Indian Journal of Pain

CASE REPORT
Year
: 2017  |  Volume : 31  |  Issue : 3  |  Page : 186--190

Use of sequential diagnostic pain blocks in a patient of posttraumatic complex regional pain syndrome-not otherwise specified complicated by myofascial trigger points and thoracolumbar pain syndrome


Kailash Kothari1, Khushali Tilvawala2, Parth Shah2, Ankur Garg2,  
1 Department of Pain management, Pain Clinic Of Pvt. Ltd; Department of Anesthesia and Pain management – King Edward Memorial (KEM) Hospital, Mumbai, Maharashtra, India
2 Fellow of Pain Medicine, Pain Clinic of Pvt Ltd, Mumbai, Maharashtra, India

Correspondence Address:
Kailash Kothari
2005/A, Cosmic heights, Bhakti Park, Wadala East, Mumbai - 400 037
India

Abstract

We are presenting a case of posttraumatic lower limb Complex regional pain syndrome – Not otherwise specified (CRPS – NOS). As it was not treated in acute phase, the pain became chronic and got complicated by myofascial and thoracolumbar pain syndrome. This case posed us a diagnostic challenge. We used sequential diagnostic pain blocks to identify the pain generators and successfully treat the patient. We used diagnostic blocks step by step to identify and treat pain generators – T12,L1 and L2 Facet joints, Lumbar sympathetic block for CRPS NOS and Trigger point injection with dry needling for myofascial pain syndrome. This case highlights the facet that additional pain generators unrelated to original pain may complicate the presentation. Identifying these pain generators requires out of box thinking and high index of suspicion.



How to cite this article:
Kothari K, Tilvawala K, Shah P, Garg A. Use of sequential diagnostic pain blocks in a patient of posttraumatic complex regional pain syndrome-not otherwise specified complicated by myofascial trigger points and thoracolumbar pain syndrome.Indian J Pain 2017;31:186-190


How to cite this URL:
Kothari K, Tilvawala K, Shah P, Garg A. Use of sequential diagnostic pain blocks in a patient of posttraumatic complex regional pain syndrome-not otherwise specified complicated by myofascial trigger points and thoracolumbar pain syndrome. Indian J Pain [serial online] 2017 [cited 2019 Dec 12 ];31:186-190
Available from: http://www.indianjpain.org/text.asp?2017/31/3/186/223671


Full Text



 Introduction



Posttraumatic neuropathic pain is known phenomenon. Many patients develop complex regional pain syndrome (CRPS). Few patients do not have all the signs and symptoms to be categorized them in CRPS I or II. These patients are now diagnosed as CRPS-not otherwise specified (CRPS-NOS).[1] Many such patients are complicated by other conditions, which may not be related to their original pain condition. Many a times, it is very difficult to differentiate between these conditions. Diagnostic pain management blocks are very useful tools to help physician know about pain generator. Sequential diagnostic blocks (with some time interval between two) in such complex patients are very useful to reach a proper diagnosis and in turn helps in treating different causes of the pain in the same patient. Using multiple pain blocks at the same time takes away the diagnostic information of the procedure. This case is a very good example of using sequential diagnostic pain blocks in confirming the diagnosis and treating the patient successfully.

 Patient Presentation



A 31-year-old female, software engineer by profession was presented to us with complaints of severe pain (NRS 8/10) in the right mid and low back, thigh, gluteal region, and lower limb. Pain starts from the gluteal area and radiates down the lower limb. Mid back pain on the right paraspinal area was dull, aching in nature while gluteal and leg pain was sharp, burning, associated with severe hypersensitivity, and difficulty in wearing cloths. The pain was constant and interfered with her work. Pain increased by sitting, standing, walking, and exertion [Figure 1].{Figure 1}

History in detail

The patient had a history of fall and trauma over foot 1 year back, which was managed conservatively (at other clinics and hospitals).

