|Year : 2014 | Volume
| Issue : 3 | Page : 189-192
Management of CRPS Type-I: Combination of stellate ganglion block and continuous brachial plexus block (ultrasound-guided): Case report
Dwarkadas Kanhayalal Baheti1, Vaibhavi Baxi2, Shweta Chandankhede3
1 Department of Anaesthesiology and Pain, Lilavati Hospital and Research Centre, Bandra, Mumbai, Maharashtra, India
2 Anesthesiologist, Lilavati Hospital and Research Centre, Bandra, Mumbai, Maharashtra, India
3 Associate Specialist Anesthesia, Lilavati Hospital and Research Centre, Bandra, Mumbai, Maharashtra, India
|Date of Web Publication||11-Aug-2014|
Dwarkadas Kanhayalal Baheti
Lilavati Hospital and Research Centre, Bandra, Mumbai - 400 050, Maharashtra
Source of Support: None, Conflict of Interest: None
The complex regional pain syndrome (CRPS) I is a neurogenic pain syndrome that is characterized by pain, vasomotor and dystrophic changes and often motor impairments. The etiology of the condition resides in multiple theories, and diagnosis can be difficult and therapy focuses on pain management and restoration of physical function. The conservative treatment includes both non-pharmacological and pharmacological methods, and invasive therapy is centered on sympathetic and somatic blocks. We report a case of CRPS type-I in a 15-year-old young boy following repeated trauma to right elbow, which was successfully managed by a stellate ganglion block and continuous interscalene brachial plexus block and function restored to its full extent.
Keywords: Brachial plexus, CRPS Type I, RSD, stellate ganglion block, sympathetic block, ultrasound guided
|How to cite this article:|
Baheti DK, Baxi V, Chandankhede S. Management of CRPS Type-I: Combination of stellate ganglion block and continuous brachial plexus block (ultrasound-guided): Case report. Indian J Pain 2014;28:189-92
|How to cite this URL:|
Baheti DK, Baxi V, Chandankhede S. Management of CRPS Type-I: Combination of stellate ganglion block and continuous brachial plexus block (ultrasound-guided): Case report. Indian J Pain [serial online] 2014 [cited 2020 Mar 28];28:189-92. Available from: http://www.indianjpain.org/text.asp?2014/28/3/189/138459
| Introduction|| |
Complex regional pain syndrome (CRPS) describes an array of painful conditions that are characterized by a continuing spontaneous and or evoked regional pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or other lesion. The pain is regional and nonspecific to nerve injury or dermatome, and usually has distal predominance of abnormal sensory, motor, sudomotor, vasomotor and/or trophic findings. CRPS I is frequently triggered by tissue injury but no underlying nerve injury. CRPS II cases are usually associated with nerve injury. The syndrome shows variable progression over time. CRPS may occur at any age and affects both men and women, though most agree that it is more common in young women.
The causes of CRPS are unknown. The sympathetic nervous system plays an important role in sustaining the pain. Theories suggest that pain receptors in the affected part of the body become responsive to catecholamines. Animal studies do not indicate that epinephrine can activate pain pathways after injury. The incidence of sympathetically mediated pain in CRPS is unknown. 
Another theory suggests that CRPS is a result of triggering of the immune response, which results in inflammatory symptoms of redness, warmth and swelling in the affected areas. It is likely that CRPS does not have a single cause.
Physiological windup and central sensitization are key neurologic processes involved in conduction and maintenance of CRPS. There is evidence of NMDA receptors involved in CNS sensitization. It is also hypothesized that elevated CNS glutamate levels promote physiological windup and central sensitization. The immune process may contribute to peripheral and central sensitization. 
