Limb Amputation and Postoperative Epineural Catheter Infusion for Treatment of End Stage CRPS

CASE: We present a 49 year old male with Complex Regional Pain Syndrome type I that resulted from arthroscopic knee surgery. Symptoms became progressively more severe over 18 years, refractory to multiple therapies including... [ view full abstract ]

CASE: We present a 49 year old male with Complex Regional Pain Syndrome type I that resulted from arthroscopic knee surgery. Symptoms became progressively more severe over 18 years, refractory to multiple therapies including high dose opiates, antiepileptics, sympathetic and spinal blocks, nerve ablations, epidural infusions, neurostimulation trials and ketamine infusions. He ultimately elected to undergo a controversial above knee amputation. However, to minimize CRPS spread and phantom limb pain, he received 4 weeks of postoperative local anesthetic infusions through a sciatic nerve epineural catheter. He is now pain free and no longer wheelchair bound with the aid of a prosthetic limb.

DISCUSSION: Amputation for treatment resistant CRPS-1 remains controversial.  There are a number of associated risks: (a) CRPS recurrence in stump, (b) spread to other limbs, and (c) phantom limb pain.  However, select patients have resolution of symptoms and improved quality of life after amputation.  Because potential complications can be severe, we suggest a strategy to decrease risk of amputation-associated morbidity.  We propose a postoperative local anesthetic infusion to a target nerve.  In this particular patient, we discovered success with the aid of a dense, continuous peripheral nerve block of extended duration (lasting weeks rather than days).  This strategy may permanently help reorganize spinal and cortical pain mapping, thereby helping prevent complications associated with amputation of a limb affected by CRPS.