There is a paucity of information related to treatment of pediatric CRPS. Treatment of CRPS in pediatric patients has been guided by adult recommendations, which consist of a multidisciplinary approach involving pharmacotherapy, physical therapy, and psychotherapy, as appropriate. Patients unable to tolerate physical therapy with traditional oral pharmacotherapy may require more invasive pain management techniques such as sympathetic blocks, epidural infusion of analgesics, or spinal cord stimulation to facilitate restoration of function. This case report describes the successful use of epidural infusion of fentanyl, clonidine, and bupivacaine through a tunneled epidural lumbar catheter for pain management in an 11-year-old girl who developed complex regional pain syndrome I (CRPS I) approximately 2 months after sustaining an injury to her right knee. Following short-lasting pain relief from 3 repeated blocks, she underwent an implant of a tunneled epidural catheter (TEC) and a 4-week infusion of fentanyl (2 mcg/mL), clonidine (1 mcg/mL), and bupivacaine (0.04%). At last follow-up, approximately 3.5 months after implant of the TEC, the patient’s pain and symptoms were completely resolved, her range of motion and function were completely restored, and her physical activity had returned to pre-injury levels. Key words: Complex regional pain syndrome (CRPS), tunneled epidural catheter, pediatric, continuous regional anesthesia, epidural analgesia, continuous epidural anesthesia, interventional pain management

No abstract

Minimally invasive sacroiliac joint (SIJ) fusion is the preferred surgical method for managing patients with recalcitrant, chronically severe SIJ pain and dysfunction refractory to conservative medical measures. The primary surgical objective of all minimally invasive SIJ fusion procedures is to provide immediate stabilization within the joint space to support osseous consolidation and the development of a mechanically solid arthrodesis. The intra-articular surgical approach to the SIJ with allograft bone placement utilizes a trajectory and easily identifiable landmarks that allow the surgeon to control the risk of violating important neuro-vascular structures. The intra-articular approach can employ a superior or inferior operative trajectory, with the former restricted to allograft placement in the ligamentous portion of the SIJ. The inferior approach utilizes decortication to surgically create a channel originating in the purely articular portion of the joint space allowing for truly intra-articular implant placement within the osseous confines of the ilium and sacrum. Positioning the implant along the natural joint line and securing it within the underlying sub-chondral bone, mortise and tenon fashion provides stabilization and large surface area contact at the bone implant interface. The inferior, intra-articular approach also places the implant perpendicular to the S1 endplate, near the sacral axis of rotation, which addresses the most significant biomechanical forces across the joint. Short-term, post-surgical observational data from a 57 patient multi-center registry using the inferior, intra-articular approach show uniform and statistically significant improvement in all clinical outcomes (p < 0.001 for all comparisons), including an average 3-point improvement in back pain severity from 6.8 preoperatively to 3.8 at 6 months. Further clinical evaluation with longer-term follow-up of the inferior, intra-articular SIJ fusion procedure is encouraged.

(1) Background: Minimally-invasive sacroiliac joint (SIJ) fusion is the preferred surgical intervention to treat chronically severe pain associated with SIJ degeneration and dysfunction. (2) Methods: This paper details the ten-step surgical procedure associated with the postero-inferior approach using the PsiF™DNA Sacroiliac Joint Fusion System. (3) Results: The posterior surgical approach with an inferior operative trajectory (postero-inferior) utilizes easily identifiable landmarks to provide the safest, most direct access to the articular joint space for transfixing device placement. Implanting the device through the subchondral bone, provides maximum fixation and stabilization of the joint by utilizing an optimal amount of cortical bone-implant interface. Approaching the joint from the inferior trajectory also places the implant perpendicular to the S1 endplate at a “pivot point” near the sacral axis of rotation, which addresses the most significant motion of the joint. (4) Conclusions: Further observational data from real-world clinical use are encouraged to further validate this procedure as the surgical preference for minimally-invasive SIJ fusion.

No abstract