Case report of lady with upper limb Complex Regional Pain Syndrome (CRPS) treated succesfully with medication and series of stellate ganglion nerve blocks
A 54 year old lady was seen in the Pain Clinic. She sustained a fracture on the right scaphoid and right radial head in June 2005. These healed satisfactorily but in the post operative period, she had been left with symptoms and signs of classical complex regional pain syndrome, i.e. pain on light touch (allodynia), exaggerated pain on pin prick (hyperalgesia), oedema, redness swelling and disability in the right arm.
She also had a continuous throbbing pain with exacerbations of electric shock-like pains going through the right arm. She had been started originally on Amitriptyline 10 mg by her GP and this had been progressively increased. She also complained of pain, tingling and numbness in the hand, elbow and forearm.
Diagnosis of upper limb Complex Regional Pain Syndrome (CRPS)
When she was seen in the pain clinic, a formal diagnosis of complex regional pain syndrome type 1 was made. On examination, she had widespread pain tenderness, epicondylitis, allodynia and hyperalgesia of the right arm. It was noted that she had been variously treated over the last few months with the Amitriptyline.
Pharmacological treatment of Complex Regional Pain Syndrome (CRPS)
When she arrived at the Pain Clinic she was started on the anti-neuropathic agent Gabapentin. This gave her some benefit in terms of symptomology, however a ceiling dose was reached where she had some pain relief but was starting to suffer from the adverse effects of the medication.
Stellate Ganglion nerve blocks for treatment of Complex Regional Pain Syndrome (CRPS)
It was then decided to start a course of 6 stellate ganglion nerve blocks. These are simple local anaesthetic blocks into the neck to interrupt the sympathetic nervous system pathways which supply the upper limb. In temporarily interrupting these with the local anaesthetic, it is sometimes possible to reduce pain in patients with upper limb CRPS.
Outcome from stellate ganglion nerve blocks
The course of 6 stellate ganglion nerve blocks were carried out and it was found that these were extremely beneficial. The patient was kept on the Gabapentin in total for 6 months and then titrated. At her last clinic visit, the pain had significantly improved, no further stellate ganglion nerve blocks were indicated and the Gabapentin dosage was stopped. The patient was discharged from the clinic.