Complex Regional Pain Syndrome.
Complex regional pain syndrome (CRPS) is a heterogeneous disorder that falls in the spectrum of neuropathic pain disorders. It is maintained by abnormalities throughout the neuraxis (the peripheral, autonomic, and central nervous systems). The pathophysiology of CRPS is not fully known. There are no scientifically well-established treatments. The diagnostic criteria for CRPS at this time are purely clinical, and the use of diagnostic tests has not been demonstrated. The most appropriate management of CRPS uses a multidisciplinary approach, with the inclusion of medical and psychologic intervention, and physical and occupational therapy. The key is gradual, persistent, functional improvement. The rational use of pain therapies must be grounded in a thorough knowledge of the neurobiology of pain, its endogenous modulation, and the clinical presentation. Potential peripheral pathophysiologic targets (and possible treatments) include increased spontaneous firing and responsiveness of peripheral afferent fibers mediated by inflammatory and other algogenic substances (somatosensory blocks, corticosteroids), altered levels of expression and functioning of multiple ion channels (local anesthetics, calcium channel blockers, anticonvulsants), abnormal interneuronal communication, and increased peripheral expression of adrenergic receptors and sympathetic excitation (sympathetic blocks, alpha-adrenergic antagonists, alpha-2 agonists). CRPS is also perpetuated by central mechanisms, with pathophysiologic targets (and possible treatments) including reorientation of dorsal horn terminals (desensitization techniques), functional reduction in inhibitory interneuron activity (tricyclic antidepressants, gabapentin, opioids), central sensitization and increased central excitability (gabapentin, topiramate, spinal cord stimulation, somatosensory blocks), impaired descending nociceptive inhibition (tricyclic antidepressants, opioids), and adaptive changes in the cortical centers underlying the sensory-discriminative and affective-motivational dimensions of pain (psychologic, physical, and occupational therapies). The treatment choices should be aimed at remodulating, normalizing, disrupting, or preventing the progression of abnormalities in pain processing. Sympathetic nerve blocks should be performed at least once to assess if sympathetically maintained pain is present. To the extent that peripheral somatosensory nerve blocks can diminish nociceptive input to the central nervous system, these techniques may help reduce the nociceptive sensitization of spinal neurons. Pain relief, however it is achieved and however temporary it is, is intended to facilitate participation in functional therapies to normalize use and to improve motion, strength, and dexterity. Psychologic therapies, such as biofeedback and cognitive-behavioral techniques targeting pain, stress, and mood disorders, are valuable adjunctive treatments for pain control and can facilitate functional improvement.