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Systemic Complications of Complex Regional Pain Syndrome

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Systemic Complications of Complex Regional Pain Syndrome Neuroscience & Medicine, 2012, *, **-** doi:10.4236/nm.2012.***** Published Online *** 2012 (http://www.scirp.org/journal/nm) Systemic Complications of Complex Regional Pain Syndrome Robert J. Schwartzman, M.D. Department of Neurology, Drexel University College of Medicine, Philadelphia, PA, USA Email: [email protected] Received July 17, 2012. ABSTRACT Complex Regional Pain Syndrome (CRPS) is a neuropathic pain disorder that is characterized by: (1) severe pain beyond the area of injury; (2) autonomic dysregulation; (3) neuropathic edema; (4) a movement disorder, atrophy and dystrophy. It is most often caused by a fracture, soft-tissue injury or surgical procedure and is divided into Type I, in which no nerve lesion is identified (classic reflex sympathetic dystrophy), and Type II where a specific nerve has been damaged (causalgia). In addition to the peripheral manifestations, there are many internal medical complications whose etiology is often not appreciated. This article will examine how CRPS affects the systems of: cognition; constitutional, cardiac, and respiratory complications; systemic autonomic dysregulation; neurogenic edema; musculoskeletal, endo- crine and dermatological manifestations; as well as urological and gastrointestinal function. Keywords: Complex Regional Pain Syndrome; CRPS; CRPS-1; CRPS-2; Chronic pain; Reflex Sympathetic Dystrophy; RSD 1. Introduction spread from the site or original injury, is long standing and comprises all components of the syndrome [4]. The Complex Regional Pain Syndrome (CRPS) is a neu- present diagnostic criterion requires at least one symp- ropathic pain disorder that is characterized by: (1) severe tom in each of the four factors and one sign in at least pain beyond the area of injury; (2) autonomic dysregula- two of the four factors [7]. In general, early in the course tion; (3) neuropathic edema; (4) a movement disorder, of the disease patients demonstrate prominent inflam- atrophy and dystrophy [1]. It is most often caused by a matory signs and symptoms that include neurogenic fracture, soft-tissue injury or surgical procedure and is edema, erythema and an increased temperature of the divided into Type I, in which no nerve lesion is identi- affected extremity while long standing patients suffer fied (classic reflex sympathetic dystrophy), and Type II pain spread and an apparent centralization of the process where a specific nerve has been damaged (causalgia). with concomitant severe generalized autonomic motor Converging evidence suggests that CRPS-I is due to in- and trophic changes of skin, nails, bone and muscle [1, jury and distal degeneration of axons and terminal twigs 8-11]. of A-δ and C fibers [2]. Cluster analysis reveals that the The epidemiology of the syndrome is uncertain. Many signs and symptoms in the syndrome comprise four dis- patients diagnosed with fibromyalgia clearly have CRPS, tinct groups: (1) abnormalities in pain processing (me- the pressure points being components of the brachial chanical and thermal allodynia; hyperalgesia, and hy- plexus, the intercostobrachial (ICB) nerve and concomi- perpathia); (2) temperature change and erythema, cyano- tant L -S , injury [12, 13]. The most representative sis or mottling; (3) neurogenic edema and sudomotor 5 1 population-based study from the Netherlands revealed an dysregulation; (4) a motor syndrome and trophic changes incidence of 40.4 females and 11.9 males per 100,000 [3-7]. There may be subtypes: (1) a limited syndrome person-years at risk [14]. The variable incidence reported with predominant autonomic dysregulation; (2) a syn- are due to the cohorts studied, the time period in the drome limited to one extremity that is characterized by course of the disease in which they were studied and the neuropathic pain with minimal autonomic dysregulation skill of the examiners [15-19]. and neurogenic edema; (3) a severe disorder that has Copyright © 2012 SciRes. NM 2 Systemic Complications of Complex Regional Pain Syndrome The purpose of this article is to discuss the systemic ward. This function is thought to demonstrate medical complications of CRPS. As Janig has pointed higher-order mental manipulation that depends on work- out, with time CRPS centralizes to affect somatosensory, ing memory and visual imagery mechanisms [26]. There autonomic and limbic components of the syndrome [20]. is also evidence that decreased output on letter fluency The immune component of neuropathic pain is now and poor performance on a backwards digit span test are viewed as pivotal to both in its initiation and mainte- correlated with left inferior frontal lobe pathology [34] . nance. Many of the features seen peripherally