Prithvi Raj

Complex regional pain syndromes: Guidelines for therapy

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.

Upper-Extremity Blocks

Brachial plexus block was first performed in 1885 by William Steward Halsted, who used cocaine and direct exposure of the roots in the neck to accomplish the block. In 1911, Hirschel and Kulenkampff described the first percutaneous brachial plexus block by the axillary and supraclavicular routes respectively. Since these historic reports, the efficacy of brachial plexus block has been confirmed, and the block is now commonly used to provide upperextremity anesthesia.

Autonomic Nerve Blocks

Selective block of the sympathetic trunk was first reported by Sellheim and, shortly thereafter, by Lawen, Kappis, and Finsterer (1905–1910). In 1924, reports were published by Brumm and Mandl and by Swertlow. After 1930, the technique and the indications were established by White in the United States and Leriche and Fontaine in Europe.

Blockaden des vegetativen Nervensystems (Sympathikusblockaden)

Uber eine selektive Blockade des sympathischen Grenzstrangs berichteten zuerst Sellheim und kurz darauf Lawen, Kappis und Finsterer (1905–1910). Im Jahre 1924 wurden Artikel von Brumm und Mandi und von Swertlow veroffentlicht. Technik und Indikationen wurden nach 1930 in den USA von White und in Europa von Leriche und Fontaine festgelegt.

Grundsätze der Behandlung des Patienten

Obwohl fur die Mehrzahl chirurgischer Eingriffe die Allgemeinanasthesie noch immer haufig angewendet wird, hat die Regionalanasthesie in den letzten Jahren an Popularitat gewonnen. Dies beruht auf der Tatsache, das man sich die Verfahren der Regionalanasthesie nicht nur in der perioperativen Phase zur Analgesie zunutze machen kann, sondern auch bei chronischen Schmerzen, postoperativen Schmerzen und Karzinomschmerzen.

Blockade der unteren Extremitäten

Die Operationen im Bereich der unteren Extremitaten werden gewohnlich entweder mit einer intraduralen oder epiduralen Blockade durchgefuhrt. Obwohl die Leitungsanasthesie eine hohe Erfolgsquote aufweist und relativ leicht durchfuhrbar ist, sind die intraduralen und epiduralen Verfahren fur bestimmte Gruppen von Patienten, wie altere, debile, arthritische, fettsuchtige oder Patienten in einem kritischen Krankheitsstadium nicht unbedingt geeignet. Bei solchen Patienten kann man die Anasthesie der unteren Extremitaten durch eine Blockade des Plexus lumbosacralis und seiner Aste erreichen.

Blockade der oberen Extremitäten

Die Blockade des Plexus brachialis wurde zuerst 1885 von William Steward Halsted durchgefuhrt, der Kokain benutzte und die Nervenwurzeln im Bereich des Halses direkt darstellte, um die Blockade zu erzielen. Hirschel u. Kulenkampff beschrieben 1911 die erste perkutane Blockade des Plexus brachialis uber den axillaren bzw. den supraklavikularen Zugang. Seit diesen historischen Berichten ist die Effektivitat der Plexus-brachialis-Blockade gesichert, und sie wird heute allgemein zur Anasthesie der oberen Extremitaten angewandt.

Blockaden im Bereich des Rumpfes und des Perineum

Die Blockade der Interkostalnerven entwickelte sich aus der thorakalen paravertebralen Blockade. Ihr Ursprung kann daher bis zum Beginn dieses Jahrhunderts zuruckverfolgt werden (s. VII.B).

Difference in analgesia following epidural blockade in patients with postoperative or chronic low back pain

&NA; Subjective responses of continuous epidural analgesia with bupivacaine were compared in 30 patients with acute (postoperative) or chronic (low back) pain. In the acute pain patients, sensory block was 4 dermatomes at 9 h and 6 dermatomes at 64 h. Corresponding values in the chronic pain patients were 8 and 6 dermatomes respectively. Motor blockade of the lower limbs was more profound in the acute pain group. The acute pain patients had significantly better pain relief (VAS: 85–96% vs. 55–70%) and a significantly higher proportion of these patients reported a global score of 3 (excellent; 80% vs. 7%). The mean dosage of bupivacaine decreased in the acute pain group from 21.0 ± 5.7 (mean ± S.D.) mg/h at 9 h to 15.1 ± 8.5 mg/h at 64 h. Corresponding values for the chronic pain group were 20.7 ± 5.9 and 12.0 ± 6.0 mg/h respectively. Mean plasma concentration of bupivacaine increased from 1.2 ± 0.8 &mgr;g/ml at 9 h to 2.1 ±1.4 &mgr;g/ml at 64 h in the acute pain patients and was 0.8 ± 0.3 &mgr;m/ml at 9 h to 1.0 ± 1.0 &mgr;g/ml at 64 h in the chronic pain patients. The incidence of side effects was approximately the same in both groups. No signs of accumulation or toxic reactions to bupivacaine were seen.

Central Neural Blocks

The spinal column consists of vertebral bodies which together form 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal vertebrae (see Transparency 1). A typical vertebra consists of two basic parts: the ventral vertebral body and the dorsal vertebral arch. Between the vertebral bodies are the intervertebral disks, which give the spinal column its flexibility. Together, the vertebral bodies and the intervertebral disks form a strong column supporting the head and trunk, while the vertebral arch protects the spinal cord. When the spinal column is viewed from the side, four flexures are visible: the thoracic and the sacrococcygeal flexures are concave ventrally, while the cervical and lumbar flexures are convex ventrally.In a supine position, L 3 is the highest point and L 5 the lowest point of the lumbar flexure.