La Spina Catherine R, Pozo Patricia, Wakim Gisele J
Anesthesiology, Jackson Memorial Hospital, Miami, USA.
Anesthesiology, University of Miami, Miami, USA.
Cureus. 2024 Nov 3;16(11):e72935. doi: 10.7759/cureus.72935. eCollection 2024 Nov.
Complex regional pain syndrome (CRPS) is a chronic neuropathic pain disorder often following trauma, associated with severe pain and autonomic disturbances in the affected limbs. Managing CRPS is challenging due to the lack of FDA-approved medications, often requiring off-label treatments. Traditional options like nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids show limited efficacy, while adjunctive treatments such as gabapentin, antidepressants, and bisphosphonates are increasingly favored. Surgical interventions, including nerve blocks and spinal cord stimulation, may help in refractory cases but have varying success rates. Recent discussions highlight intraoperative ketamine, which targets N-methyl-D-aspartate (NMDA) pathways linked to CRPS. This case study illustrates the complexity of CRPS management, particularly how psychosocial factors and secondary trauma can exacerbate or alleviate symptoms. The case centers on a treatment-resistant flare-up of CRPS, managed through revision neurolysis of the sciatic, tibial, and perineal nerves, along with the release of the right tibial nerve and intraoperative ketamine. Trauma's impact is evident, as the patient initially went into remission after nerve decompression, only for symptoms to return severely following a subsequent trauma. This emphasizes the need for a multipronged treatment approach. Intraoperative ketamine provides rapid pain relief during and after surgery, benefiting patients with severe chronic pain while reducing post-surgery opioid needs and minimizing dependency risks. Patients typically achieve improved functional recovery and better rehabilitation engagement. Research suggests ketamine may offer long-lasting pain relief and psychological benefits, positively impacting mood and anxiety.
复杂性区域疼痛综合征（CRPS）是一种慢性神经性疼痛疾病，常继发于创伤后，与受影响肢体的剧烈疼痛和自主神经功能紊乱有关。由于缺乏美国食品药品监督管理局（FDA）批准的药物，治疗CRPS具有挑战性，通常需要使用未获批准的治疗方法。非甾体抗炎药（NSAIDs）和皮质类固醇等传统治疗方法疗效有限，而加巴喷丁、抗抑郁药和双膦酸盐等辅助治疗方法越来越受到青睐。包括神经阻滞和脊髓刺激在内的手术干预可能有助于治疗难治性病例，但成功率各不相同。最近的讨论突出了术中使用氯胺酮，它作用于与CRPS相关的N-甲基-D-天冬氨酸（NMDA）通路。本病例研究说明了CRPS管理的复杂性，特别是心理社会因素和继发性创伤如何加重或缓解症状。该病例聚焦于CRPS的难治性发作，通过对坐骨神经、胫神经和会阴神经进行翻修神经松解术，以及松解右侧胫神经和术中使用氯胺酮进行治疗。创伤的影响很明显，因为患者在神经减压后最初病情缓解，但在随后的创伤后症状又严重复发。这强调了需要采取多管齐下的治疗方法。术中使用氯胺酮可在手术期间和术后迅速缓解疼痛，使患有严重慢性疼痛的患者受益，同时减少术后对阿片类药物的需求并将依赖风险降至最低。患者通常能实现更好的功能恢复和更好地参与康复治疗。研究表明，氯胺酮可能提供持久的疼痛缓解和心理益处，对情绪和焦虑产生积极影响。
