Conclusion
Most patients with CRPS I reported minor trauma prior to the development
of symptoms, such as a sprain, fracture, fall, crush injury, burn, or
soft tissue injury.2 The pathogenesis of CRPS is not
understood. However, evidence now emerging from many different fields
suggests a multifactorial disorder triggered by an initial, sometimes
relatively minor injury. There is then an aberrant response by the body
with exaggerated immune response, maladaptive neuroplasticity, and
abnormal vasomotor function within the tissues of the affected
limb.5 The International Association for the Study of
Pain (IASP) has endorsed the Budapest criteria for the diagnosis of
CRPS. CRPS I is not associated with an identifiable nerve injury,
whereas CRPS II is associated with a nerve injury.5Physical and occupational therapy is a critical component of the
rehabilitation process in patients with CRPS and is recommended as the
first-line treatment.3 Historically, Sympathectomy has
been used to treat CRPS. This can now be performed using radiofrequency,
chemicals, and surgery.7,8 Sympathectomy has a
significant complication rate, including local anhydrosis and Horner’s
syndrome.5 Ackerman showed that stellate ganglion
blockade is effective for pain management in CRPS.9
A randomized study involving 24 patients with CRPS, SCS plus physical
therapy (PT) reduced pain and improved health-related quality of life
more than PT alone for up to two years.10 The
potential that combination therapy with t-SCS and DRG-S may be
beneficial in patients with severe and refractory
CRPS.11,12 Data from the ACCURATE study suggests that
DRGS could be used in patients suffering from chronic intractable pain
conditions that are refractory to t-SCS.13
Unilateral epidural stimulation is an effective type of SCS in the
treatment of pain syndromes. It may make sense for some patients to have
neuromodulation instead of DREZ ablation. In our opinion, ablation is
preferable for patients with a relatively poor prognosis of survival for
palliative purposes. In other cases, we consider neuromodulation
primarily. The possibility of conducting a minimally invasive
stimulation trial, the reversibility of the technique, and the ability
to control the stimulation process, in our opinion, is an advantage over
destructive interventions. Our clinical case confirms the possibility of
using unilateral epidural stimulation with “adaptive stim” regimen to
treat complex pain syndromes such as CRPS. Cases of migration of
epidural leads have been reported in the literature, but improvements in
implantation techniques have minimized this risk.14The preoperative selection plays a crucial role in good results. If SCS
effects do slowly diminish over time, DRG stimulation seems to be a
treatment alternative.15 For patients who seem
resistant to all other forms of therapy, some doctors argue that there
is a case for amputation of the affected limb.5 In our
opinion, limb amputation does not apply to patients with CRPS since the
rapidly developing technique of neuromodulation opens up new
possibilities in the treatment of pain syndromes.