Kenyada Williams, MD
Resident
Medstar/Georgetown
Washington, District of Columbia, United States
James Pendleton, MD
Attending Physician
Medstar/Georgetown
Washington, District of Columbia, United States
CRPS
Case Description: A 16 year-old male sustained a gunshot wound resulting in a T12 AIS B spinal cord injury (SCI). His clinical course was complicated by severe residual neuropathic pain in the bilateral lower extremities which was minimally responsive to near maximum doses of neuropathic medications resulting in marked sedation, limiting re-integration and participation in school. He met the Budapest Criteria for Complex Regional Pain Syndrome (CRPS) in the left foot/ankle as evidenced by allodynia, temperature asymmetry, hyperemia, and edema. Assessment of motor and trophic changes were confounded by the SCI. In an effort to reduce his pain and address his dependence on sedating medications, the patient underwent a series of left lumbar sympathetic blocks which resulted in a >70% reduction in his pain lasting 2 weeks and another 60% reduction in his pain lasting 4 weeks, with plans for a third block.
Discussions: There is limited literature on the presentation of CRPS in patients with spinal cord injury. The application of the Budapest Criteria in these patients is challenging due to overlapping pathophysiological mechanisms and categorical symptoms, which can lead to delayed diagnosis. In this case, despite early intervention and the up-titration of neuropathic pain agents, the patient's pain continued to worsen, raising suspicion for CRPS. The diagnosis was further supported by the significant pain relief observed following the sympathetic block.
There are very few cases demonstrating the utility of successive lumbar sympathetic blocks in treating CRPS in patients with incomplete SCIs. Here we found that successive lumbar sympathetic blocks resulted in additive pain reduction.
Conclusions: In patients with traumatic incomplete spinal cord injury who have asymmetric lower extremity pain that is refractory to physical therapy and oral medication, CRPS should be considered. If CRPS is suspected, a trial lumbar sympathetic nerve block may be both therapeutic and confirmatory for the diagnosis.