After 2 months of initial injury, patient gradually developed severe pain (NRS 8/10) which was sharp, which was sharp, burning in nature, radiating upwards, towards the thigh and gluteal region starting from the right foot. Associated with paraesthesia and hypersensitivity in the right lower limb, ankle pain, and brownish discoloration around the injury area [Figure 2].{Figure 2}

Patient was diagnosed as having reflex sympathetic dystrophy by primary physician. She was advised physiotherapy, TENS, ultrasound, and oral medication (amitriptyline, steroids). Pain did not reduce.

At 3 months, there was severe pain and spasm of the back. Pain was radiating to posterior thigh and gluteal region starting from the foot. Patient underwent magnetic resonance imaging (MRI) LS spine. It showed L4–L5 level mild central disc bulge with facet arthropathy. Right-sided L4 and L5 transforaminal epidural steroid injection and medial branch block at L4, L5 (MBB) were performed at other hospital. She had 20%–30% pain relief for 2–3 days. After 3 days, pain was back to same.

At 7 month, she started getting severe pain and spasm of hip, buttock, and thigh region. Pain was continuous, stabbing in nature, associated with burning with swelling and pink discoloration of the foot around injury site. Now, she was feeling heaviness and tightness in the upper back (new symptom) and gluteal region. Now pain started from mid back and radiated downward toward thigh and right side of the foot. NRS was 6/10. She underwent chirotherapy (12 sessions), IFT, manual manipulation and SI joint injection over the period of 2 months. Muscle tightness and heaviness decreased. Pain decreased 30% for 1–2 months. However, she had constant ongoing moderate pain which was not responding to any medication.

At 11 months, she presented to orthopedic surgeon with severe pain in the hip region, for which she underwent MRI hip, which was suggestive of acetabular labrum tear. She underwent manipulation of hip joint under GA followed by intraarticular steroid injection. Postinjection, she was advised to do physiotherapy 1 h/day for 5 days. Pain did not reduce.

All the blood investigations throughout the time period of 1 year (CBC, ESR, BUN/CREAT, FBS/PPBS, CRP, Vit B12, FOLIC ACID, URIC ACID, HLA B27, ANA, RA FACTOR, anti CCP Antibodies, andS. PROLACTIN) were normal except for Vit D deficiency (18.7 ng/ml), which was corrected over next few months to 52.9 ng/ml.

Over the period of 1 year, she was prescribed neuropathic drugs (gabapentin 900 mg/d, pregabalin 150 mg/d, and amitriptyline 75 mg/d), muscle relaxants (tizanidine 6 mg/d, chlorzoxazone 1000 mg/d), steroids (deflazacort 18 mg/d and tapering doses), mild opioids (tramadol), nonsteroidal anti-inflammatory drugs, and various health supplements (mega free flex, chymoral forte, S-adenosyl methionine, and methylcobalamin) by different practitioners with very little or no relief.

During first consultation at our clinic

On examination, patient had antalgic gait, severe allodynia over the right gluteal region. Tenderness was present in the right paraspinal region from thoracic region to buttocks. Faber on the right side was positive, statutory liquidity ratio was 50° on the right side, paraspinal muscle spasm was present, right T11-L3 facets were very tender with moderate pressure on palpation.

As patient had already undergone various procedures in the past 1 year, she was advised for sequential diagnostic block to identify the pain generators. After proper counseling, discussion about risk/benefit ratio, and detailed plan of diagnostic blocks she gave consent.

Right-sided T12-L2 diagnostic MBB performed with 1 ml 0.5% bupivacaine at each level – upper back pain was relieved by 90%. However, gluteal and leg pain persisted at 1 h postprocedureOn reexamination trigger points (TrPs) were palpated in piriformis and gluteus medius [Figure 3].{Figure 3}

As per plan, we performed fluoroscopy-guided piriformis injection using 0.5% bupivacaine 7 ml. She reported no change in her pain at 1 h postinjection.

TrP injection on gluteus medius muscle was performed with injection. Bupivacaine 0.5% 2 ml at each point. There was 70% pain relief in gluteal region and 20% relief in leg pain.

