amputation to treat crps of the leg?

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TheLoneWolf

TheLoneWolf

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www.dailymail.co.uk

Mother has leg amputated after dropping perfume bottle on her foot

Gill Haddington, 42, of Morecambe, Lancashire, saw her foot swell to twice the size from September 2015. Doctors diagnosed the excruciating condition complex regional pain syndrome.
www.dailymail.co.uk www.dailymail.co.uk

Article doesn’t describe any treatments leading up to this. Surprised she could find a surgeon to perform a bka for crps. Had djd and fibro prior to the accident. Extreme and not standard of care.
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Great. sounds like a setup for Phantom limb pain
 
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Amputation is on the treatment algorithm for intractable CRPS with data for support
www.ncbi.nlm.nih.gov

Amputation in patients with complex regional pain syndrome: a comparative study between amputees and non-amputees with intractable disease - PubMed

Amputation should be considered as a form of treatment for patients with intractable CRPS.
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Even at some place in Cleveland
www.ncbi.nlm.nih.gov

Amputation as an Unusual Treatment for Therapy-Resistant Complex Regional Pain Syndrome, Type 1

Complex regional pain syndrome, type 1 (CRPS-1) causes severe pain that can be resistant to multiple treatment modalities. Amputation as a form of long-term treatment for therapy-resistant CRPS-1 is controversial.We report the case of a 38-year-old man ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
 
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I saw this as a resident. BKA on one side then the CRPS "spread" to the other side and another BKA.... terrible
 
Orin said:
Amputation is on the treatment algorithm for intractable CRPS with data for support
www.ncbi.nlm.nih.gov

Amputation in patients with complex regional pain syndrome: a comparative study between amputees and non-amputees with intractable disease - PubMed

Amputation should be considered as a form of treatment for patients with intractable CRPS.
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Even at some place in Cleveland
www.ncbi.nlm.nih.gov

Amputation as an Unusual Treatment for Therapy-Resistant Complex Regional Pain Syndrome, Type 1

Complex regional pain syndrome, type 1 (CRPS-1) causes severe pain that can be resistant to multiple treatment modalities. Amputation as a form of long-term treatment for therapy-resistant CRPS-1 is controversial.We report the case of a 38-year-old man ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
Click to expand...
Is a real Bad idea
 
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Whoa! Nothing quite like the appeal to emotion of a pt telling you to "take the leg" in an attempt at convincing you they hurt!
 
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lonelobo said:
Is a real Bad idea
Click to expand...

Yeah, that's generally what I counsel folks, but there are data to support it.

Fortunately I have not yet had to suggest it to a patient or felt it warranted if they asked. My thought process about it is that if local anesthetic helps temporarily, I will support it if they have failed multiple other reasonable options, are medically appropriate, and psychiatrically cleared for it, but I really hope I'm never in that position to have to advocate for it. If it still hurts despite a dense peripheral nerve block, then I suspect it's not a peripherally mediated issue and amputation is high risk for more badness, although I have not reviewed any data about that.
 
Yep I have seen post amputee for CRPS and guess what? Still hurts. That's horrifying enough that I don't care what the supporting data is. We can't take peoples limbs off for a "maybe" outcome.
 
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swamprat said:
My anecdotal experience is this **** don't work since the pathology is higher up.
Click to expand...


What would the incidence of CRPS at the area of the residual limb/stump site? I am talking about separate incidence from phantom pain. I would guess the incidence of residual post amputation pain of some type has to be approaching 100%?
 
CRPS, then amputation, then patient, “I have stump and phantom pain worse than the CRPS!”

A fool’s errand.
 
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Wait til that stump neuroma grows too.
 
I inherited a patient with history of work related accident that lead to CRPS, she OD'd on pain meds is now a R AKA and left BKA as a result with....... PHANTOM limb and multiple other issues. Just awful
 
I knew someone with pretty bad CRPS, was the absolute strangest thing. She was considering amputation for QOL, but given that it only works about 50% of the time she said screw it, I'll just deal with the pain.
 
Colleague came to me and asked about any new treatment for recalcitrant CRPS. I have not seen the patient, nor examined any records, but was told he tried "everything" including two separate stim trials (not sure if implanted). Patient now seeking AKA of his lower limb by surgeon.

Assuming traditional treatment options have been entertained (analgesics, desensitization therapy, LSB, SCS...) is there anything new to consider?

I vaguely recall someone using phenoxybenzamine for cold CRPS. Also heard of someone using IVIG. Any of these valid options? Keep in mind, I haven't seen the patient.
 
DrSwede said:
Colleague came to me and asked about any new treatment for recalcitrant CRPS. I have not seen the patient, nor examined any records, but was told he tried "everything" including two separate stim trials (not sure if implanted). Patient now seeking AKA of his lower limb by surgeon.

Assuming traditional treatment options have been entertained (analgesics, desensitization therapy, LSB, SCS...) is there anything new to consider?

I vaguely recall someone using phenoxybenzamine for cold CRPS. Also heard of someone using IVIG. Any of these valid options? Keep in mind, I haven't seen the patient.
Click to expand...


If everything above has been tried...maybe a trial of lidocaine or ketamine infusions, and consider nucynta or methadone therapy.