We report a successfully managed CRPS type I of right upper extremity with a stellate ganglion block, supplemented with a continuous brachial plexus block (ultrasound guided), which resulted in excellent pain relief and restoration of pain-free movements.
| Case Report|| |
A 15-year-old male (APT) weighing 125 kg visited pain management clinic of this hospital with complaints of pain (even a slight touch resulting in severe pain), swelling, burning, decreased sweating and painful movements of right upper extremity for a duration of 8 months. He gave a history of repeated fall and injury to the right elbow almost 8 months back. There was no radiographic or otherwise evidence of bone or nerve injury. The patient complained of pain and swelling of the right arm, forearm and hand. The pain was described as sharp, shooting with intensity, being a 9/10 on Visual Analog Scale (VAS); burning; and manifested even on light touch (even clothes touching the arm was painful (allodynia). He was unable to use his right upper limb and was rendered disabled as this was his dominant upper extremity. The use of multiple drugs, including NSAIDs, opioids, steroids and neuropathic medications were without any significant benefit.
The clinical examination revealed circumferential edema all over the arm from shoulder to palm. Skin appeared shiny with hyperalgesia to light touch. There was no evidence of hyperhidrosis or excessive hair growth. However, patient did mention about decreased sweating in right upper limb. The movements of the upper limb at shoulder, elbow, wrist and finger were minimum and painful. The trophic changes were evident on the extremity involved.
The probable diagnosis of CRPS type I and a right stellate ganglion block, supplemented with a continuous brachial plexus block (ultrasound guided) was planned. He was put on medications, Gabapentin, Amitriptyline, Tramadol, Paracetamol and Pantaprazol with Domperidone.
After explaining the procedure and obtaining an informed consent from the father (patient being minor) and routine blood investigations, he was posted for the above-mentioned procedure.
In the operating room, the patient was given supine position with head slightly extended and turned to left side. The monitoring included pulse oximetry, non-invasive blood pressure and continuous ECG monitoring. An IV line was secured on left hand.
Stellate Ganglion Block (Rt.) - After preparation of the area, the transverse process of C6 was identified under fluoroscopy. The right sternocleidomastoid muscle and carotid artery were retracted laterally with firm pressure of operator's three fingers just above supra sterna notch. A 22-gauge needle filled with normal saline was directed medially and inferiorly toward the body of C6, to hit transverse process and then withdrawn by 1-2 mm to rest outside the longus colli muscle. Inj. Omnipaque (non-ionic contrast) 3 ml was injected and spread of dye was confirmed fluoroscopically.
Then, Inj. Loxicard 2% (preservative-free lignocaine) 10 ml was injected with intermittent repeated negative aspiration. The patient informed immediate pain relief VAS 2-3/10 and could move his right elbow, wrist and fingers.
Brachial plexus block (Rt.) - With the patient in the same position, scanning of supraclavicular fossa using ultrasound was done to identify the subclavian artery as it passes over the first rib. The brachial plexus was identified as a "bunch of grapes" lying supero-lateral to the subclavian artery. Using in-plane approach a 50 mm 22 g contiplex needle was inserted from lateral to medial direction at a shallow angle under ultrasound so that the entire shaft and the tip of the needle was visualized [Figure 1].
|Figure 1: Ultrasound image of an in-plane needle lying next to nerve structures in interscalene groove. UT: Upper trunk, MT: Middle trunk, LT: Lower trunk of brachial plexus.|
Click here to view
The nerve stimulator was connected to the stimulating needle and set to deliver a 0.8 to 1.0 mA current at 1 Hz frequency and 0.1 ms of pulse duration. The needle was slowly advanced until the upper trunk was identified by a muscle twitch of the shoulder muscles. Inj. Loxicard (preservative-free lignocaine) 2-3 ml was injected to hydro-dissect and open up the fascial plane to clearer visualization of the nerve structures. Then, Inj. Bupivacaine 0.25% 4-5 ml was injected slowly with intermittent negative aspiration for blood, which spread anterior and posterior to the nerve structures and surrounded the nerve like a doughnut-shaped hypoechoic area.
