How are therapeutic injections used in the pain management for complex regional pain syndromes (CRPS)?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Answer

Answer

Complex regional pain syndromes (CRPS) develop as an exceedingly disproportionate consequence relative to the causative trauma affecting the limbs. Causalgia (CRPS 2) is a painful disorder that results from traumatic nerve injuries, most commonly when such damage is partial. Causalgia is a syndrome of sustained, diffuse, burning pain; allodynia (pain produced by non-noxious stimuli) with hyperpathia (painful overreaction to stimuli); and vasomotor and sudomotor disturbances.

When advanced, CRPS 2 is associated with trophic changes of the affected tissues. Treatment of CPRS 1 and 2 entails sympathetic denervation of the entire limb, thus LA volume and concentration with diffusion must be sufficient to block the entire portion of the sympathetic chain that supplies the affected extremity. Following sympathetic interruption, patients should be questioned and urged to keep a diary as to the extent and duration of relief from burning pain, hyperpathia, allodynia, and sudomotor changes.

Three "critical sites" can be used to interrupt the peripheral sympathetic nervous system: the cervicothoracic (stellate) ganglion, celiac plexus, and lumbar sympathetic plexus. Usually, injection of 15-20 mL of an LA solution into the proper fascial plane near the stellate ganglion allows for sufficient spread to block the sympathetic chain from the superior cervical ganglion to the T5 ganglion, thereby inducing interruption of sympathetic innervation to the head and neck, upper extremities, heart, and most of the esophagus and lungs. Likewise, sufficient spread of 15-25 mL of an LA injectate near the celiac plexus should interrupt all sympathetic (and vagal), efferent, and afferent fibers serving the viscera in the upper abdomen. Injection of 15-20 mL at the anterolateral surface of the L2 or L3 vertebral body interrupts sympathetic innervation to the ipsilateral lower extremity and pelvis.

Three important sites that can be used to interrup Three important sites that can be used to interrupt the peripheral sympathetic nervous system. The colored areas represent patterns of diffusion of local anesthetic solutions for the following techniques: cervicothoracic sympathetic block, celiac-splanchnic block, and lumbar sympathetic block.

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