Complex Regional Pain Syndrome

The panelists discuss current diagnostic criteria for complex regional pain syndrome (CRPS) and the various treatment options available for the neuropathic pain condition.

Christopher Gharibo, MD, says “diagnosing CRPS can be quite a conundrum,” because while the neuropathic pain condition is a “combination of sensory, motor, somatic, and superficial changes, and motor changes,” other ailments such as infection, vascular disease, diabetic mononeuritis, cancer, and nerve compression can present similar symptoms — which Gharibo says has resulted in “many patients that are, I think, being overdiagnosed with CRPS that really don’t have CRPS.”

Nevertheless, Joseph Pergolizzi, MD, believes it’s best to start “aggressive, adequate, and appropriate analgesics regimens … as well as physical and occupational therapy” as soon as patients present CRPS symptoms, and then investigate later on to determine whether those patients actually have the condition.

To devise such a treatment plan, Jeffrey A. Gudin, MD, notes that “the treatment modality for this is what I call the kitchen sink, because this is probably, in my opinion, one of the worst neuropathic pain conditions that patients can have.”

“These patients … have a deformity of one of their limbs, they have extreme pain, they don’t sleep, they lose their jobs, and they become socially dysfunctional because of those issues, so I think about the kitchen sink philosophy, and I really try to maximize that multimodal analgesic approach,” Gudin says. “I try to limit opioids at first, but it’s such a bad condition that eventually most of my patients, I’d say, do end up on opioids.”

When Gharibo proposes surgical treatment options such as lumbar sympathetic blocks, plexus blocks, and ketamine infusions, moderator Peter Salgo, MD, interjects that “we’re talking big guns here”, though Gudin stresses that they’re needed because CRPS is “a devastating condition.”

“When you look at the future of various types of potential treatment modalities, you have alpha-lipoic acid, you have protein kinase C inhibitors, but nothing really has been a home run, either. So I think we have to really get used to what we have at the current time and incorporate those strategies early on,” Pergolizzi adds. “We don’t want to overdiagnose patients with this, but at the same time, in the process of figuring it all out, maybe that’s what you need to do.”