title: Informed Decision-Making Regarding Amputation for Complex Regional Pain Syndrome Type I.
abstract: BACKGROUND
  Literature on complex regional pain syndrome type I (CRPS-I) discussing the decision to amputate or not, the level of amputation, or the timing of the amputation is scarce. We evaluated informed decision-making regarding amputation for CRPS-I.
  
  
  METHODS
  We describe our findings in a retrospective study of the decision-making process of thirty-six patients who underwent amputation for CRPS-I at our university medical center from 2000 to 2012. Additionally, we present the incidents preceding the CRPS-I, the reasons for and the levels of the amputation, and the outcomes after the amputations.
  
  
  RESULTS
  Team members and the patient decided together whether or not to amputate and the level of amputation. Issues such as level of pain or allodynia, infection, desired length of the residual limb, joint range of motion, strength of all extremities, ability to use walking aids, and psychological "green, yellow, and red flags" were weighed in this process. There were no complications during the amputation surgery, a 22% rate of complications (infection in all but one patient) immediately postoperatively (reamputation not required), a 72% rate of phantom pain immediately after or within the first three months after the amputation, and a 77% rate of phantom pain more than one year after the amputation.
  
  
  CONCLUSIONS
  Informed decision-making regarding amputation for CRPS-I remains a complex process for which little evidence is available to support patient choices; patient-specific outcomes are not predictable. However, amputation should not be ignored as a treatment option for long-standing therapy-resistant CRPS-I.
  
  
  METHODS
  Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Department of Rehabilitation Medicine, Center for Rehabilitation (M.I.B., P.U.D., E.S., and J.H.G.), Department of Oral and Maxillofacial Surgery (P.U.D.), Department of Surgery (J.J.v.d.D.), and Department of Pathology and Medical Biology (W.F.d.D.), University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands.
authors.forename: Marlies I
authors.initials: MI
authors.lastname: Bodde
authors.affiliation: Department of Rehabilitation Medicine, Center for Rehabilitation (M.I.B., P.U.D., E.S., and J.H.G.), Department of Oral and Maxillofacial Surgery (P.U.D.), Department of Surgery (J.J.v.d.D.), and Department of Pathology and Medical Biology (W.F.d.D.), University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands.
authors.forename: Pieter U
authors.initials: PU
authors.lastname: Dijkstra
authors.affiliation: Department of Rehabilitation Medicine, Center for Rehabilitation (M.I.B., P.U.D., E.S., and J.H.G.), Department of Oral and Maxillofacial Surgery (P.U.D.), Department of Surgery (J.J.v.d.D.), and Department of Pathology and Medical Biology (W.F.d.D.), University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands.
authors.forename: Ernst
authors.initials: E
authors.lastname: Schrier
authors.affiliation: Department of Rehabilitation Medicine, Center for Rehabilitation (M.I.B., P.U.D., E.S., and J.H.G.), Department of Oral and Maxillofacial Surgery (P.U.D.), Department of Surgery (J.J.v.d.D.), and Department of Pathology and Medical Biology (W.F.d.D.), University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands.
authors.forename: Jan J
authors.initials: JJ
authors.lastname: van den Dungen
authors.affiliation: Department of Rehabilitation Medicine, Center for Rehabilitation (M.I.B., P.U.D., E.S., and J.H.G.), Department of Oral and Maxillofacial Surgery (P.U.D.), Department of Surgery (J.J.v.d.D.), and Department of Pathology and Medical Biology (W.F.d.D.), University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands.
authors.forename: Wilfred F
authors.initials: WF
authors.lastname: den Dunnen
authors.affiliation: Department of Rehabilitation Medicine, Center for Rehabilitation (M.I.B., P.U.D., E.S., and J.H.G.), Department of Oral and Maxillofacial Surgery (P.U.D.), Department of Surgery (J.J.v.d.D.), and Department of Pathology and Medical Biology (W.F.d.D.), University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands.
authors.forename: Jan H
authors.initials: JH
authors.lastname: Geertzen
mesh_terms: D000328:Adult; D000671:Amputation, Surgical; D001132:Arm / Q000601:surgery*; D020918:Complex Regional Pain Syndromes / Q000523:psychology* / Q000601:surgery*; D003657:Decision Making; D005260:Female; D006801:Humans; D007866:Leg / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D010591:Phantom Limb / Q000453:epidemiology; D011183:Postoperative Complications / Q000453:epidemiology; D011788:Quality of Life; D012189:Retrospective Studies; D016896:Treatment Outcome