Matthew Nguyen, BS
Medical Student
Drexel University College of Medicine
Springfield, Pennsylvania, United States
Harrison Jordan, DO
Resident
East Carolina University
Greenville, North Carolina, United States
Anish Rana, BA
Medical Student
University of Rochester Medical Center, Strong Memorial Hospital
Glen Mills, Pennsylvania, United States
Shiraz Mumtaz, MS
Medical Student
Drexel University College of Medicine
Philadelphia, Massachusetts, United States
Sidharth Sahni, DO, DPT, CSCS
Resident Physician
NYU
New York, New York, United States
A 72-year-old male with a history of atrial fibrillation, right upper extremity amputation, complex regional pain syndrome (CRPS) status post spinal cord stimulator (SCS) placement with multiple revisions, and phantom limb pain (PLP).
Case Description:
The patient presented with one day of right lower extremity (RLE) weakness after a fall. PLP and CRPS were managed outpatient with previously implanted SCS in addition to Gabapentin and Percocet. Notably, he reported 10/10 pain in the right upper extremity (RUE) residual limb with no other symptoms. Physical exam revealed weakness in RLE dorsiflexion and plantarflexion and RUE tenderness. Stroke workup demonstrated acute/subacute left anterior cerebral artery territory infarcts. Magnetic resonance imaging was not possible given the implanted SCS. Initially, patient was treated with home Gabapentin and Percocet without pain relief. Additionally, he received Tylenol, Duloxetine, and a Lidocaine patch twice daily. The patient endorsed improved pain with these inpatient medications. He was discharged to continue physical and occupational therapy (PT/OT).
Discussions:
First-line CRPS treatment includes PT/OT, with second-line options involving non-steroidal anti-inflammatory drugs, anticonvulsants, and antidepressants. Opioids and interventional methods such as trigger point injections and nerve blocks can be considered if medications fail. PLP management starts with non-pharmacological methods, such as mirror therapy and electrical nerve stimulation, followed by medication if needed. Prognosis for both conditions lacks extensive research. Despite this, the patient had not been actively participating in PT/OT due to transportation issues and prior lack of improvement. Insurance obstacles halted pain management for a year, preventing previous serotonin-norepinephrine reuptake inhibitor (SNRI) trial.
Conclusions: This represents a rare case of post-stroke exacerbation of RUE residual limb pain in a patient with a complex medical history where conservative treatment provided the most relief. Further studies should explore the use of SNRIs in managing PLP and CRPS in post-stroke patients.
