Complex Regional Pain Syndromes
Conclusion. When managed early, patients complicated
with CRPS after TKA have a similar prognosis
to patients with uncomplicated TKA.Complex regional pain syndrome complicating
total knee arthroplasty
AWR Burns, DA Parker, MRJ Coolican, K Rajaratnam Journal of Orthopaedic Surgery 2006;14(3):280-3 full text
Reflex sympathetic dystrophy syndrome (RSDS) has been recognized since the Civil War when it was called causalgia, a name chosen to describe intense, burning extremity pain after an injury. Since then, RSDS has had a number of name changes. Bonica coined the term reflex sympathetic dystrophy in 1953. The American Association of Hand Surgery proposed changing the name to sympathetic maintained pain syndrome. A consensus expert panel recommended a change to complex regional pain syndrome (CRPS). However, although many clinicians still use the term RSDS, the terms currently in favor are complex regional pain syndrome I (the equivalent of RSD) and complex regional pain syndrome II, also known as causalgia.
CRPS/RSDS has readily identifiable signs and symptoms and is treatable if recognized early; however, the syndrome may become disabling if unrecognized. Emergency physicians are frequently in a position to identify the problem and may play a significant role in minimizing impact of this common entity.
Synonyms and related keywords: RSDS, RSD, reflex sympathetic dystrophy syndrome, causalgia, sympathetic maintained pain syndrome, complex regional pain syndrome, CRPS, CRPS I, CRPS II, peripheral nerve injury, complex regional pain syndrome I, complex regional pain syndrome II
Steven J Parrillo, DO, FACEP 2008
Complex regional pain syndrome (CRPS) may develop as a disproportionate consequence of a trauma affecting the limbs without nerve injury (CRPS I, or reflex sympathetic dystrophy [RSD]) or with obvious nerve lesions (CRPS II, or causalgia).
Synonyms and related keywords: complex regional pain syndrome, CRPS, complex regional pain syndrome I, CRPS I, reflex sympathetic dystrophy, RSD, complex regional pain syndrome II, CRPS II, causalgia, mimo-causalgia, Sudeck atrophy of bone, shoulder-hand syndrome, algoneurodystrophy, reflex dystrophy, reflex neurovascular dystrophy
Singh et al 2008
Synonyms (commonly used interchangeably although they are not strictly speaking all the same entity): reflex sympathetic dystrophy, causalgia, Sudeck's atrophy, post traumatic dystrophy, shoulder hand dystrophy, reflex neurovascular dystrophy.
In 1979, the International Association for the Study of Pain (IASP) stated that pain is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or, is described in terms of such damage” and in 1994, it went on to specify that "Pain is always subjective. Each individual learns the applications of the word through experiences relating to injuries in early life”.
CRPS is a complex and poorly understood condition. It is typically characterised by segmental limb pain after a (usually) relatively minor injury to a limb but is more severe and lasts much longer than would normally be expected given the injury. It may also encompass a range of problems involving one or more of the nerves, skin, muscles, blood vessels and bone. Occasionally, it affects parts of the body other than the limbs and it may also arise in the absence of injury. It is thought to arise as a result of abnormal sympathetic nerve healing following trauma although the exact pathophysiology still remains very much a mystery.
Purpose. To evaluate the role of sympathetic skin
response (SSR) and three-phase bone scintigraphy
(TPBS) in the diagnosis of complex regional pain
Conclusion. TPBS is a very sensitive corroborative test to confirm the clinical suspicion of CRPS during the initial stages, but not in late cases. SSR can be used to document the sympathetic dysfunction in cases
having an associated sweating abnormality and may
have some diagnostic value in late cases of CRPS,
when TPBS is less reliable.
Diagnosis of post-traumatic complex regional
pain syndrome of the hand: current role of
sympathetic skin response and three-phase
A Pankaj, PP Kotwal, R Mittal, KK Deepak, CS Bal
Journal of Orthopaedic Surgery 2006;14(3):284-90 full text
Wheeless' Textbook of Orthopaedics
“RSD” is an imprecisely used term; has been used to describe changes in soft tissue and bone;
- RSD may not involve the sympathetic nervous system and may not be the consequence of a reflex;
- 1995: IASP Consensus Conference: “Complex regional pain syndrome” replaced RSD
- CRPS Type 1: noxious event;
Type 2: nerve injury (causalgia)
- pain/hyperalgesia not limited to single nerve distribution, disproportionate to inciting event
- described as abnormal pain, swelling, vasomotor instability, contracture, and osteoporosis following injury or noxious stimulus.
- CRPS: other names
- reflex sympathetic dystrophy, Sudeck’s atrophy, causalgia (minor and major), algodystrophy, shoulder-hand syndrome,
post-traumatic pain syndrome, Painful post-traumatic osteoporosis, Transient migratory osteoporosis
Reflex Sympathetic Dystrophy aka RSD, Sudek's Atrophy
Reflex Sympathetic Dystrophy (RSD) affects extremities. It is also known as
Etiology unknown but felt to be neural s/p
Trauma of any degree.
Myocardial infarction (usually left hand).
Clinically, one observes
Skin findings including STS, hyperthesia, vasomotor changes.
Radiographically, there is
Prominent periarticular osteopenia.
Preservation of joint space. (very important).
Increased uptake on bone scan.
Rarely, only a segment of an extremity is involved.
Prognosis is variable
Some cases last for years and may become irreversible.
Various arthridities (erosions and/or loss of joint space should be present.)
Osteoporosis and syndromes associated with osteoporosis.
