This report aims to present an orderly approach to the treatment of Chronic Regional Pain Syndrome (CRPS) types I and II through an algorithm. The central theme is functional restoration: a coordinated but progressive approach that introduces each of the treatment modalities needed to achieve both remission and rehabilitation. Reaching objective and measurable rehabilitation goals is an essential element. Specific exercise therapy to reestablish function after musculoskeletal injury is central to this functional restoration. Its application to CRPS is more contingent on varying rates of progress that characterize the restoration of function in patients with CRPS. Also, the various modalities that may be used, including analgesia by pharmacologic means or regional anesthesia or the use of neuromodulation, behavioral management, and the qualitatively different approaches that are unique to the management of children with CRPS, are provided only to facilitate functional improvement in a stepwise but methodical manner. Patients with CRPS need an individual approach that requires extreme flexibility. This distinguishes the management of these conditions from other well-described medical conditions having a known pathophysiology. In particular, the special biopsychosocial factors that are critical to achieving a successful outcome are emphasized. This algorithm is a departure from the contemporary heterogeneous approach to treatment of patients with CRPS. The underlying principles are motivation, mobilization, and desensitization facilitated by the relief of pain and the use of pharmacologic and interventional procedures to treat specific signs and symptoms. Self-management techniques are emphasized, and functional rehabilitation is the key to the success of this algorithm.

This study comprises 78 patients who were treated for chronic back pain at a multidisciplinary, multimodal pain treatment center. These patients were selected from 494 patients examined by the authors because all of their previous medical records, operative notes, and imaging studies were available for review. The records and imaging studies were reviewed independently by a neurosurgeon and an orthopedist, and a retrospective decision was made concerning the historical and physical findings correlated with imaging studies in order to provide justification for the intervention. At the time of admission to the pain treatment center, 16 patients had no physical abnormalities that would explain their back complaint and 16 patients exhibited minor postoperative changes insufficient to cause disabling pain. Twenty-seven patients suffered from a complication of previous surgery, 13 had spondylotic disease, and in six a new diagnosis was established. Comprehensive psychiatric evaluation of the 78 patients revealed that 10 patients had a definitive psychiatric diagnosis, 34 were diagnosed as having a maladaptive personality disorder, and 34 had a normal pre-pain personality. Sixty-seven patients suffered from reactive depression. Fifty-four patients were taking medications at doses higher than usually prescribed, 58 misused narcotics, nine had drug addiction, and 54 were suffering withdrawal symptoms. Of the 78 patients, 64 underwent a total of 171 operations, an average of 2.6 per patient. The authors applied the clinical criteria approved by the American Association of Neurological Surgeons and the American Academy of Orthopedic Surgeons for selection of surgery or chemonucleolysis in the treatment of the herniated disc to these patients. Preoperative imaging studies were normal or demonstrated nonspecific degenerative disc disease in 52 patients. Twenty-six patients had a diagnosis based on radiological findings that warranted surgery. Clinical criteria justifying intervention were met in 25 patients and not met in 53. Imaging and clinical criteria for a second operation were met in 18 (40%) of the patients. After the second operation all patients met the criteria: subsequent surgery was necessary to treat effects of an earlier operation in 73%. These data indicate that many of these patients with failed-back syndrome underwent an original operation based on a persistent complaint of pain, frequently coupled with an underlying psychiatric abnormality, although they did not meet the criteria generally accepted by neurosurgeons for intervention at the time of first surgery.

No abstract

No abstract

Persisting neck pain and headache is a common complication of acceleration/deceleration injury. Seventy patients with normal imaging studies and persisting pain after injury (median 1.7 y), who had failed all usual conservative forms of care were offered a diagnostic block protocol to determine the origins of the persisting pain. Blocks included C-2-3 roots bilaterally; C-2-3-4 zygapophyseal joints, and provocative discography at C-3-4, 4-5, 5-6, 6-7. Seventy patients entered the study; 67 completed the block protocol. On the basis of response to blocks, 44 patient were chosen for posterior cervical fusion of C-l, 2, 3, 4 in several combinations. Seventynine percent of patients achieved complete pain relief; 14% received satisfactory pain relief; fusion was achieved in 95%. These data support the hypothesis of Bogduk and associates that upper cervical facet injury is a common consequence of acceleration/deceleration accidents. The symptoms can be relieved by upper cervical fusion in some patients selected by concordant blocks.