928 - Postoperative rehabilitation after DREZ lesioning procedure for the treatment of CRPS

Case Diagnosis: This case describes the postoperative rehabilitation of a 52-year-old female with a 2-year history of left upper limb complex regional pain syndrome (CRPS) treated with left C4-T1 dorsal root entry zone (DREZ) lesioning procedure.

Case Description: The patient developed CRPS following ORIF of a left distal radius fracture. Symptoms were refractory to numerous treatment modalities, including medications, multidisciplinary pain rehabilitation, spinal cord stimulator, and intrathecal ziconotide. She experienced constant severe pain and complete paralysis of the left upper limb.

Left limb pain resolved following C4-T1 DREZ lesioning procedure, and strength improved from complete paralysis to intact motor activation throughout her left upper extremity. She was transferred to acute rehab three days post procedure. Her rehabilitation course was complicated by left leg weakness contributing to gait dysfunction. She made notable improvements in functional use of her left upper extremity, left lower extremity strength, and mobility. After six days of acute inpatient rehabilitation, she was discharged home.

Discussions: Although the DREZ lesioning procedure yielded immediate improvement of ipsilateral upper limb pain and weakness, the patient’s early rehabilitation course was complicated by ipsilateral lower limb weakness. The etiology of her new left lower limb weakness and gait dysfunction remains uncertain, however strength and gait improved with physical therapy. Similarly, the mechanism for return of strength to the left upper limb remains uncertain, but it could be attributed to resolution of pain inhibition.

Conclusions: The DREZ lesioning procedure may be an effective strategy for the management of refractory CRPS-related pain and weakness. Future cases should evaluate for subtle weakness and gait instability to assess whether these findings may be associated with the DREZ lesioning procedure.