Resident Physician Mount Sinai, Department of Rehabilitation and Human Performance New York, New York, United States
Case Diagnosis: Complex regional pain syndrome (CRPS)
Case Description: 33 year-old woman with history of left thumb amputation due to workplace injury presented to the emergency department for three days of severe left shoulder pain with radiation to the left hand, unable to move arm due to pain. The pain was described as a tearing and a pressure-like sensation inside the arm. No recent trauma. Physical examination revealed left hand edema, induration, hyperpigmentation, and warmth to touch. Passive range of motion of the left upper extremity was limited by the patient being guarded with severe allodynia. Physical medicine and rehabilitation was consulted and recommended outpatient bone scan, physical and occupational therapy, pregabalin and duloxetine, and consulting pain management service for formal evaluation of CRPS and potential ketamine or stellate ganglion block. The patient was given methocarbamol, ketorolac, acetaminophen, and lidocaine patch, and discharged one day later with only mild improvement in pain, and dermatology and rheumatology follow up.
Discussions: This patient meets the Budapest criteria for diagnosing CRPS, however she did not receive the proper aggressive management to not only improve pain, but restore function. Prior studies have shown the mean duration of CRPS symptoms prior to pain center evaluation is 30 months. Without the specific interprofessional approach to CRPS - physical and occupational therapy, pharmacotherapy, behavioral therapy, and potential procedural interventions - patients can develop significant muscle atrophy, contractures, and ultimately disability.
Conclusions: We present the case of a woman with likely CRPS based on Budapest criteria who was evaluated in the emergency department but ultimately not referred to pain medicine specialists. It remains critically important to provide CRPS awareness and education to physicians across all specialties in order for patients to receive tailored management to ultimately reduce pain-related disability and restore function.
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