Title: Traumatic Injury Resulting in Complex Regional Pain Syndrome Alleviated Following Implantation of Cervical Spinal Cord Stimulator

Authors: Christopher Hollabaugh, MD, MPH, MBA. Tyler Concannon, MD

Introduction:

Complex regional pain syndrome (CRPS) is a rare and perplexing chronic regional pain disorder that can present many challenges with its management and occasionally requires advanced treatment modalities. It is characterized by hyperalgesia, allodynia, edema, motor disturbance, and vasomotor instability, and typically occurs following surgery or trauma. In type-I CRPS there is no confirmed nerve injury, while peripheral nerve injury is present in type-II CRPS. The Budapest criteria are currently the most-accepted diagnostic criteria. ¹

Materials and Methods:

 

There are no conflicts of interests to disclose. As the case report is devoid of patient identifiable information, it is exempt from IRB review requirements as per University of Missouri – Kansas City policy. Patient informed consent was obtained for submission. There are no off-label indications, promotional content of a commercial entity, copyrighted figures, images, or content.

 

Results/Case Report:

This case involves a 29-year-old female diagnosed with CRPS Type 2 of the LUE following an MVC rollover in 2012 resulting in winging of her scapula and chronic pain. In 2022, her symptoms worsened following a chiropractor adjustment. Her symptoms and presentation progressed to involve extreme pain in her left neck/shoulder/axilla, cyanosis of the affected area, temperature changes, heat/cold intolerance and hypersensitivity consistent with a diagnosis of CRPS. In the interim, the patient has failed conservative measures including physical therapy, injections, and medication management. The patient was seen by neurosurgery, orthopedic surgery, PM&R, and prior interventional chronic pain specialists. As part of this multidisciplinary workup, the etiology of the patients’ pain remained unclear with numerous diagnostic modalities including advanced imaging and EMG. After extensive discussion with the patient regarding existing treatment options, the decision to proceed with a cervical spinal cord stimulator was made. On 11/16/23, trial spinal cord stimulator leads were placed successfully. Positioning was accessed via the T3-4 interspace using a paramedian LOR technique with leads terminating at the top of C2 and C6. Lead placement was chosen to capture the dorsal scapular nerve takeoff and brachial plexus, along with traditional LUE. During follow up, the patient reported up to 65% relief in her left scapular region and near resolution of the left axillary pain. She was able to complete all tasks of daily living without increases in her pain. Following a successful trial, the patient elected to proceed with implantation on 1/11/24. The leads were placed in a similar fashion at the C2 and C6 vertebral body. The patient healed postoperatively without complications and during initial follow up in clinic, reported a 70-80% relief of pain as well as improvement in function.  

Discussion:

As seen within this case, the treatment of CRPS presents many challenges, particularly for patients escalating through conservative measures while enduring the pain and lifestyle modifications of this syndrome. Though preoperative selection plays a crucial role, fortunately for this patient population, multiple studies have shown that spinal cord stimulation is a promising option. ² Numerous studies have demonstrated pain scores, and psychological distress are often improved following SCS implementation, and this treatment modality should be kept in mind for therapy refractory cases. ³