Guidelines Summary

Royal College of Physicians

Updated guidelines regarding the management of CRPS in adults were published in 2018 by the Royal College of Physicians.^[32]

Treatment by surgeons

These guidelines include the following:

Management should be initiated with simple analgesia (nonsteroidal anti-inflammatory drugs and paracetamol) and possibly tricyclic antidepressants (eg, amitriptyline) or anticonvulsants (eg, gabapentin), although follow-up and titration of doses may be best arranged by the patient’s general practitioner
If anticonvulsants or strong opiates are required, surgeons should consider urgent patient referral to a pain consultant
Urgent physical therapy, the mainstay of CRPS treatment, should be organized
Although plastic surgeons should not administer guanethidine blocks, pain clinicians may consider employing them; however, randomized, controlled trials have not demonstrated a benefit to their use

Surgery

Surgical guidelines include the following:

Limbs that have previously been affected by CRPS can be treated with elective surgery, with less than 15% disease recurrence in patients who undergo surgery after acute symptoms have settled; following settlement of symptoms, surgery should, if possible, be delayed another 12 months or longer
In patients with CRPS type II who have sustained a recognized nerve insult or in whom the nerve appears to have been caught in a suture or scar contracture, surgery may be indicated
Surgery in CRPS should be performed by a surgeon with experience in managing the condition; the anesthetist should also be a pain specialist

Amputation

Guidelines regarding amputation include the following:

Cases in which amputation is being considered should involve a multidisciplinary team that at minimum includes, along with a surgeon, a pain consultant, an appropriate psychologist or psychiatrist, and a physical therapist and/or occupational therapist
Amputation should be performed only after all other treatments have been assessed
Generally, amputation should not be performed within the first 2 years after CRPS has been diagnosed; intractable infection is the one strong indication for amputation

Medication

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Media Gallery

A 29-year-old woman with reflex sympathetic dystrophy in the right foot demonstrates discoloration of the skin and marked allodynia.
This photo shows the same patient as in the above image, following a right lumbar sympathetic block. Marked increase in the temperature of the right foot is noted, with more than 50% pain relief.
A 68-year-old woman with complex regional pain syndrome type II (causalgia).
A 36-year-old woman with right arm reflex sympathetic dystrophy and dystonic posture (movement disorder).
Normal laser Doppler study of the upper extremities. When the patient performs inspiratory gasp repeatedly during laser Doppler image acquisition, the transient capillary flow decreases are displayed easily and dramatically (as dark bands) in the pseudocolor image.
Laser Doppler study of the upper extremities in a patient with right hand reflex sympathetic dystrophy.
Laser Doppler study of the lower extremities in a 25-year-old woman with reflex sympathetic dystrophy in the right foot.
Algorithm for the management of chronic regional pain syndrome (CRPS). Resolution of this syndrome does not commonly occur, and the patient will need chronic pain management.

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Author

Manish K Singh, MD Assistant Professor, Department of Neurology, Teaching Faculty for Pain Management and Neurology Residency Program, Hahnemann University Hospital, Drexel College of Medicine; Medical Director, Neurology and Pain Management, Jersey Institute of Neuroscience

Manish K Singh, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Pain Medicine, American Headache Society, American Association of Physicians of Indian Origin, American Medical Association, American Society of Regional Anesthesia and Pain Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Jashvant Patel, MD, MS Physician in Pain Medicine, Interventional Pain Management and Santa Maria Radiation Oncology, Dignity Health

Jashvant Patel, MD, MS is a member of the following medical societies: Alberta Medical Association, American Academy of Pain Medicine, American Academy of Physical Medicine and Rehabilitation, American Medical Association, American Society of Regional Anesthesia and Pain Medicine, Medical Society of the State of New York

Disclosure: Nothing to disclose.

John Grothusen, PhD Director of Quantitative Sensory and Autonomic Nervous System Laboratory, Associate Professor, Department of Neurology, Drexel University College of Medicine

Disclosure: Nothing to disclose.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Stephen Kishner, MD, MHA Clinical Professor, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Debra Ibrahim New York College of Osteopathic Medicine

Disclosure: Nothing to disclose.

Leia Rispoli Rutgers New Jersey Medical School

Disclosure: Nothing to disclose.