18 - Complex Regional Pain Syndrome Treated With Combined Stellate Ganglion and Axillary Approach Brachial Plexus Blocks - A Case Series
Davood Tarzi, Tadeh Setaghian, Eduard Vaynberg
Boston Medical Center - Department of Anesthesiology & Perioperative Medicine, Boston, MA, USA
Purpose Complex regional pain syndrome (CRPS) is a taxonomic system representing two types of neuropathy. Type I CRPS represents regional sympathetic dystrophies in individuals with no proof of nerve damage. Type II CRPS represents those neuropathies in patients who have nerve damage, also termed causalgia. CRPS presents most commonly in middle-aged women with traumatic upper extremity injuries, though it can present in various ways in both children and adults of both sexes. Spontaneous CRPS is less common, though it is also possible. CRPS is most commonly associated with a constant and severe burning-like pain located at or near the affected limb, which is out of proportion to the initial injury or event. As the condition progresses, additional symptoms may include the spread of pain to surrounding areas, fluctuation in pain sensation, fluctuation in temperature, swelling, sweating, limb weakness or tremors, as well as changes in growth of hair, skin, and nails. Unfortunately, there is currently no specific test to confirm the diagnosis of CRPS. Chronic regional pain syndrome treatment is individualized to each patient based on his or her unique clinical presentation. Options include physical and occupational therapies, neuropathic and anti-inflammatory medications, as well as, interventional procedures, such as, nerve blocks and spinal cord stimulators. No treatment proves superior than another and some individuals may require treatments of varying frequency and modality. Based on current studies, most individuals who are diagnosed with CRPS see significant clinical improvement within the first year. Though, this is not guaranteed as the condition is highly variable and may persist despite treatment. The purpose of this case series is to identify and follow two unique cases of CRPS. This allows us to track the progression of the disease and symptoms in tandem with varying treatment modalities. In particular, these patients required escalating care, and both combinations of stellate ganglion blocks and somatic nervous system blockade with reported improvement in pain relief. More studies are needed on the treatment options of CRPS including those exploring the viability of combined sympathetic and somatic nervous systems blockade. Methods Two patients identified to have chronic regional pain syndrome type I were followed in clinic over the course of one and five years, respectively. During clinic visits patients underwent routine physical examinations and were asked questions detailing the development and improvement of their symptoms. When appropriate, medical therapies were adjusted as needed. Prior to any procedures, patients were informed of the risks and benefits in being treated with multi-modal therapies, including stellate ganglion and brachial plexus blocks. For the stellate ganglion block, patients were placed supine. The neck was sterilely prepped and draped. Under fluoroscopic guidance, a 25-gauge needle was advanced to the anterior border of C6 vertebra. Aspiration was negative confirmed with contrast AP lateral view and no intravascular intrathecal uptake was ensured. Patients were injected with a varying formulation of dexamethasone, 0.5% bupivacaine, and 1.5% lidocaine with epinephrine. After that, needle was removed. For the axillary approach brachial plexus block, the axilla was sterilely prepped and draped in usual axillary approach and using a nerve stimulator the brachial plexus was located with a hand twitch. Once patient twitch persisted at appropriate voltage and aspiration was confirmed negative a formulation of 0.5% Marcaine, 1.5% lidocaine with epinephrine and dexamethasone was injected in divided doses. Needles were then removed, the area cleaned, and Band-Aid applied. Patients followed up at varying intervals as dependent on personal schedules, symptomatic improvement, and the outbreak of COVID-19. Results A 23-year-old femalewith Ehlers-Danlos and multiple joint dislocations requiring a total of 20 surgeries including, bilateral di-rotational osteotomies, open-reduction-internal-fixation-left-knee-surgery, and hardware removals presented with sensations of temperature change, skin color changes (purple), and hypersensitivity to light touch in her right leg one year after her surgery in 2013 with resolution in 2015, and reappearance in 2017 in the left leg. She was diagnosed with CRPS-I, and she failed therapeutic measures with physical therapy, medical management, and multiple lumbar plexus blocks. In August 2019, a spinal-cord-stimulator provided adequate relief, but symptoms spread to her left-upper extremity. In September 2019, a left stellate ganglion block provided symptomatic relief for 1-week. She then underwent combined stellate ganglion and axillary brachial plexus blocks with complete resolution with slow recurrence after one week. The blocks were repeated with diminishing efficacy three weeks later with return of lower extremity symptoms. At two-week follow-up another set of blocks was performed and her spinal cord stimulator was reprogrammed with symptomatic improvement lasting three weeks. She then underwent a cervical spinal cord stimulator trial and presented two weeks later with CRPS-like symptoms in her right upper extremity. Combined blocks were performed for her right upper extremity to slow progression of CRPS. In April 2020, patient reported spread of CRPS to right leg and both upper extremities, and she underwent right lumbar sympathetic, stellate ganglion, and brachial plexus blocks with symptomatic improvement. The patient continues to be followed. A 31-year-old female with thoracic outlet syndrome status-post left first-rib removal and veno-lysis in February 2002, presented with worsening left-sided neck and upper-extremity pain, weakness, temperature-changes, and numbness for three months in July 2015. She was diagnosed with CRPS-I in her left upper extremity after failing therapy with a chiropractor, heat and cold, multiple physical therapy regimens, and medical management. She subsequently underwent and experienced good relief with a spinal cord stimulator and periodic brachial plexus and stellate ganglion blocks. She weaned off hydromorphone over the course of several months following several surgeries excising scar tissues developing around the original insult. Her other medical therapies included clonidine, occasional cyclobenzaprine, duloxetine, nortriptyline, and etodolac. Almost six months after her initial combination blocks, the patient underwent a repeat combination block in January 2020 with subsequent manageable pain control with spinal cord stimulator and adjustments to medical management. She eventually weaned off nortriptyline in May 2020. The patient continues to be followed. Conclusions Finding an algorithmic approach to treating chronic regional pain syndrome remains elusive. The complex nature of these cases require a multi-modal approach that should address both symptomatic improvement, as well as, restoration of function. Exercise and physical therapies act as foundational treatments to improve motion and strength of involved extremities. Pharmacological intervention provides pain relief to facilitate improvement in functionality. In our cases, various medications were used at varying time periods throughout treatment with fluctuating efficacy. Among the medications employed for our patients were, NSAIDs, steroids, opioids, tri-cyclic antidepressants, alpha-2-antagonists, serotonin-norepinephrine reuptake inhibitors, muscle relaxants, anti-convulsants, and anti-arrhythmics. Failure to achieve symptomatic improvement with these therapies inspires the pursuit of alternative options. In our patients, we achieved significant symptomatic improvement with spinal cord stimulation. Furthermore, where spinal cord stimulation failed, we achieved symptomatic relief with combined stellate ganglion and axillary approach brachial plexus blocks, albeit with significantly different temporal efficacy. These blocks aimed at treating the sympathetic and somatic components of the symptoms of our patients. Further case reports outlining treatment methods and course of disease may help elucidate important clues that may help in understanding the pathophysiology of CRPS and improvement in its treatment.