occur in CRPS group III patients’ memory deficits suggest execu- systemic organs. tive (retrieval) rather than amnesic (encoding) dysfunc- tion. The improvement of this group in the delayed rec- 2. Neuropsychological Deficits Associated ognition test suggests impairment of frontal memory with CRPS systems [38]. This detailed evaluation of over 500 pa- tients suggests that a wide network of cortical and sub- Severe neuropathic chronic pain is associated with poor cortical anatomical nodes is involved in the illness and performance on neuropsychological tests that assess that a dysexecutive syndrome is the primary deficit. A working memory, language and executive function neurocognitive study on nine patients prior to and fol- [21-23]. Patients whose pain was due to a variety of un- lowing a ketamine anesthesia protocol [39] by Koffler derlying medical conditions demonstrated decreased demonstrated improvement in brief auditory attention information processing speed [24]. and processing speed [40] . Levels of depression and Over 500 patients with severe CRPS (met all IASP cri- extent (number of limbs involved) or duration of illness teria [25]) underwent a battery of neuropsychological is not a factor in these cognitive changes. tests that assesses executive systems function, naming/ Functional MRI (fMRI) studies in patients with CRPS- lexical retrieval, memory and learning prior to treatment I and II have given insights into cognitive function and with an outpatient ketamine protocol. The assessment activity dependent neuroplasticity in this illness. There is method is based on the work of Libon et al [26]. Execu- clear alteration of the CRPS hand representation in the tive system function was measured by the digit span primary somatosensory cortex (SI) cortex of the affected subtest from the Wechsler Adult Intelligence Scale – III versus unaffected side [41-44]. The side opposite the (WAIS-III) [27] . The digits backward portion of the test affected hand is decreased or increased [44] in parallel was used to evaluate working memory deficits [28, 29]. with the degree of mechanical hyperalgesia and pain Executive function was also evaluated by tests of letter intensity [41, 42] which reversed with recovery [42] fluency which activate the left dorsolateral prefrontal [43]. In a recent study, patients with CRPS estimated cortex in both young and older patients [30]. Naming their hand size of the affected extremity to be larger was assessed with the Boston Naming Test [31] and when compared to expanded or compressed schematic lexical retrieval by a test of semantic fluency [32]. drawings of hands. The overestimation correlated with Converging evidence supports category fluency tests as a disease duration, increased two-point discrimination and measure of lexical retrieval and semantic knowledge that neglect score [44]. In addition to tactile and propriocep- activate the left temporal lobe [33, 34]. Memory and tive deficits [45], a significant proportion of CRPS pa- learning was evaluated by the California Verbal Learn- tients feel as if their hand is “foreign or strange” [46] or ing Test – II [35]. Delayed free recall and delayed recog- not belonging to their body [47]. Studies with fMRI dur- nition discrimination index have been linked to parahip- ing electrical stimulation of both index fingers revealed pocampal atrophy and the presence of anterograde am- smaller signals in both contralateral SI and secondary nesia [29]. Adjunctive tests administered with the above somatosensory cortices (SII) that were associated with were the McGill Pain Inventory [36] and the Beck De- impaired 2-point discrimination deficits. This suggests pression Inventory – II [37]. The patterns of neuropsy- that patterns of cortical reorganization in both SI and SII chological impairment seen in this large cohort of CRPS parallel impaired tactile discrimination [48] and pain patients were determined by a statistical cluster algo- intensity. In addition to plastic aberrations of the body rithm which demonstrated three distinct groups. Ap- schema in CRPS patients, increased activation of areas proximately 35% of patients had no neuropsychological thought to process affective components of pain, the deficits, group I. The second, group II, 42% of patients cingulate gyrus and frontal cortices have been demon- had mild dysexecutive deficits. Group III, 22% of pa- strated that may persist after recovery [41, 49]. A recent tients had cognitive impairment that included poor per- paper describes the neuropsychological dissociation in formance on tests of executive function, naming and which a CRPS patient had preservation of object recog- memory. Both affected CRPS groups II and III (65%) of nition and naming but was unable to recognize object patients) had difficulty with repeating numbers back- orientation (agnosia for object
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