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Case Reports  |   June 1997
Development of Complex Regional Pain Syndrome after a Cervical Epidural Steroid Injection 
Author Notes
  • Assistant Professor of Anesthesiology.
  • Received from Department of Anesthesiology, College of Physicians and Surgeons, Columbia University, New York, New York, and the Pain Management Center, Presbyterian Hospital, New York, New York. The work was performed at The Columbia-Presbyterian Medical Center. Submitted for publication November 18, 1996. Accepted for publication February 28, 1997.
  • Address reprint requests to Dr. Siegfried: Pain Management Center, Presbyterian Hospital, 622 West 168th Street, PH 5–500, New York, New York 10032.
Article Information
Case Reports
Case Reports   |   June 1997
Development of Complex Regional Pain Syndrome after a Cervical Epidural Steroid Injection 
Anesthesiology 6 1997, Vol.86, 1394-1396. doi:
Anesthesiology 6 1997, Vol.86, 1394-1396. doi:
The pathophysiology of the complex regional pain syndrome (CRPS) remains uncertain, and many events have been implicated as causative factors. Events as serious as major trauma and as seemingly innocuous as venipuncture have been incriminated. [1 ] Trauma to nervous tissue can be a causative factor in CRPS, type II. [2 ] This report describes a patient in whom a constellation of symptoms consistent with CRPS, type II developed after a cervical epidural steroid injection.
Case Report 
A woman, aged 49 yr, was referred with a history of right upper extremity pain secondary to C4-C5 and C3-C4 herniated discs. She had undergone a C4-C5 anterior discectomy with interbody fusion followed by a C3-C4 anterior discectomy with interbody fusion. Both of these surgeries failed to relieve her right upper extremity pain. A post-myelogram computed tomography (CT) scan performed 2 months after surgery showed spinal cord impingement at C4-C5 and C6. Despite management with physical therapy and nonsteroidal antiinflammatory drugs (NSAIDS), her symptoms failed to improve.
On initial presentation, the patient complained of constant sharp pain in the left shoulder and lateral upper arm. Physical examination revealed a normal-appearing extremity. There was decreased sensation to pinprick in the left shoulder and lateral upper arm and decreased strength in the deltoid and biceps muscles. Brachioradialis, biceps, and triceps deep tendon reflexes were intact. Examination of the contralateral extremity was normal. Given this evidence for cervical radiculopathy, a cervical epidural injection was planned.
The patient was placed in the sitting position with the arms at the side, the neck flexed, and the head resting on a cushion. An 18-gauge Hustead needle was inserted into the C5-C6 interspace using a midline approach. The hanging drop technique was used to locate the epidural space. The epidural space was entered at 5-cm depth from the skin. On entering the epidural space, the patient immediately complained of the sudden onset of throbbing pain in the right shoulder.
After more than 30 s, this pain resolved. No cerebrospinal fluid or blood could be aspirated through the Hustead needle. A solution containing 4 ml of preservative-free normal saline and 2 ml (80 mg) of methylprednisolone was injected. The patient reported no discomfort during the injection. On withdrawing the needle, the patient again began complaining of throbbing right shoulder pain. During a 15-min period, this pain resolved completely, and the patient was discharged.
During routine follow-up evaluation 2 days later, the patient reported that the throbbing pain returned 6 h after the procedure and spread throughout the entire right arm. She reported spontaneous lancinating pain originating in the distal portion of the right first digit and radiating up the arm to the elbow. She kept her right index finger in extension, avoiding contact with the other digits of the hand. There was no difference in the appearance and temperature of her upper extremities. Motor function and deep tendon reflexes were intact. Sensation to pinprick was unchanged from the initial examination. The right index finger exhibited significant allodynia in a circumferential distribution extending from the proximal interphalangeal joint to the finger tip. Lightly touching this area caused lancinating pain radiating up the arm. The remaining portions of the right upper extremity had normal sensation. The patient was started on carbamazepine at a dosage of 200 mg by mouth every 8 h.
