Introduction Algonurodystrophy Algodystrophy Sudek atrophy Shoulder hand syndrome Complex regional syndrome sympathetically mediated pain syndrome( SMP)

What is CRPS CRPS (Chronic regional pain syndrome)is a debilitating neurologic syndrome , ‘ follows a musculoskeletal trauma :

Pathogenesis A- original injury initiate a pain in pulse which is carried from sensory nerves to the to the central nervous system

Pathogenesis B-pain impulse in turn trigger an impulse in the sympathetic nervous system which return to original area of injury

Pathogenesis  C- Sympathetic impulse trigger the inflammatory response causing the vessels to dilate . This leads to swelling an increased pain

Pathogenesis  D- Pain trigger another impulse establishing a cycle of pain and swelling

Epidemiology Common in younger adults Mean 41.8 years 2.3 to 3 times more frequent in females than males Usually involves a single limb in the early stage

Causes of RSDS No clear etiology in 25-35%. Trauma (about 60-65% of cases), Treatment with antituberculous drugs or phenobarbital Atypical causes such as pregnancy or postpartum causes, diabetes mellitus, malignant tumors, parkinsonism or other CNS disorders(stroke, hemiplegia)

Statistically significant associations Cigarette smoking Patients frequently show high scores on schizophrenia or depression scales.. wartime casualties.

Clinical Aspects of CRPS

Sensory Changes in CRPS Allodynia(Increased sensitivity to a nonpainful sensory stimulation) Hyperalgesia (Abnormally exaggerated subjective response to painful stimuli ) Hyperesthesia Pain disproportionate to any inciting event

Autonomic Signs in CRPS Edema Swelling in limb Color change Temperature (cooler or warmer) Sweating

Swelling in limb Diffuse Nonpitting or pitting Occur in distal part of limb Don’t occur in hip or shoulder

Trophic Changes Altered nail growth Altered hair growth Skin changes

Abnormal Sweating

Skin changes

Psychological Changes Fear Anxiety Anger Depression

Neurologic changes hyperesthesia (glove and stocking distribution) in coordination tremor muscle spasms Limited range of movement and paresis

Spread of CRPS

Stages of RSD / CRPS STAGE I Onset of severe, pain limited to the site of injury Increased sensitivity of skin to touch and light pressure (hyperasthesia). Localized swelling Muscle cramps Stiffness and limited mobility At onset, skin is usually warm, red and dry and then it may change to a blue (cyanotic) in appearance and become cold and sweaty. Increased sweating (hyperhydrosis). .

Stages of RSD / CRPS STAGE II Pain becomes even more severe and more diffuse. Swelling tends to spread and it may change from a soft to hard (brawny) type. Hair may become coarse then scant, nails may grow faster then grow slower and become brittle, cracked and heavily grooved. Spotty wasting of bone (osteoporosis) occurs early but may become severe and diffuse Muscle wasting begins .

Stages of RSD / CRPS STAGE III Marked wasting of tissue (atrophic) eventually become irreversible. For many patients the pain becomes intractable and may involve the entire limb. A small percentage of patients have developed generalized RSD affecting the entire body.

X Ray finding patchy or diffuse osteopenia of the underlying bones

Bone scanning Three-phase technetium Tc 99m commonly is used. Scan findings are considered positive if flow is asymmetric in phase 1, 2, and/or 3.

bone scintography

Imaging : bone scintography Immediate Flow phase Pooling phase

MRI Non spesific soft tissue change Low signal in T1-T2

Differential Diagnoses Diabetic and small-fiber peripheral neuropathies Entrapment neuropathies Thoracic outlet syndrome Discogenic disease Deep vein thrombosis Cellulitis Vascular insufficiency Lymphedema

Treatment

physical therapies Active and passive range of motion exercises Transcutaneous electrical nerve stimulation (TENS) Desensitization techniques

Pharmacologic agents Steroid Antidepressants: These drugs modulate sympathetic activity and provide analgesia (eg, amitriptyline). Anticonvulsants (eg, phenytoin, carbamazepine) Membrane stabilizing agents (eg, lidocaine, tocainide) Adrenergic compounds (clonidine) Calcium channel blockers Intranasal calcitonin IV alendronate (bisphosphonate)

Surgical Care Chemical sympathectomy Surgical sympathectomy Implantable electrical stimulators

Prognosis weakness of the extremity resulting from this condition is seen in almost 50-65% of patients, 18-24 months following initial diagnosis Full range of movement accompanying the above aggressive therapies is seen in 60-74% of patients. Prolonged morbidity is observed in about 50% of patients with psychiatric diathesis