The patient was diagnosed with thoracolumbar syndrome + myofascial pain syndrome (MPS) causing her mid back and gluteal pain, respectively.

On follow-up after 10 days, the upper back pain was relieved but gluteal and leg pain was persistent (NRS 7/10). The pain was continuous. On examination, the right side faber test was + ve, right SI joint was tender, and TrPs were present over gluteal and anterior thigh areas.

With her signs and symptoms, we decided to perform right SI joint injection (20 mg triamcinolone +0.5% bupivacaine 1 ml). Pain in the gluteal region was relieved by 40% but leg pain with burning and hypersensitivity still persisted. The patient had minimal relief in her symptoms at 1 week post-SI joint injection. She was asked to wait for 1 more week to see if steroid effect can be seen in another 1 week.

After 14 days, gluteal pain persisted with continuous leg pain associated with burning and hypersensitivity. Pain at local injury site (dorsum of right foot) was present (NRS 8/10).

She was suspected to have sympathetically mediated neuropathic pain, and diagnostic Lumbar sympathetic block was given. 10 ml 0.25% bupivacaine was given at right L2 and L4 level under fluoroscopy guidance (5 ml at each level).

Postprocedure right leg burning and paresthesia were relieved up to 90%. Myofascial gluteal, thigh and calf pains were still present. tablet Paracetamol 325 mg + tramadol 37.5 mg, tolperisone 150 mg BD and tablet etoricoxib 90 mg were given postoperatively.

Ten days postlumbar sympathetic block (LSB), overall pain relief was about 50%–60% (NRS– 6/10). Burning and hypersensitivity were absent (NRS 0/10). She could walk for 10–15 min without pain and was able to sit for 30 min. Now, her pain increased with exertion with walking for >15 min. It was also interfering with her work. She was unable to sit for more than 40-45 min. Pain was localized to the right gluteal, thigh and calf, which had dull aching character. On examination, multiple TrP along with tightness of muscle was present in the right gluteal, and thigh and calf regions.

Gluteal TrP + dry needling (gluteal, anterior, posterior and lateral thigh and calf) performed and muscle relaxant (tablet Tolperisone 150 mg for 7 days) was prescribed.

On the follow-up visit after 7 days, pain reduced to 40% (NRS– 5/10). The patient was able to do office work and could sit for prolonged period (2–3 h). The pain was worsening with exertion. Examinations revealed three TrP in gluteal region. She underwent TrP injection + dry needling (gluteal and anterior thigh region).

She underwent total five sessions of dry needling in gluteal, thigh and calf regions over the period of 2 months. Pain relieved by about 95%. Little pain is present after prolonged exertion (6 h), and patient is now able to sit for prolonged period (8–9 h) and returned to her routine daily activity.

 Discussion



Posttraumatic neuropathic pain is not an uncommon occurrence.[1] Early diagnosis and treatment hold key for a successful outcome.

In this case, posttraumatic neuropathic pain could explain her leg pain. However, her mid back pain and gluteal pain were not explained by this diagnosis.

Myofascial pain is quite common in computer professional due to improper posture, long working hours, and lack of exercises.[2]

Here, the question arises about which diagnostic block to be first and which should be later. There is no set protocol. This is usually at treating physician discretion. Here, in CRPS of lower limb, we expect pain in the lower limb and may be gluteal area. However, this condition does not explain the mid back pain, which was equally severe. Another reason is that the mid back (Thoracolumbar pain syndrome) might be reason for her gluteal pain. The referral pattern commonly is from superior to inferior structures, not a vice versa. Another point was that she was not fitting into CRPS picture completely. Considering all these, after discussion with patient in detail, we decided to go for diagnostic T12-L2 MBB first and then other procedures. In other scenario, lumbar sympathetic block can be selected first if physician is surer about her CRPS status.

