Location
Philadelphia, PA
Start Date
10-5-2021 12:00 AM
End Date
13-5-2021 12:00 AM
Description
Setting: Outpatient Pain Management
Patient: A 28-year-old male with a history of cryptogenic stroke, bilateral lower extremity compartment syndrome, and severe left foot pain secondary to emergent fasciotomy.
Case Description: This patient presented to the office with a chief complaint of left foot pain. Past medical history was significant for cryptogenic stroke and bilateral lower extremity compartment syndrome, status post emergent fasciotomy. Severe left foot pain began after emergent fasciotomy, and he required a walker for ambulation. While hospitalized, several different treatment modalities were utilized in an attempt to alleviate the pain. Previous treatments included tricyclic antidepressants, gabapentin, and saphenous nerve blocks, but did not provide any relief. Ice initially provided relief, but later resulted in frostbite and severe ulceration. The patient was in severe distress due to pain and was considering amputation after failure of previous treatments. He then presented to the outpatient office for a second opinion and interventional pain management evaluation. Physical examination of the left foot was significant for swelling, dryness, allodynia, and weakness in dorsiflexion and plantar flexion. Based on examination findings, the patient was diagnosed with Complex Regional Pain Syndrome (CRPS) of the left lower extremity using the Budapest Criteria. The Budapest Criteria is based on pain out of proportion to the inciting event, signs and symptoms relating to alterations in sensory, vasomotor, sudomotor/edema, and motor categories, and the absence of any other diagnosis that can better explain the signs and symptoms. CRPS is a hypersympathetic response to trauma, which accounts for the findings in this patient. A left lumbar sympathetic block under fluoroscopic guidance was recommended for treatment. The block was completed using 9 mL of 0.2% Ropivacaine and 1 mL of Dexamethasone 10 mg/mL, injected in 1 mL aliquots along the anterior border of the L3 vertebral body. Assessment/Results: The patient returned for follow-up two weeks post-injection and reported 95% improvement of his left foot pain and decreased medication requirements. Pain began to return two months later, and a second injection was completed with 95% relief. He continues to undergo additional lumbar sympathetic blocks for maintenance therapy as needed, and now only relies on a cane for ambulation.
Discussion: CRPS is a form of severe, chronic neuropathic pain that typically develops after a trauma, such as emergent fasciotomy. This case indicates that lumbar sympathetic blocks can offer significant pain relief in patients with CRPS that have not responded to other treatment modalities.
Conclusion: Lumbar sympathetic blocks can provide a long-term, narcotic-free treatment option for patients with CRPS that develop severe, refractory pain.
Embargo Period
6-10-2021
Lumbar sympathetic block as a treatment modality for complex regional pain syndrome
Philadelphia, PA
Setting: Outpatient Pain Management
Patient: A 28-year-old male with a history of cryptogenic stroke, bilateral lower extremity compartment syndrome, and severe left foot pain secondary to emergent fasciotomy.
Case Description: This patient presented to the office with a chief complaint of left foot pain. Past medical history was significant for cryptogenic stroke and bilateral lower extremity compartment syndrome, status post emergent fasciotomy. Severe left foot pain began after emergent fasciotomy, and he required a walker for ambulation. While hospitalized, several different treatment modalities were utilized in an attempt to alleviate the pain. Previous treatments included tricyclic antidepressants, gabapentin, and saphenous nerve blocks, but did not provide any relief. Ice initially provided relief, but later resulted in frostbite and severe ulceration. The patient was in severe distress due to pain and was considering amputation after failure of previous treatments. He then presented to the outpatient office for a second opinion and interventional pain management evaluation. Physical examination of the left foot was significant for swelling, dryness, allodynia, and weakness in dorsiflexion and plantar flexion. Based on examination findings, the patient was diagnosed with Complex Regional Pain Syndrome (CRPS) of the left lower extremity using the Budapest Criteria. The Budapest Criteria is based on pain out of proportion to the inciting event, signs and symptoms relating to alterations in sensory, vasomotor, sudomotor/edema, and motor categories, and the absence of any other diagnosis that can better explain the signs and symptoms. CRPS is a hypersympathetic response to trauma, which accounts for the findings in this patient. A left lumbar sympathetic block under fluoroscopic guidance was recommended for treatment. The block was completed using 9 mL of 0.2% Ropivacaine and 1 mL of Dexamethasone 10 mg/mL, injected in 1 mL aliquots along the anterior border of the L3 vertebral body. Assessment/Results: The patient returned for follow-up two weeks post-injection and reported 95% improvement of his left foot pain and decreased medication requirements. Pain began to return two months later, and a second injection was completed with 95% relief. He continues to undergo additional lumbar sympathetic blocks for maintenance therapy as needed, and now only relies on a cane for ambulation.
Discussion: CRPS is a form of severe, chronic neuropathic pain that typically develops after a trauma, such as emergent fasciotomy. This case indicates that lumbar sympathetic blocks can offer significant pain relief in patients with CRPS that have not responded to other treatment modalities.
Conclusion: Lumbar sympathetic blocks can provide a long-term, narcotic-free treatment option for patients with CRPS that develop severe, refractory pain.