Successful Pain Management of Primary and Independent Spread Sites in a Child with CRPS Type I Using Regional Nerve Blocks

Abstract

A 14-year-old girl reported severe pain of the left first toe after a sprain of the left ankle joint when she was 9 years old. She complained of continuous pain in her chest, back, abdomen, and left first toe. The pain at all the sites was of a burning type with intensity of 6 on the numerical rating pain scale. She was unable to walk due to pain. Mechanical allodynia was present. Redness and swelling were recognized over the left first toe. It was concluded that she suffered from Complex Regional Pain Syndrome type I. Initial therapy was started with medications such as nortriptyline, etc. However, they did not work well. Clinical interviews were conducted by a clinical psychologist and a psychiatrist to investigate whether the pain was related to psychogenic factors; they concluded that her pain was mainly related to physical factors rather than psychological ones. It was thought that blockade of inputs from the peripheral nerves would be necessary. We provided an outline of the nerve blocks to the patient and her mother, and obtained their written consent for the procedure. An epidural catheter was inserted at the Th8-9 interspace. 6 mL of 1% lidocaine was injected, which reduced pain and mechanical allodynia. A 0.15% ropivacaine infusion was started at the rate of 6 mL/h for 7 days. This 7-day infusion regime was done twice during 4 weeks. After withdrawal of the epidural catheter, pain relief continued. However, her first left toe pain and mechanical allodynia remained. A nerve block needle was inserted under ultrasound guidance and 10 mL of 0.2% ropivacaine was injected in the peritibial nerve area. A catheter was inserted and 10 mL of 0.2% ropivacaine was injected. A 0.1% ropivacaine infusion was started at the rate of 6 mL/h for 5 days. Her left first toe pain and mechanical allodynia disappeared and she was able to walk. Interestingly, even after withdrawal of the catheter, pain and allodynia did not recur, she was discharged. At 1-year follow-up, the patient was able to attend school.The etiology of the pain spreading with time was believed to be central sensitization. Three patterns of spread of the pain site in CRPS type I patients have been identified: contiguous spread, independent spread, and mirrorimage spread [1]. This patient probably had independent spread.The persistent central sensitization in this patient could have been due to continuous afferent inputs even from normal sensations. Blockade of peripheral nerve input resulted in desensitization of the central nervous system. Reference1 Maleki J, LeBel AA, Bennett GJ, Schwartzman RJ.Patterns of spread in complex regional pain syndrome, type I (reflex sympathetic dystrophy). Pain 2000;88: 259-66.

Applications of regional anaesthesia in paediatrics

“…Peripheral nerve blocks are also increasingly utilized in paediatric chronic pain management to facilitate physical therapy while providing sympathectomy; such interventional approaches have become more plausible with the use of ultrasound guidance. 36 Serial peripheral nerve blocks can be performed to treat chronic neuropathic pain in children. In such circumstances, the pain relief often outlasts the duration of conduction block, which might be attributable to reduced central sensitization, and interruption of the circuit established between nociceptor, central nervous system, and motor unit.…”

Interventional Procedures for Chronic Pain in Children and Adolescents: A Review of the Current Evidence

“…Serial peripheral nerve blocks and continuous peripheral nerve blocks (CPNBs) have been reported as effective in facilitating physical therapy and controlling pain in both inpatient and outpatient settings . Peripheral nerve blocks may be utilized as adjunctive therapy in children with CRPS, migraine, neuropathic pain, cancer pain, phantom limb pain, musculoskeletal pain, and sickle cell crisis pain . These procedures are traditionally performed using either landmarks or nerve stimulators; however, the evolution of ultrasound‐guided techniques has led to safer practices with improved success rates …”

“…A variety of behavioral, pharmacological, and physical therapies are employed in pediatric chronic pain treatment regimens. Unlike in the adult cohort, where it is used as an initial diagnostic and therapeutic modality, interventional procedures are often introduced after patients fail other treatment approaches . The purpose of this review is to examine the role of interventional procedures in managing pediatric chronic pain.…”

Complex Regional Pain Syndrome in a Patient with Muscular Dystrophy

“…In pediatric patients, peripheral nerve blocks, intravenous regional anesthesia, and lumbar sympathetic blocks were used successfully for the treatment of CRPS [5,6]. None of these procedures is the current standard for the treatment of CRPS I.…”