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Early ID of Complex Regional Pain Syndrome By Dr Brian Lee, Pain management specialist, Perth Complex regional pain syndrome is a bit of a mythical creature; often talked about, but not clearly understood. So let’s demystify. A patient comes to see you who is in considerable distress with their persistent pain. Perhaps the pain started after an appropriately treated wrist or ankle injury. Some months later, the patient describes ongoing pain out of proportion to the objective suggestions of adequate healing. What do you do? Despite what the name suggests, not all ‘complex’ pain in a region of the body is a Complex Regional Pain Syndrome (CRPS). While its pathophysiology is not well understood, its old term ‘Reflex Sympathetic Dystrophy’ alludes to its common findings associated with cutaneous sympathetic dysregulation.
CRPS generally occurs in body extremities (most commonly upper limb, such as hand/wrist) and follows an injury. This can include verifiable neural injury (such as in CRPS 2/causalgia), but do not in the majority of cases. Pain is almost certainly out of proportion to the original injury, and persists well after normal healing has occurred. A good tool to aid practitioners is the Budapest diagnostic criteria for CRPS, which summarises the common complaints and presentation associated with this condition including the four categories of symptoms/signs: 1. Sensory abnormalities: allodynia and/or hyperalgesia. While not specified in the criteria, patients often describe other neuropathic characteristics such as electric shock, burning, paraesthesia and
Key messages
CPRS pain is typically in an extremity
The pain sounds neuropathic and impairs movement
Temperature skin and hair changes plus extreme tenderness may be present. hypoalgesia. These generally do not follow a discernable dermatome distribution. 2. Vasomotor abnormalities: presumed vascular dysregulation often results in a noticeable colour asymmetry, which can be red ‘hot’ or blue ‘cold’. This is associated with temperature asymmetry, which can be assessed accurately with an infrared thermometer.
Marker Clips - info for GPs Patients returning from BreastScreen WA’s Assessment Clinic may ask their GP about marker clips. A marker clip is a small metal clip (a few mm long) that may be inserted into the breast by a radiologist to mark the site of a biopsy when the imaging detected lesion has been substantially removed during the core biopsy process. Marker clips may be required when multiple lesions are present to differentiate between lesions. This allows the biopsy site to be located if surgery is required, at which time the marker clip is removed. All marker clips have a small metallic component which is visible on X-ray. If the area of breast tissue containing the marker clip does not need to be surgically removed, the marker clip will indicate on
future mammogram studies that the patient has had a biopsy. Are marker clips safe? • The marker clips used at BreastScreen WA clinics are not harmful to the body, and have been approved for use in Australia by the Therapeutic Goods Administration. • It is safe for a marker clip to stay in the body if it does not have to be removed. • The marker clips do not rust or corrode. Women will be able to have an MRI examination if required. The clip will not set off a security metal detector. • International medical studies have not shown an increased risk or any long term complications associated with having a marker left in the breast.
Women may book online - www.breastscreen.health.wa.gov.au - or phone 13 20 50 42 | MARCH 2020
Mar ‘18
What if your patient has any questions? If your patient has any queries about marker clips, she can call 9323 6710 to speak to a breast assessment nurse.
MEDICAL FORUM | PAIN MANAGEMENT ISSUE
