23rd Annual Pain Medicine Meeting 2024

Title: Complex Regional Pain Syndrome in a 73-Year-Old Female Post-Needlestick Injury: Interventional Pain Management Strategy

Authors: Mohamed Awad, MD, Adam Betcher, MD, Ria Malhotra, MD, Sayed Wahezi, MD

Instituition: Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY, Physical Medicine and Rehabiliation1

Introduction:

Complex Regional Pain Syndrome (formerly reflex sympathetic dystrophy/causalgia) follows trauma to a limb.

Budapest Criteria for CRPS Diagnosis:

Budapest 1 Criteria (Strict Diagnostic Criteria):

Primarily for research (more stringent).

Requires signs and symptoms in all 4 categories:

Sensory: Hyperesthesia and/or allodynia.
Vasomotor: Temperature asymmetry or skin color changes.
Sudomotor/Edema: Edema or sweating changes/asymmetry.
Motor/Trophic: Reduced range of motion, motor dysfunction, or trophic changes (skin, hair, nails).

Diagnosis:

Symptoms in ≥3 categories.
≥1 sign in ≥2 categories during physical exam.

Budapest 2 Criteria (Less Strict Clinical Criteria):

Used in clinical practice (more flexible).
Same 4 categories as Budapest 1.
Allows diagnosis with fewer signs/symptoms.
Less stringent physical exam requirements.

Needlestick-induced neuropathic pain is rare but disabling.

Materials and Methods:

Informed consent obtained from the patient. Report contains no identifiable information.

IRB exemption granted per Montefiore Medical Center policy.

Case Study:

Patient Profile: 73-year-old female with severe left-hand pain.

Cause: Pain followed a needlestick injury at the antecubital fossa.

Onset: Pain began the day after the injury; attributed to nerve damage.

Symptoms:

Swelling
Significant functional limitations (unresponsive to occupational therapy)

Examination Findings:

Met Budapest criteria for CRPS
Exhibited:
Allodynia
Atrophy of intrinsic hand muscles
Vascular changes
Mild edema

Diagnostic Imaging: X-ray revealed osteoarthritis in the fingers.

Diagnosis: CRPS Type 3 secondary to needlestick nerve injury (left upper extremity).

Treatment Options Discussed:

Spinal cord stimulation (SCS)
Peripheral nerve stimulation (PNS)

Future Plan: Patient opted for PNS targeting:

Left radial and musculocutaneous nerves
Ulnar nerve as an alternative

Follow-up Plan: Resumption of occupational therapy post pain control improvement.

Discussion:

Risk of Injury: Venipuncture at the antecubital fossa may cause nerve injury due to close proximity of nerves to veins.

Rarity of CRPS Development:

Such injuries rarely result in CRPS, as demonstrated in this case.

Management Challenge:

Treating symptoms post-CRPS diagnosis is complex.

Peripheral Nerve Stimulation (PNS):

Promising in managing CRPS-related pain.
Hassenbusch et al. study: 30 of 32 patients achieved ≥50% pain reduction with permanent electrode implants.
63% reported good or fair relief after 2-4 years.
VAS pain scores improved from 8.3 ± 0.3 to 3.5 ± 0.4.
20% returned to work.

Additional Findings:

Cooney's research showed PNS improved pain, sleep, and psychological well-being in CRPS patients.

Case Implications: Highlights potential for needlestick injuries to cause chronic CRPS and the effectiveness of PNS for severe pain and functional limitations.

Need for Ongoing Evaluation: Continuous assessment and therapy adjustments are essential for optimal outcomes.

Evidence Quality: Most studies on PNS for CRPS are case series or reports (Level IV evidence), indicating a need for higher-quality research.

REFERENCES:

Bruehl, S., & Warner, D. S. (2010). Anesthesiology, 113, 713–725. https://doi.org/10.1097/ALN.0b013e3181e3db38
Hassenbusch, S. J., et al. (1996). J Neurosurg, 84(3), 415–423. https://doi.org/10.3171/jns.1996.84.3.0415
Hirata, H. (2014). Hand Surgery, 19(2), 151–162. https://doi.org/10.1142/S0218810414400012
Ramos, J. A. (2014). Braz J Anesthesiol, 64(2), 131–133. https://doi.org/10.1016/j.bjane.2013.06.003
Xu, J., et al. (2021). Pain Physician, 24(2), E131-E152.

23rd Annual Pain Medicine Meeting 2024

CRPS (COMPLEX REGIONAL PAIN SYNDROME) IN A 73-YEAR-OLD FEMALE POST NEEDLESTICK INJURY: INTERVENTIONAL PAIN MANAGEMENT STRATEGY

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