Some vascular AKA/BKA trainwrecks did best when transitioned to methadone
 
Have they tried ketamine infusions, medical marijuana? Wouldn’t be surprised if THC helped CRPS
 
I assumed that infusion therapy, plus the aforementioned analgesics, would have been tried, but you know what they say about assumptions...
 
Bisphosphonate? I’d put a pump in before amputation
 
nvrsumr said:
Bisphosphonate? I’d put a pump in before amputation
Click to expand...
I'll have to ask about the bisphosphonate.

Haven't done pumps since fellowship. Would Prialt be a good medication for CRPS? I don't recall the types of pain it is recommended for.
 
DrSwede said:
Colleague came to me and asked about any new treatment for recalcitrant CRPS. I have not seen the patient, nor examined any records, but was told he tried "everything" including two separate stim trials (not sure if implanted). Patient now seeking AKA of his lower limb by surgeon.

Assuming traditional treatment options have been entertained (analgesics, desensitization therapy, LSB, SCS...) is there anything new to consider?

I vaguely recall someone using phenoxybenzamine for cold CRPS. Also heard of someone using IVIG. Any of these valid options? Keep in mind, I haven't seen the patient.
Click to expand...

Did the patient try LDN?
 
Two stim trials, does that mean traditional and DRG? Peripheral nerve stimulator?

Also make sure no vascular problems in the leg. I saw a very pissed off patient whose leg pain turned to out to be ischemic and his previous pain doc and orthopedic surgeon missed it.
 
did one of these (left below shoulder) on a young woman in fellowship after a dog bite 20+ years ago....i couldnt believe the attendings allowed it
 
I would be very wary of amputation for CRPS as it could morph into an awful phantom limb pain
 
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Agast said:
Two stim trials, does that mean traditional and DRG? Peripheral nerve stimulator?

Also make sure no vascular problems in the leg. I saw a very pissed off patient whose leg pain turned to out to be ischemic and his previous pain doc and orthopedic surgeon missed it.
Click to expand...

I had the same question about DRG vs traditional vs PNS. Don't know.

Good comments and recs so far. I'm going to see if he found any of this info in the record review.
 
I have a patient who had a BKA for CRPS, it was a lifesaver literally. He had tried all the treatments mentioned above. He does very well now on Cymbalta and Lyrica for some phantom limb symptoms mostly at night.
 
I had a patient with CRPS, very young. failed pretty everything, couldn't tolerate SCS trial. Ended up with BKA at local academic center, doing fantastic so far. Surprised they went ahead at an academic place, and more surprised in their notes they noted whatever studies that showed >50% of patients getting amputation for CRPS were happy with the outcomes. I should have looked up that study
 
Nice meta-analysis
Surgical data is quite good for it, especially in the better studies.
www.ncbi.nlm.nih.gov

Quality of life after amputation in patients with advanced complex regional pain syndrome: a systematic review

Cite this article: EFORT Open Rev 2019;4:533-540. DOI: 10.1302/2058-5241.4.190008
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
1703099098207.png


I would suggest if it is a distal extremity, consider a nerve block or nerve block catheter at the proximal nerves/plexus. If their pain/other function improves greatly, I would suggest this is more a peripherally generated state where amputation and removal of the noxious stimulus may help. If not, then an amputation may help with other things like open wounds/dressing/etc but not necessarily pain.

If they do want an amputation, would suggest they do it at center where they're skilled at doing the nerve cuffing/TMR/etc to help reduce amputation related pain issues.

Ziconotide trial is reasonable to preserve the limb but it can be a tricky drug.
 
I’ve seen it work a few times - usually with significant dystrophic changes. One guys ankle was turned in 90 degrees.
 
A lot anecdotal cases. I never think of it as a treatment option though did have 1 patient with a BKA for CRPS of his ankle that took his pain away completely. I had recommended against it. He lost 100 lb as he was then able to work out with a prosthesis which in turn helped the rest of his pain in other places. He does have some phantom pain that is well managed with medications.
 
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Replace one difficult pain syndrome with another, no thank you
 
Orin said:
Nice meta-analysis
Surgical data is quite good for it, especially in the better studies.
www.ncbi.nlm.nih.gov

Quality of life after amputation in patients with advanced complex regional pain syndrome: a systematic review

Cite this article: EFORT Open Rev 2019;4:533-540. DOI: 10.1302/2058-5241.4.190008
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov
View attachment 379983

I would suggest if it is a distal extremity, consider a nerve block or nerve block catheter at the proximal nerves/plexus. If their pain/other function improves greatly, I would suggest this is more a peripherally generated state where amputation and removal of the noxious stimulus may help. If not, then an amputation may help with other things like open wounds/dressing/etc but not necessarily pain.

If they do want an amputation, would suggest they do it at center where they're skilled at doing the nerve cuffing/TMR/etc to help reduce amputation related pain issues.

Ziconotide trial is reasonable to preserve the limb but it can be a tricky drug.
Click to expand...
Interesting, thanks. I'll pass it on.

One thing I did note was that this patient was sent to a local surgeon who was considering it, not an academic center which we do have one nearby.
 
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