An 18 g catheter was introduced through the contiplex cannula and 5 ml of local anesthetic injected through the catheter, the spread of which was visualized under ultrasound to confirm proper catheter placement. The catheter was secured by tunneling in the skin.
An elastomeric balloon pump containing 300 ml of 0.125% bupivacaine and fentanyl 2 mic/ml was attached to the catheter at the rate of 5 ml/h. Patient had immediate relief of about 40-50% with VAS score going down to 4/10 after the block. The catheter was removed after 24hrs of continuous infusion and patient was discharged. The stay at hospital was uneventful.
On follow up after 4 weeks, the patient had significant improvement in the neuropathic pain VAS 2-3/10 and range of pain-free movements of the arm improved. There was no edema. The allodynia, hyperalgesia, was negligible. The sweating in the right upper extremity increased.
At the fifth week, we repeated a stellate ganglion block with continuous interscalene brachial plexus block for 24 hours. The stay at hospital was uneventful. The patient was advised physiotherapy and got involved in all the activities.
| Discussion|| |
CRPS is a more accepted terminology for various clinical syndromes such as Sudeck's atrophy, traumatic arthritis, minor causalgia, post-traumatic osteoporosis, post-traumatic pain syndrome, post-traumatic edema, post-traumatic angiospasm, shoulder-hand syndrome, etc. CRPS was defined by the International Association for the Study of Pain (IASP) as continuous pain in a portion of an extremity after trauma, which may include fracture but does not involve major nerves. It is associated with sympathetic nervous system changes but is not a disease of the sympathetic nervous system.
The IASP list diagnostic criteria for CRPS  as presence of an initiating noxious event or a cause of immobilization, allodynia or hyperalgesia disproportionate to the inciting event, evidence of edema, change in skin blood flow or abnormal sudomotor activity in the area of pain.
The treatment approach for CRPS and sympathetically maintained pain syndromes is multi-modal, which includes medications, sympathetic blockade and physiotherapy. Sympathetic blockade in upper extremity includes stellate ganglion block, cervical epidural sympathetic block, interscalene brachial plexus blocks and intravenous regional (Bier) block. The basis of physiotherapy is passive range of motion, isometric strengthening, to rehabilitate the joint or joints that are not functioning properly and to strengthen the muscles and to do this while the sympathetic blockade is in effect and a wide dynamic range of neurons are being rested.
Many different drugs are used to treat CRPS, including NSAIDs, topical analgesics, anti-seizure drugs, relaxants, antidepressants, hypnotics, corticosteroids, calcium channel blockers and upload. TENS and acupuncture may sometimes help. It may be necessary to remove a trigger zone e.g., small neuromas on peripheral nerves, which may be removed through the use of surgery, radiofrequency, alcohol or cryoneurolysis.
If the CRPS is from a compressed nerve, such as with carpal tunnel syndrome, then surgery to release pressure on the nerve may be needed (i.e., carpal tunnel release). Occasionally, surgical sympathectomy is used to divide the sympathetic nerves in patients that are helped by nerve blocks, but its use is controversial. Other options include spinal cord stimulation and intrathecal drug pumps, in which pain medications are injected continuously into the space around the spinal cord.
Stellate ganglion block is associated with Horner's syndrome, which includes ptosis, enophthalmos, and redness of the eye (conjunctiva) and may also lead to increased amplitude of accommodation, paradoxical contralateral eyelid retraction, transient decrease in intraocular pressure and changes in tear viscosity.
Although the standard practice is to use Inj. Xylocaine 1% but we preferred, Inj. Xylocaine 2% to have motor block, as the patient had intractable pain and severe hyperalgesia. The patient had hoarseness of voice for about 45 minutes but there were no signs of ptosis or drooping of eyelid.
We decided to go for continuous infusion at the interscalene groove for brachial plexus block and a single shot of local anesthetic at the stellate ganglion. Also, the continuous brachial plexus block would provide analgesia for both sympathetic and the somatic components of his pain.