The patient was reexamined 5 days later. She reported gastric upset and no pain relief from the carbamazepine. The right upper extremity was held close to the body with the elbow and wrist flexed. The hand was swollen, and the skin temperature of the right index finger was 5 degrees Celsius lower than the left. There was significant allodynia involving the extremity extending from the finger tips to midway between the elbow and the shoulder. Motor function and deep tendon reflexes appeared intact. The diagnosis of CRPS was entertained. The inability to establish peripheral venous access precluded a diagnostic intravenous infusion of phentolamine. [3 ] A decision was made to treat with the oral alpha-adrenergic blocking agent terazosin, which was begun at a dose of 1 mg by mouth at bedtime. [4 ] Arrangements were made for an occupational therapy evaluation and institution of an aggressive program of desensitization and stress-loading exercises. [5 ] However, 4 days later, no improvement was noted. The terazosin dosage was increased to 2 mg. No improvement was noted 4 days later, and the decision was made to proceed to a stellate ganglion block. A CT-guided technique was planned because of the previous anterior cervical surgery and resulting distorted anatomy of the neck. [6 ]
Sequential coronal CT views were used to guide placement of a 22- gauge, 3.5-inch quincke tip spinal needle onto the head of the right first rib via an anterolateral approach. Proper placement was confirmed using iohexol (Omnipaque 180(R)). After this, 4 ml of lidocaine, 1%, were injected. An 8.5 degrees Celsius unilateral (right) temperature increase was achieved within 10 min. The patient noted total relief of pain and return of full active range of motion of the right upper extremity coinciding with onset of sympathetic blockade. This occurred within 10 min. No sensory or motor deficits consistent with somatic blockade developed. Physical examination revealed complete resolution of allodynia in the extremity in all regions. No subsequent sympathetic nerve blocks were undertaken. The patient discontinued physical therapy 2 weeks later. All signs and symptoms consistent with sympathetically mediated pain have remained resolved at 1 yr after block, despite discontinuation of terazosin at 4 weeks. The patient has returned to her baseline functional level.
Discussion 
The precipitating event for the development of CRPS in this patient appears to be trauma to a cervical nerve root. Elicitation of a paresthesia during the insertion of the needle into the epidural space can provide clinical evidence of contact with a nerve root. Ideally, electrodiagnostic studies would be required to support the diagnosis of nerve root trauma. Because this patient responded to treatment rapidly, these studies were not performed.
The variation in clinical presentation among patients, and in an individual patient over the course of the disorder, makes diagnosis difficult. Conventional diagnostic tests such as plain radiographs and triple-phase bone scans have a limited role. These tests should be combined with information from the history, physical examination, and sympathetic testing to establish the diagnosis.
Management of CRPS can be approached in several different ways. The resistance of this disorder to treatment may require a multimodal and multidisciplinary approach. Intensive physical rehabilitation emphasizing restoration of function is at the core of any management plan. Although pain relief is of paramount importance to allow the patient's active participation in such a program, it may not be achievable using conventional types of analgesics via the oral, intravenous, or transdermal routes. Peripheral or neuraxial somatic neural blockade may provide pain relief while sacrificing the patient's active participation in therapy. Sympathetic blockade remains the mainstay of pain relief in sympathetically mediated pain states. Systemic sympatholytic drugs may be used. Phentolamine (intravenous) may be used for diagnosis and terazosin (oral) for management. Despite encouraging reports of oral and intravenous sympatholysis, sympathetic neural blockade remains the standard. Given the history of two anterior cervical spine surgeries in this patient, systemic sympatholysis was attempted. Ultimately, a stellate ganglion block was necessary. Unlike somatic neural blockade, sympathetic neural blockade can provide pain relief while sparing motor function. This allows the patient's active participation in rehabilitation. The stellate ganglion block is the most practical technique for unilateral upper extremity pain. The CT-guided approach to the stellate ganglion permits the performance of sympathetic blockade in patients with distorted cervical anatomy. Although intravenous regional sympathetic blockade may also be used in this situation, it was not chosen in this case because of the difficulty with intravenous access.
Complex regional pain syndrome needs to be in the differential diagnosis of any patient who presents with pain combined with any of the neurologic signs and symptoms mentioned previously. Rapid diagnosis and aggressive treatment clearly enabled this patient to return to normal function after a relatively short course of treatment.
References 
References 
Bonica JJ: Causalgia and other reflex sympathetic dystrophies, The Management of Pain, 2nd ed. Edited by Bonica JJ. Philadelphia, Lea & Febiger, 1990, pp 220-43.
Baron R, Blumberg H, Janig W: Clinical characteristics of patients with complex regional pain syndrome in Germany with special emphasis on vasomotor function, Reflex Sympathetic Dystrophy: A Reappraisal. Edited by Janig W, Stanton-Hicks M. Seattle, IASP Press, 1996, pp 25-48.
Raja SN, Treede RD, Davis KD, Campbell JN: Systemic alpha-adrenergic blockade with phentolamine: A diagnostic test for sympathetically maintained pain. Anesthesiology 1991; 74:691-8.
Stevens DS, Robins VF, Price HM: Treatment of sympathetically maintained pain with terazosin. Reg Anesth 1993; 18:318-21.
Carlson L, Watson HK: Treatment of reflex sympathetic dystrophy using the stress-loading program. J Hand Ther 1988; 4:149-53.
Hogan QH, Erickson SJ, Abram SE: Computerized tomography-guided stellate ganglion blockade. Anesthesiology 1992; 77:596-9.