Case report: Favorable outcomes of spinal cord stimulation in complex regional pain syndrome Type II consistent with thermography findings
- Department of Neurosurgery, Fukuoka University, Fukuoka, Japan.
- Department of Anesthesiology, Fukuoka University, Fukuoka, Japan.
Takashi Morishita, Department of Neurosurgery, Fukuoka University, Fukuoka, Japan.
DOI:10.25259/SNI_959_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Kazunori Oda1, Takashi Morishita1, Shiho Shibata2, Hideaki Tanaka1, Norimasa Hirai2, Tooru Inoue1. Case report: Favorable outcomes of spinal cord stimulation in complex regional pain syndrome Type II consistent with thermography findings. 08-Dec-2021;12:598
How to cite this URL: Kazunori Oda1, Takashi Morishita1, Shiho Shibata2, Hideaki Tanaka1, Norimasa Hirai2, Tooru Inoue1. Case report: Favorable outcomes of spinal cord stimulation in complex regional pain syndrome Type II consistent with thermography findings. 08-Dec-2021;12:598. Available from: https://surgicalneurologyint.com/surgicalint-articles/11275/
Background: Complex regional pain syndrome (CRPS) is a chronic pain disorder that develops as a consequence of trauma to one or more limbs. Despite the availability of multiple modalities to diagnose CRPS, a gold standard technique for definitive diagnosis is lacking. Moreover, there are limited reports describing the use of spinal cord stimulation (SCS) to treat CRPS Type II, given the low prevalence of this condition. Herein, we present the case of a patient with CRPS Type II with novel thermography findings who underwent SCS for pain management after an Achilles tendon repair surgery.
Case Description: A 38-year-old woman was referred to our institute because of chronic left leg pain after Achilles tendon rupture repair surgery. Her case was diagnosed as CRPS Type II based on the International Association for the Study of Pain diagnostic criteria. After an epidural block, thermography showed a significant increase in the body surface temperature of the foot on the observed side. She was subsequently treated with SCS, following which her pain ameliorated. She reported no pain flare-ups or new neurological deficits over 2 years of postoperative follow-up assessments.
Conclusion: SCS could be a useful surgical treatment for medication refractory CRPS Type II as supported by our thermography findings. We may refine surgical indication for permanent implantation of SCS with the presented method.
Keywords: Complex regional pain syndrome Type II, Neurosurgery, Spinal cord stimulation, Thermography
Complex regional pain syndrome (CRPS) is a chronic pain disorder that develops as a consequence of trauma to one or more limbs.[
Spinal cord stimulation (SCS) is a useful treatment modality for reducing chronic pain. SCS has been generally reported to be a highly effective method for the treatment of CRPS Type I, but its use in CRPS type II has been reported in only a few cases due to the low prevalence.[
A 38-year-old woman was referred to our institute because of chronic left leg pain after Achilles tendon rupture repair surgery. She ruptured her left Achilles tendon and experienced persistent pain after undergoing open surgery for a ruptured left Achilles tendon at a previous hospital. She received oral treatment and epidural blocks at the previous hospital’s pain clinic, but these treatments were not effective. Six months after the surgery, she visited our pain clinic and was diagnosed with left lower extremity CRPS Type II based on the International Association for the Study of Pain diagnostic criteria. Thermography showed that the body surface temperature of the affected foot was 2°C lower than that of the unaffected foot on the healthy side. After an epidural block, thermography showed a significant increase in the body surface temperature of the foot with the pain relief on the observed side. Subsequently, she underwent peroneal nerve dissection during orthopedic surgery, but the pain persisted with decreased temperature of the affected side on thermography [
The patient was placed in a prone position. A straight skin incision (length, approximately 5 cm) was made in the midline to perform the puncture at the L1/L2 and L2/3 levels. The lead implantation was performed under local anesthesia. The first stimulating electrode was placed from the L2/L3 intervertebral space on the left side of the midline so that the tip spanned the level of the upper end of Th9. Stimulus-evoked sensations were confirmed to coincide with the pain site. The second electrode was then implanted from the L1/L2 intervertebral space to the right (approximately midline) of the first electrode [
The patient showed a favorable postoperative course without complications. The numerical rating scale score was 8 points preoperatively, but it improved to 2 points postoperatively. Postoperative findings included an improvement in the temperature decrease on the affected side on preoperative thermography [
CRPS is a chronic neurological pain disorder involving the limbs that are characterized by severe pain along with sensory, autonomic, motor, and trophic abnormalities.[
In a population-based study, the estimated overall incidence rate of all CRPS was 26.2/100,000 person years (95% CI: 23.0–29.7).[
Achilles tendon rupture repair surgery has been reported to cause nerve-related complications. The overall incidence of nerve-related complications in open and percutaneous Achilles tendon rupture repair surgery ranges from 3% to 18%.[
A diagnosis of CRPS is supported by the relatively higher temperature in the pain-affected area, which can be primarily attributed to increased sympathetic activity. Krumova et al. reported that a skin temperature of two degrees Celsius or greater in pain-affected areas demonstrated a diagnostic sensitivity of 73% and specificity of 94% in the diagnosis of CRPS.[
Neuromodulation has been shown to play an important role in treating CRPS, especially in patients who are unresponsive to multiple medical management modalities and sympathetic blockade. Santon reported that if patients do not respond to conventional treatment within 12–16 weeks, SCS should be considered for surgical management.[
Various mechanisms of action for SCS have been suggested. The effects of SCS on the vascular symptoms of CRPS are thought to occur via two main mechanisms: antidromic activation of spinal afferent neurons and inhibition of the sympathetic nervous system.[
SCS could be a useful surgical treatment for medication refractory CRPS type II as supported by our thermography findings. We may refine surgical indication for permanent implantation of SCS with the presented method.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
The authors certify that they have obtained all appropriate patient consent.
This study was partially supported by Japan Society for the Promotion of Science (JSPS) Grant-in-Aid for Scientific Research (C) (Grant number: 18K08956), and the Central Research Institute of Fukuoka University (Grant number: 201045).
There are no conflicts of interest.
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