Pain

Analgesic use is controversial with regard to opiates. There has been a feeling that opiate analgesics were ineffective in neuropathic pain and that their use would predispose patients to addiction. These fears, while not groundless, have been overstated and there is evidence from RCTs that, at least in the short term, narcotic analgesics have a place in the management of neuropathic pain. It would seem, therefore, reasonable to try narcotic analgesics for patients with neuropathic pain that has not responded to the more conventional approaches outlined above [2,3,6,7].

Invasive Therapies

Interventional techniques have been used -both somatic and autonomic blockade. Permanent somatic block, where feasible, does not normally produce long-lasting relief and has largely fallen out of favor.

Sympathetic blockade may be achieved para-vertebrally or by a simpler, less invasive regional approach. This technique can be used in both the upper and lower limbs (although sedation will be needed for lower-limb blockade, as it can be extremely uncomfortable). The limb is exsanguinated and a double cuff applied, inflated to 100 mmHg above the patient's systolic blood pressure. Guanethidine (5-10 mg) mixed with prilocaine is then injected intravenously, with the cuff left inflated for 10-15 minutes. Guane-thidine depletes the sympathetic nerve endings of noradrenaline, the local anesthetic being added to provide pain relief during the procedure, as it can be very uncomfortable. Other drugs used include ketanserin and bretylium.

The sympathetic supply to the upper limb can easily be blocked by injection of local anesthetic around the stellate ganglion lying on the transverse process of C6. The sympathetic supply to the lower limbs can be blocked, either by an epidural or by a lumbar sympathetic block. The sympathetic supply to legs and lower gut lies on the lateral aspects of the bodies of L2-L4. Using X-ray control and contrast, needles can be accurately placed in order to inject either local anesthetic or neurolytic solutions (although caution should prevail before injecting neurolytic solutions in younger patients because of the incidence of genitofemoral neuralgia). Sympathetic blockade should be accompanied by active physiotherapy to increase function within the affected limb.

There is no one, single, proven successful treatment of CRPS and, indeed, there is a group of patients in which treatment will never be successful. It is also worth remembering that the longer the condition is left untreated, the more difficult it becomes to treat, as disuse leads to further pain and the development of a more permanent disability. The majority of patients can expect to be incapacitated for 12-18 months before return to normal function occurs.

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