Thoracolumbar syndrome results from irritation of the thoracolumbar facet joints. Pain from these joints gets referred to the distribution of the cluneal nerves from T12, LI, and L2 [Figure 4].{Figure 4}

The posterior ramus supplies the subcutaneous tissue of the upper buttocks and lower waste, while the anterior ramus and the lateral cutaneous branch supply lower abdomen, groin, and trochanter, respectively. Therefore, patients may complain of pseudovisceral pain in the lower abdomen, pseudosciatica, pubic tenderness, and irritable bowel symptoms besides low back pain, which can lead to misdiagnosis.[3] Treatment includes manipulation, infiltration with corticosteroids, electrocoagulation and/or surgical denervation of the involved zygapophyseal joint.[4]

We performed MBB at T12–L2. The patient reported immediate relief of her mid back pain. This pain relief was long lasting and did not recur. This proved the fact that this pain was not related to her gluteal and leg pain, which were of same severity and character postprocedure.

We examined the patient for gluteal pain. We found severe pain on palpation over piriformis muscle. The piriformis test was positive. However, postpiriformis injection of local anesthetic patient had no relief at all.

We re-examined the patient. TrP's were identified and marked [Figure 2]. We performed gluteus medius trigger point injections. Patient had 70% relief in her gluteal pain. However, leg pain, burning, and hyperalgesia persisted.

At 10 days postinjection, her gluteal pain was still bad (7/10) with persistent leg pain of same severity. On examination, she had severe SI tenderness with positive Faber test and Fortin finger-point tests. It is known that SI can produce severe gluteal pain with leg pain mimicking S1 radicular pain.[5] She already had one SI joint injection in the past, but due to strong clinical suspicion, we decided to perform SI joint local anesthetic with steroid injection. Addition of steroid in SI joint makes it diagnostic + therapeutic block. We decided to add steroid, as it does not interfered in diagnostic value of the test. She had no relief in her symptoms at the end of 2 weeks after the procedure. At this time, her neuropathic leg pain and gluteal pain were 8/10.

This patient developed severe neuropathic pain postinjury. She had signs and symptoms, which were not enough to, categorized her as CRPS.

CRPS is described as an array of painful conditions characterized by a continuing (spontaneous and/or evoked) limb pain that is seemingly disproportionate in time or degree to the usual course of any known trauma or other lesion. The pain is regional (not in a specific nerve territory or dermatome) and usually has a distal predominance of abnormal sensory, motor, sudomotor, vasomotor, and/or trophic findings.[6]

CRPS is a clinical diagnosis based on patient symptoms and signs elicited on physical examination. The IASP diagnostic criteria have very good sensitivity (0.99), but poor specificity (0.41), leading to over diagnosis. The Budapest clinical diagnostic criteria retain the sensitivity of the IASP criteria but improve the specificity (0.68) [Table 1].[1],[6]{Table 1}

The IASP Budapest consensus group retained the division of CRPS into Types I and II subtypes depending on the absence or presence of evidence of peripheral nerve injury, respectively. Approximately 15% of the patients previously diagnosed as CRPS according to 1994 IASP criteria, failed to fulfill the new clinical criteria. Hence, they recommended a third diagnostic subtype called CRPS-NOS. Patients who have fewer than three symptoms or two sign categories, or who were not showing a sign at the time of the examination, but had exhibited this previously, and whose signs and symptoms were felt to be best explained by CRPS would receive a diagnosis of CRPS-NOS [Table 1].[1],[6]

When the patient presented to us, she had severe burning pain, hypersensitivity, and allodynia. Considering all her symptoms and signs at first consultation and previous history, we diagnosed her as a case of CRPS-NOS.

LSB nerve has been used to treat sympathetically mediated pain conditions such as complex regional pain syndrome, failed back surgery syndrome, peripheral vascular diseases, and Raynaud's disease.[7]

Patient's burning leg pain and hypersensitivity were markedly improved after LSB, but dull aching pain with palpable TrPs was still present over the gluteal, thigh and calf areas. These areas were treated with TrP injections and dry needling of the muscles (adductor longus, adductor brevis, adductor magnus, tensor fascia lata, biceps femoris, semimembranosus, semitendinosus, and gastrocnemius).

