Amputation in patients with complex regional pain syndrome

Midbari, Ayelet; Suzan, Erica; Adler, T.; Melamed, Eyal; Norman, Doron; Vulfsons, Simon; Eisenberg, Elon

doi:10.1302/0301-620x.98b4.36422

Cited by 34 publications

(21 citation statements)

References 26 publications

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“…He suggested, after gathering results, that if allodynia is present at the level of amputation it can lead to recurrence. On the other hand, results from Bodde et al 19 and Midbari et al 23 did not support this idea. Mitton et al 29 and Kashy et al 30 each reported one case with amputation of a leg followed by significant improvement in quality of life and rehabilitation.…”

Section: Resultsmentioning

confidence: 86%

“…Care was taken while synthesizing the results to keep in view the quality of these studies in order to minimize bias and to assess true effect, size and direction of treatment. Studies by Midbari et al 23 and Bodde et al 24 were designed scientifically considering the restraints of complexity and rarity of CRPS. These successfully managed to recruit and compare control groups, and enabled analysis of demographics and consideration of confounders (see Table 3 for examples of excluded study).…”

Section: Resultsmentioning

confidence: 99%

“…In one of the studies, 18 amputations were for lower limbs while one patient had an upper limb amputation, all of which were performed above the allodynia level through healthy skin. 23 In a study by Groeneweg et al, 26 two legs and one arm were amputated. Pagoti, Lawrence and Hambidge 27 reported two upper limb amputations.…”

Section: Resultsmentioning

confidence: 99%

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Quality of life after amputation in patients with advanced complex regional pain syndrome: a systematic review

et al. 2019

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The majority of included studies (8 out of 11, n = 54) supported the concept of considering amputation for selected, unresponsive cases of complex regional pain syndrome (CRPS) as a justifiable alternative to an unsuccessful multimodality nonoperative option. Of patients who underwent amputation, 66% experienced improvement in quality of life (QOL) and 37% were able to use a prosthesis, 16% had an obvious decline in QOL and for 12% of patients, no clear details were given, although it was suggested by authors that these patients also encountered deterioration after amputation. Complications of phantom limb pain, recurrence of CRPS and stump pain were predominant risks and were noticed in 65%, 45% and 30% of cases after amputation, respectively and two-thirds of patients were satisfied. Amputation can be considered by clinicians and patients as an option to improve QOL and to relieve agonizing, excruciating pain of severe, resistant CRPS at a specialized centre after multidisclipinary involvement but it must be acknowledged that evidence is limited, and the there are risks of aggravating or recurrence of CRPS, phantom pain and unpredictable consequences of rehabilitation. Amputation, if considered for resistant CRPS, should be carried out at specialist centres and after MDT involvement before and after surgery. It should only be considered if requested by patients with poor quality of life who have failed to improve after multiple treatment modalities. Further high quality and comprehensive research is needed to understand the severe form of CRPS which behaves differently form less severe stages. Cite this article: EFORT Open Rev 2019;4:533-540. DOI: 10.1302/2058-5241.4.190008

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Section: Resultsmentioning

confidence: 86%

Section: Resultsmentioning

confidence: 99%

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Quality of life after amputation in patients with advanced complex regional pain syndrome: a systematic review

et al. 2019

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“…Supplies of the study medication dispensed on day 1 and day 2 post randomisation were blinded (and the IVIg prescribed on days 43 and 64 was open label). Blinding was achieved by preparing the investigational medicinal product/active and placebo solution (0.1% albumin in normal saline) into bottles of identical appearance, including the labelling and the batch numbers/expiry dates.…”

Section: Randomisation and Blindingmentioning

confidence: 99%

“…[40][41][42] This remains an area of large unmet need, a fact that is also underpinned by the recently discussed, patient-driven, generally futile approaches to achieve pain relief by surgical removal of the painful limb. 43 The trial strengths include the multicentre set-up, the size, the swift recruitment to plan, the high patient retention (low withdrawal) and the high patient adherence. Patient demographics and disease characteristics are typical for those with long-standing CRPS, as seen in secondary and tertiary care.…”

Section: Limb Temperature and Volumementioning

confidence: 99%

A randomised placebo-controlled Phase III multicentre trial: low-dose intravenous immunoglobulin treatment for long-standing complex regional pain syndrome (LIPS trial)

et al. 2017

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Background Complex regional pain syndrome (CRPS) is a rare, severe post-traumatic pain condition affecting distal limbs. Patients who do not spontaneously improve in 12 months are classed as having ‘long-standing CRPS’ and often cannot be effectively treated, leading to a poor prognosis. CRPS is associated with functional autoantibodies. Two small trials, including a randomised controlled trial, have suggested that low-dose intravenous immunoglobulin (IVIg) may be an effective treatment for some patients. Objective We hypothesised that low-dose IVIg is effective for reducing pain in long-standing CRPS. Methods A randomised, double blinded placebo-controlled multicentre trial in seven UK pain management centres. Patients were eligible if they had moderate or severe long-standing CRPS that they had experienced for up to 5 years. Participants were randomly allocated to receive 0.5 g/kg IVIg, the active intervention, or visually indistinguishable 0.1% albumin in saline placebo. Randomisation was initiated by study sites via an independent online randomisation system and was 1 : 1 with varying block sizes, stratified by study centre. Participants, investigators and assessors were blinded to group assignment. The study drug/placebo was infused intravenously at the study centres on day 1 and day 23 after randomisation. The primary outcome was the 24-hour average pain intensity between day 6 and day 42, on an 11-point (0–10) numeric rating scale, compared between the groups. Outcomes were analysed using a mixed-effects regression model that used 37 measurements of pain intensity (the primary outcome) per participant. All patients who received an infusion and provided any outcome were included in the intention-to-treat analysis. Results A total of 111 patients were recruited and assigned between 27 August 2013 and 28 October 2015. Three patients were excluded because they had been inappropriately randomised, five patients were withdrawn from the primary analysis because they provided no outcomes and 103 patients were analysed for the primary outcome. The average pain score in the IVIg group was 0.27 units (95% confidence interval –0.24 to 0.80 units) higher than in the placebo group. Therefore, there is no significant evidence of a treatment effect at the 5% level and there was no significant difference between groups. Six serious adverse events but no suspected unexpected serious adverse reactions were reported during the blinded and open-label phase. Conclusion and future work Low-dose immunoglobulin was not effective in relieving pain in patients with moderate to severe CRPS of 1–5 years’ duration. Better drug treatments for long-standing CRPS are urgently required. Trial registration Current Controlled Trials ISRCTN42179756. Funding This project was funded by the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research partnership. Additional funding was obtained by the Pain Relief Foundation. Biotest UK Ltd provided the active study medication at no cost.

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Combined use of peripheral nerve stimulation and dorsal root ganglion stimulation for refractory complex regional pain syndrome type I to avoid amputation: A case report

Aman

Ibrahim

Buluk

et al. 2023

Clinical Case Reports

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Amputation in patients with complex regional pain syndrome

Abstract: Amputation should be considered as a form of treatment for patients with intractable CRPS.

Cited by 34 publications

References 26 publications

Quality of life after amputation in patients with advanced complex regional pain syndrome: a systematic review

Quality of life after amputation in patients with advanced complex regional pain syndrome: a systematic review

A randomised placebo-controlled Phase III multicentre trial: low-dose intravenous immunoglobulin treatment for long-standing complex regional pain syndrome (LIPS trial)

Combined use of peripheral nerve stimulation and dorsal root ganglion stimulation for refractory complex regional pain syndrome type I to avoid amputation: A case report

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