Sudeck dystrophy, causalgia, shoulder-hand syndrome, post-traumatic osteoporosis
* pain, tenderness, soft tissue swelling out of proportion to injury
* vasomotor instability (Raynaud, vasoconstriction/-dilation)
* end stage (6-12 months): contractures, atrophy (skin and soft tissues)
* location: hands and feet distal to injury
* injury (fracture, frost bite; may be trivial)
* myocardial infarction
* periarticular soft tissue swelling
* patchy dimineralization
* increased uptake (periarticular) on bone scan
* perfusion and blood pool phases not sensitive
RSD is a descriptive term meaning a complex disorder or a group of disorders that may develop as a consequence of trauma affecting the limbs, with or without an obvious nerve lesion. RSD also may develop after visceral diseases or CNS lesions or, rarely, without an obvious antecedent event. It consists of pain and related sensory abnormalities, abnormal blood flow and sweating, abnormalities in the motor system, and changes in structure of both superficial and deep tissues ("trophic" changes). Not all components need be present.
Synonyms and related keywords: acute peripheral trophoneurosis, algodystrophy, causalgia, chronic traumatic edema, mimocausalgia, neurovascular posttraumatic painful syndrome, neurovascular reflex dystrophy, neurovascular reflex sympathetic dystrophy, posttraumatic chronic edema, posttraumatic osteoporosis, posttraumatic pain syndrome, posttraumatic sympathetic dystrophy, RSD, shoulder-hand syndrome, spreading neuralgia, Sudeck atrophy, sympathalgia, thermalgia, traumatic angiospasm, traumatic vasospasm, complex regional pain syndrome type 1, CRPS
Eugenia-Daniela Hord, MD & Sajjad Mueed, MD 2006
Author: Satishchandra Kale, MD, FRCS 2005
Reflex sympathetic dystrophy (RSD) is a condition that is often described under various synonyms that point to its incompletely understood etiology. In 1864, Weir Mitchell coined the term causalgia to designate severe pain following nerve injury. In 1900, Sudeck described regional demineralization accompanying posttraumatic pain. In 1923, Leriche described vasomotor disequilibrium. In 1947, Evans introduced the term reflex sympathetic dystrophy. In 1993, the International Association for the Study of Pain renamed algodystrophy complex regional pain syndrome (also known as chronic regional pain syndrome or CRPS).
Synonyms and related keywords: RSD, algodystrophy, Sudeck atrophy, painful dysfunction syndrome, reflex neurovascular dystrophy, shoulder-hand syndrome, chronic regional pain syndrome, CRPS, causalgia, complex regional pain syndrome, sympathetically mediated pain syndrome, SMP, algodystrophy complex regional pain syndrome
Reflex sympathetic dystrophy (RSD) is an incompletely understood response of the body to an external stimulus, resulting in pain that usually is nonanatomic and disproportionate to the inciting event or expected healing response. As early as the 1930s and 1940s, a short circuit in the reflex arc between somatic afferent sensory fibers and autonomic sympathetic efferents was postulated to explain overall increased sympathetic stimulation. Currently, no specific pathologic, histologic, or biochemical markers of this condition exist.
Although controversy continues regarding the term, definition, and process of diagnosis, the presence of sympathetically maintained pain is accepted as an etiology for, or at least as a significant component of, many regional pain problems.
Synonyms and related keywords: complex regional pain syndrome type I, CRPS-I, sympathetically mediated pain syndrome, SMPS, causalgia, algodystrophy, algodynia, Sudek's atrophy, Sudek atrophy, shoulder-hand syndrome, RSD
Lawrence E Holder, MD 2005
Reflex sympathetic dystrophy (RSD) is a clinical syndrome of variable course and unknown cause characterized by pain, swelling, and vasomotor dysfunction of an extremity. This condition is often the result of trauma or surgery. In 1864, Mitchell referred to this malady as causalgia, a Greek word meaning burning pain. Newer taxonomy refers to RSD as a type of complex regional pain syndrome (CRPS), which may develop after an initiating event such as trauma or surgery or may occur spontaneously.1 Under this classification, causalgia is a type of CRPS that develops after nerve injury. In patients with either of these conditions, sympathetic mediation of the pain (ie, improvement with sympathetic blockade) may or may not be evident.
Synonyms and related keywords: reflex sympathetic dystrophy, RSD, causalgia, Sudeck's atrophy, Sudeck-Leriche syndrome, minor traumatic dystrophy, major traumatic dystrophy, shoulder-hand syndrome, neurovascular dystrophy, post-traumatic vasomotor disorder, sympathetic neurovascular dystrophy, post-traumatic vasospasm, postinfarct sclerodactyly, traumatic angiospasm, transient regional osteoporosis, algodystrophy, complex regional pain syndrome, CRPS
Revis, Goldberg & Weinstein 2007
During the chronic stage of Complex Regional Pain Syndrome (CRPS), impaired microcirculation is related to increased vasoconstriction, tissue hypoxia, and metabolic tissue acidosis in the affected limb. Several mechanisms may be responsible for the ischemia and pain in chronic cold CPRS.
The diminished blood flow may be caused by either sympathetic dysfunction, hypersensitivity to circulating catecholamines, or endothelial dysfunction. The pain may be of neuropathic, inflammatory, nociceptive, or functional nature, or of mixed origin.
Regulation of peripheral blood flow in Complex Regional Pain Syndrome: clinical implication for symptomatic relief and pain management
George Groeneweg , Frank JPM Huygen , Terence J Coderre and Freek J Zijlstra
BMC Musculoskeletal Disorders 2009, 10:116 Full text available