CRPS Bugle May 20th

Complex Regional Pain Syndrome can be a complication after spinal surgery according to this study.

Eur Neurol. 2012;68(1):52-8. doi: 10.1159/000337907. Epub 2012 Jun 22.

Complex regional pain syndrome following spine surgery: clinical and prognostic implications.

Wolter T, Knöller SM, Rommel O.


Complex regional pain syndrome (CRPS) has been reported following spinal surgery, but its frequency after spinal surgery is unknown. The aim of this study was to determine the frequency of spinal surgery preceding CRPS and to examine these patients regarding the course of the disease and prognostic factors.


We examined 35 CRPS patients regarding the symptoms and signs of CRPS, the type of CRPS (I or II), the origin and grade of the disease, the type of surgeries prior to CRPS onset, the course of the disease, and the therapies following diagnosis of CRPS.


In 6 patients, CRPS began during the postoperative course (lumbar spine surgery, n = 5; cervical spine surgery, n = 1). Four of these patients suffered from CRPS II. The course of the disease in the 6 patients was not different from that of patients with CRPS of other origins. First symptoms of CRPS could be observed 1-14 days after surgery.


CRPS is a rare complication after spinal surgery, but spinal surgery precedes the onset of CRPS of the lower limb in almost one-third of the cases. The first typical symptoms of CRPS emerge within 2 weeks after spinal surgery.


Knoeller at al. (2011) report on a case of CRPS 1 following artificial disc surgery – bear in mind that this is a case study and hence the conclusions cannot be extrapolated to a wider population. These case histories are however, a vital part of a learning process and raise awareness.

CRPS I following artificial disc surgery: case report and review of the literature

We report a case of type 1 complex regional pain syndrome (CRPS I) of the left leg following the implantation of an artificial disc type in the L4/5 segment of the lumbar spine using a midline left-sided retroperitoneal approach. This approach included the mobilisation of the sympathetic trunk with incision and resection of the intervertebral disc. The perioperative and immediate postoperative periods were uneventful, but on the second postoperative day the patient complained of a progressive allodynia of the whole left leg in combination with weakness of the limb. Neurological examination did not reveal any radicular deficit or paresis. A sympathetic reaction following the mobilisation of the sympathetic trunk during the ventral preparation of the spine was suspected and investigated further. A diagnosis of CRPS I was proposed, and the patient was treated with analgesia, co-analgesics for pain alienation, and systemic corticosteroid therapy. A computed tomography-guided sympathetic block and lymphatic drainage were performed. Following conservative orthopaedic rehabilitation therapy, the degree of pain, allodynia, weakness, and swelling were reduced and the condition of the patient was ameliorated. The cost–benefit ratio of spinal arthroplasty is still controversial. The utility of this paper is to debate a possible cause of a painful complication, which can invalidate the results of a successful operation.

Full article available here


Veldman et al. in 1993 published this important paper in The Lancet, describing the signs and symptoms in CRPS.

Lancet. 1993 Oct 23;342(8878):1012-6.

Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients.

Veldman PH, Reynen HM, Arntz IE, Goris RJ.

The pathogenesis of reflex sympathetic dystrophy–variously known as Sudeck’s atrophy, causalgia, algodystrophy, and peripheral trophoneurosis–is not yet understood, and diagnosing and treating patients is difficult. We have prospectively studied 829 patients, paying particular attention to early signs and symptoms. In its early phase, reflex sympathetic dystrophy is characterised by regional inflammation, which increases after muscular exercise. Pain was present in 93% of patients, and hypoaesthesia and hyperpathy were present in 69% and 75% respectively. With time, tissue atrophy may occur as well as involuntary movements, muscle spasms, or pseudoparalysis. Tremor was found in 49% and muscular incoordination in 54% of patients. Sympathetic signs such as hyperhidrosis are infrequent and therefore have no diagnostic value. We found no evidence consistent with the presence of three consecutive phases of the disease. Early symptoms are those of an inflammatory reaction and not of a disturbance of the sympathetic nervous system. These data support the concept of an exaggerated regional inflammatory response to injury or operation in reflex sympathetic dystrophy.


These two case study based papers demonstrate some benefit but this must be viewed with caution when considering the methodologies.

Pain Med. 2010 Sep;11(9):1415-8. doi: 10.1111/j.1526-4637.2010.00929.x. Epub 2010 Aug 23.

Botulinum toxin A (Botox) for treatment of proximal myofascial pain in complex regional pain syndrome: two cases.

Safarpour D, Jabbari B.


To describe development of myofascial pain syndrome (MFPS) with trigger points in the proximal muscles of the patients with complex regional pain syndrome (CRPS1) and improvement of distal symptoms of CRPS 1 after successful treatment of proximal MFPS.


In our practice, we frequently encounter patients in whom a proximal myofascial pain syndrome develops ipsilateral to the distal limb of CRPS1 patients. We describe two such patients in detail with their treatment. PATIENT 1: A 48-year-old woman experienced severe allodynia, swelling and autonomic changes in the right hand after surgery for carpal tunnel syndrome. Over the succeeding months, she developed painful trigger points in the right trapezius and upper back muscles which was treated with administration of botulinum toxin A (BoNT-A) into the trigger points (20 unit/point). PATIENT 2: A 41-year-old woman following a traumatic forearm injury suffered from CRPS1 affecting the left hand and forearm. Proximal MFPS gradually developed on the same side over 12 months and was treated with administration of BoNT-A into the trapezius, splenius capitis, and rhomboid muscle trigger points.


In both patients treatment with BoNT-A improved the proximal pain of MFPS and the distal symptoms of CRPS1.


proximal MFPS develops ipsilateral to the distal painful limb in patients with CRPS1. Administration of BoNT-A into the affected proximal muscles may alleviate both MFPS and the distal allodynia, discoloration and, tissue swelling of CRPS.


Pain Physician. 2011 Sep-Oct;14(5):419-24.

Intramuscular botulinum toxin in complex regional pain syndrome: case series and literature review.

Kharkar S, Ambady P, Venkatesh Y, Schwartzman RJ.


Pain associated with Complex Regional Pain Syndrome (CRPS) is frequently excruciating and intractable. The use of botulinum toxin for relief of CRPS-associated pain has not been well described.


To assess whether intramuscular botulinum toxin injections cause relief of pain caused by CRPS, and to assess the risks of this treatment.


Retrospective chart review.


Outpatient clinic.


37 patients with spasm/dystonia in the neck and/or upper limb girdle muscles.


EMG-guided injection of Botulinum Toxin – A (BtxA), 10-20 units per muscle. Total dose used was 100 units in each patient. Local pain score was measured on an 11-point Likert scale, 4 weeks after BtxA injections.


Mean pain score decreased by 43% (8.2 ± 0.8 to 4.5 ± 1.1, P < 0.001). 97% patients had significant pain relief. One patient had transient neck drop after the injections.


This is a retrospective study, it lacks a control group and hence the placebo effect cannot be eliminated. This study does not provide information on the efficacy of this treatment after 4 weeks.


Intramuscular injection of botulinum toxin in the upper limb girdle muscles was beneficial for short term relief of pain caused by CRPS. The incidence of complications was low (2.7%).


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