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.