Ultrasound visualization of anatomical structures offers safe blocks of superior quality by optimal needle positioning. In addition, the amount of local anesthetic needed for effective nerve block can be minimized by directly monitoring its distribution.  A study conducted by Chan et al on 188 patients undergoing elective hand surgery demonstrated that ultrasound guidance, with or without concomitant nerve stimulation, significantly improves the success rate of axillary brachial plexus block. 
Murray et al.  reported continuous brachial plexus block for successful management of reflex sympathetic dystrophy. Toshniwal et al.  compared the efficacy of continuous stellate ganglion (CSG) block with that of continuous infraclavicular brachial plexus (CIBP) block in management of CRPS type I of upper extremity in a group of 33 patients each. They used an infusion of 0.125% Bupivacaine at a rate of 2-5 ml/h. CIBP group showed statistically significant improvement in neuropathic pain scale score (NPSS) compared with CSG group during the first 12 hours after the procedures (P value <0.05). After 12 hours, the NPSS was comparable between the groups. At 4 weeks, both groups showed clinically significant improvement in edema score and range of movement of all upper extremity joints when compared with the baseline. This study concluded that CIBP block and CSG block may be effective interventional techniques for the management of CRPS type I of upper extremities.
Ribbers et al.  published a study of six patients of CRPS type I and II that benefitted from continuous axillary brachial plexus block. In another case report by Day et al.  a patient of longstanding CRPS I was successfully treated by continuous infraclavicular brachial plexus block. Everett et al.  in a case report describes the rapid resolution of an unusual presentation of CRPS type I after four days of treatment with a continuous sciatic peripheral nerve block and a concomitant parenteral ketamine infusion.
| Conclusion|| |
CRPS is a complex pain syndrome with many known and unknown etiologies and it's a challenging for treating physician and needs a multimodal approach. If the pain is out of proportion to any injury they have suffered, it should be assumed that the source is CRPS or sympathetically maintained pain until proven otherwise.
Most physicians believe that early treatment is helpful to limit the disability from CRPS. Patient should be referred to a pain specialist or to a pain center that specializes in the treatment of these conditions. The backbone of treatment for this disease is blocks, physical therapy, drugs and psychological counseling.
| References|| |
|1.||Datta S. Complex Regional Pain Syndrome (CRPS): Causes and Pain Management, Symptom Oriented Pain Management. In: Baheti et al. Delhi: Jaypee Medial Publishers; 2012. p. 406-15. |
|2.||Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med 2007;8:326-31. |
|3.||Marhofer P, Greher M, Kapral S. Ultrasound guidance in regional anaesthesia. Br J Anaesth 2005;94:7-17. |
|4.||Chan VW, Perlas A, McCartney CJ, Brull R, Xu D, Abbas S. Ultrasound guidance improves success rate of axillary brachial plexus block. Can J Anaesth 2007;54:176-82. |
|5.||Murray P, Floor K, Atkinson RE. Continuous axillary brachial plexus blockade for reflex sympathetic dystrophy. Anaesthesia 1995;50:633-5. |
|6.||Toshniwal G, Sunder R, Thomas R. Management of complex regional pain syndrome type I in upper extremity-evaluation of continuous stellate ganglion block and continuous infraclavicular brachial plexus block: A pilot study. Pain Med 2012;13:96-106. |
|7.||Ribbers GM, Geurts AC, Rijken RA, Kerkkamp HE. Axillary brachial plexus blockade for the reflex sympathetic dystrophy syndrome. Int J Rehabil Res 1997;20:371-80. |
|8.||Day M, Pasupuleti R, Jacobs S. Infraclavicular brachial plexus block and infusion for treatment of long-standing complex regional syndrome type 1: A case report. Pain Physician 2004;7:265-8. |
|9.||Everett A, Mclean B, Plunkett A. A unique presentation of complex regional pain syndrome type i treated with a continuous sciatic peripheral nerve block and parenteral ketamine infusion: A case report. Pain Med 2009;10:1136-9. |