MPS is the sensory, motor, and autonomic symptoms caused by myofascial TrPs. Myofascial TrP is a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. The spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction, and autonomic phenomena.[8]

Perpetuating factors for the myofascial TrP are mechanical stress of the muscles (poor posture, abuse of muscles, immobility, and repetitive movement), nutritional inadequacies, metabolic and endocrine inadequacies, psychological factors, chronic infection and infestation, and nerve impingement.[9]

Dry needling of muscles is a known treatment for chronic myofascial pain.[10],[11] After performing five sessions of TrP injections + dry needling of above-mentioned muscles, patient got almost 95% relief from the pain and returned to daily activity.

Chang [12] observed similar cases where overlapping symptoms of posttraumatic CRPS with myofascial TrP s were present. He treated them with sympathetic block (lumbar epidural injection) and TrP injections at weekly intervals. He concluded that TrP injection with sympathetic nerve blockade can be the most effective method for the management of CRPS. In our view, performing two procedures simultaneously is not ethical. As patient responded to this treatment, physician does not know which procedure benefitted the patient. By assuming that both the procedures are relieving patient's pain, patient was treated with both the procedures on every visit. In our experience, it is better to perform one procedure at a time and assess its effectiveness. Our patient responded to sympathetic block very well, and her neuropathic component got relieved. Her myofascial component still persisted which was then treated successfully by TrP injections and dry needling. In this way, we have evidence that the two conditions are different and need different treatment.

 Conclusion



Posttraumatic CRPS is not a very uncommon condition. There are some neuropathic pain patients who do not fit into Budapest IASP criteria and are categorized as CRPS-NOS. This case is unique as it has three different problems – CRPS-NOS, myofascial TrPs, and postural thoracolumbar syndrome (facet joint pain). Some patients do have pain conditions, which might be unrelated to primary condition. Use of diagnostic nerve block is very important in such situations. If we perform multiple diagnostic injections simultaneously, the diagnostic value is lost. We strongly recommend performing and assessing each diagnostic block separately for maintaining the diagnostic value of the procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Sebastin SJ. Complex regional pain syndrome. Indian J Plast Surg 2011;44:298-307.
2Mohandoss M, Sharan D, Ranganathan R, Jose J. Co morbidities of myofascial neck pain among information technology professionals. Ann Occup Environ Med 2014;26:21.
3Maigne R. Diagnosis and Treatment of Pain of Vertebral Origin: A Manual Medicine Approach. Baltimore: Williams & Wilkins; 1996.
4Maigne R. Low back pain of thoracolumbar origin. Arch Phys Med Rehabil 1980;61:389-95.
5Fortin JD, Dwyer AP, West S, Pier J. Sacroiliac joint: Pain referral maps upon applying a new injection/arthrography technique. Part I: Asymptomatic volunteers. Spine (Phila Pa 1976) 1994;19:1475-82.
6Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med 2007;8:326-31.
7de Oliveira R, dos Reis MP, Prado WA. The effects of early or late neurolytic sympathetic plexus block on the management of abdominal or pelvic cancer pain. Pain 2004;110:400-8.
8Simons DG, Travell JG, Simons LS. Introduction Glossary. In: Johnson EP, editor. Myofascial Pain and Dysfunction: The Trigger Point Manual. Part I. Ch. 1. Baltimore: Williams & Wilkins; 1999. p. 1-10.
9Simons DG, Travell JG, Simons LS. Perpetuating factors. In: Johnson EP, editor. Myofascial Pain and Dysfunction: The Trigger Point Manual. Ch. 4. Baltimore: Williams & Wilkins; 1999. p. 178-235.
10Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, et al. Acupuncture and dry-needling for low back pain: An updated systematic review within the framework of the Cochrane collaboration. Spine (Phila Pa 1976) 2005;30:944-63.
11Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: A systematic review. Arch Phys Med Rehabil 2001;82:986-92.
12Chang SH. Complex regional pain syndrome is a manifestation of the worsened myofascial pain syndrome: Case review. J Pain Relief 2017;6:294.