The Development of Complex Regional Pain Syndrome Following Nerve Injury in the Lithotomy Position: A Case Report
Victor Yu, MD; Chelsey-Ann Patry, MD; Priyanka Singla, MD
Department of Anesthesiolgoy, University of Virginia Health System
Introduction
ØComplex regional pain syndrome (CRPS) - painful and debilitating condition
ØTypically presents after sustaining trauma or surgical insult to a limb
ØFew case reports of CRPS developing in an uninjured limb after prolonged immobilization during surgery.
Case Summary
Ø37 yo M PMH kidney stones, ADHD, cystic fibrosis/w pancreatic insufficiency for robotic low anterior approach rectal resection for rectal cancer
ØUnderwent GA in the supine lithotomy position with no intraoperative complications
ØAfter waking up from surgery, the patient complained of LLE pain as well as numbness over the middle 3 toes of the left foot à swelling and tenderness over the area.
ØNegative in hospital work up à lidocaine infusion
ØOut patient follow up in pain clinic - diagnosed with neuropathic pain in sciatic distribition, ordered EMG
ØEMG - left sciatic neuropathy with the lesion likey localizing to the left hip or thigh with moderate axonal loss with involvement of both the fibular and tibial distributions of the nerve.
ØConservative treatment – PT, pregabalin, duloxetine with reasonable control of his symptoms.
ØAfter 6 months, developed allodynia and skin color changes. Evaluated and diagnosed with CRPS Type 2.
Discussion
ØCRPS type 2 - developed in a patient who sustained a nerve injury related to intra - operative positioning.
ØAlmost 81% of lithotomy related injuries result in damage to the common peroneal nerve
ØMechanism - excessive stretching of the sciatic nerve caused by flexion of the hip during positioning.
ØPathophysiology of CRPS - multiple theories exist:
- Inflammatory process leading to central sensitization and eventually autonomic features
ØTreatment modalities include a broad range of therapies. Physical therapy remains the cornerstone of treatment. Psychological treatment with CBT
Pharmaceutical options - SNRIs, TCAs, and gabapentinoids
Refractory cases - selective nerve block or PNS/SCS
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References
1.Matthew K. Tollefson, Stephen A. Boorjian, Bradley C. Leibovich, COMPLICATIONS OF THE INCISION AND PATIENT POSITIONING, Editor(s): Samir S. Taneja, Complications of Urologic Surgery (Fourth Edition),W.B. Saunders, 2010, Pages 225-236,ISBN 9781416045724,https://doi.org/.
2.2. Huygen FJ, De Bruijn AG, De Bruin MT, Groeneweg JG, Klein J, Zijlstra FJ. Evidence for local inflammation in complex regional pain syndrome type 1. Mediators Inflamm. 2002 Feb;11(1):47-51.
3.3. Jarrell JF, Vilos GA, Allaire C, Burgess S, Fortin C, Gerwin R, Lapensee L, Lea RH, Leyland NA, Martyn P, Shenassa H, Taenzer P. No. 164-Consensus Guidelines for the Management of Chronic Pelvic Pain. J Obstet Gynaecol Can. 2018 Nov;40(11):e747-e787.
4. Buddapest criteria table: https://img1.wsimg.com/isteam/ip/98e44764-d15a-424e-9103-d3847aa458d4/blob-49b55c1.png/:/cr=t:13.32%25,l:13.55%25,w:76.92%25,h:76.92%25/rs=w:984,h:738
