs care (orthopaedics and rehabilitation medicine). The orthopaedic team were keen to point out that the benefits of the surgery were functional and that even if JM were to become pain free with conservative treatment then it would not solve his functional problems. At follow up one month after starting the lignocaine 5 % patches JM was managing extremely well. His pain was down to a manageable level and by wearing the patches he could function nearly normally. He is now walking without a stick and had managed to return to playing tennis and had attended a work conference. He had decided against having the amputation and was happy to carry on with the current medical management of his condition. Further treatment options, should his pain flair up again, were discussed. These included IVRA (intravenous regional anaesthesia) and a spinal cord stimulator. Discussion CRPS is a pain syndrome with an unclear pathophysiology and unpredictable clinical course. The diagnosis of CRPS is based upon a set of signs and symptoms derived from the history and examination of the patient. The treatment of CRPS is aimed at improving function and requires the use of a interdisciplinary team encompassing physiotherapy, psychological therapies and pain management. The management of CRPS depends on prompt diagnosis and early management as response to treatment is adversely affected by any delays. In the UK recent guidelines have been developed for the diagnosis and management in the context of both primary and secondary care (2). JM in this case had been managed primarily by an orthopaedic team who had not linked his symptoms with a diagnosis of CRPS. CRPSs management requires a multidisciplinary approach based upon the published Four Pillars of Intervention (3). The Four Pillars of Treatment for CRPS Patient information and education Patients should be provided with appropriate education about CRPS to support self management Patients should be reassured the physical and occupational therepy are safe and appropriate and engaged in the process of goal setting and review Pain relief (medication and procedure) No individual drug can be recommended at current time due to lack of evidence but the following may be considered a)neuropathic pain medication b)pamidronate 60mg iv single dose in pts with CRPS