CRPS preventative anesthesia plan

[bedrock]

I'm PMR/Pain. I have a long standing patient who I've been treating for chronic right SIJ dysfunction and mild left knee OA. Patient is a early 50s RN and previously underwent steroid injections to left knee and right SIJ without issues, but demonstrated moderate but noticeable hyperalgesia when I gave her a left ankle injection last year after she tore her lateral ankle ligaments and failed PT/orthotics.

She needs a brostrum and calcaneal osteomy for left ankle instability/hindfoot varus. She posed a question to me that I couldn't answer which is why I post it here as it overlaps both pain and anesthesia.

She had a left thigh sarcoma removed 20 year ago which required heavy XRT to the posterior thigh. Due to radiation she has a chronic, mild-moderate, left sciatic neuropathy, with mild hyperalgesia of the LLE distal to the radiation field (posterior thigh through the popliteal fossa), but overall she is very functional and prior to tearing her ankle tendons in a fall last year, was hiking 4-5 miles every weekend.
She does require QHS tramadol and baclofen for her leg pain/neuropathic spasm. She previously failed 4 neuropathic medications.

She is concerned that she carries a higher risk of CRPS for her upcoming ankle surgery (brostrum/calcaneal osteotomy) in her cancer leg (with the sciatic neuropathy and mild hyperalgesia) and she trying to be proactive about minimizing her risk of developing CRPS post surgery.

I have two questions to the group.

1- what would be your anesthesia plan for this patient who likely has a higher CRPS risk, but who can't have a sciatic block or popliteal catheter due to extensive radiation scarring of both areas?
1a- I assume that you'd recommend blocks of all nerves at the ankle if sciatic/popliteal blocks are out, correct?
1b-Is there much added value to adding a spinal? Or is it unnecessary from a CRPS prevention standpoint if the patient gets distal ankle blocks?

2- Anything else you'd add to your IV anesthesia meds to help prevent wind up in this patient?
2a-Anything you recommend I write for her in the pre/perioperative standpoint, to minimize windup such as QHS gralise the night before surgery, etc?

Thanks

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[nimbus]

Nerve blocks have been implicated as a cause of CRPS so some anesthesiologists will not perform nerve blocks on CRPS patients.

Regarding IV anesthetics, there is some anecdote that ketamine may be helpful.

Best way to prevent an exacerbation of CRPS is to avoid trauma and avoid surgery. That may not be an option for your patient and she should understand that risk. AFAIK, there is nothing that an anesthesiologist can do that will reliably prevent CRPS or prevent an exacerbation of CRPS.

 

[DirtDocMD]

Nerve blocks have been implicated as a cause of CRPS so some anesthesiologists will not perform nerve blocks on CRPS patients.

Regarding IV anesthetics, there is some anecdote that ketamine may be helpful.

Best way to prevent and exacerbation of CRPS is to avoid trauma and avoid surgery. That may not be an option for your patient and she should understand that risk.

If she has extreme “concern” or “risk” for CRPS, I wouldn’t even THINK about putting a needle in her, for any blocks. Probably more data out there that would “implicate” them (like Nimbus says) than data that says they “prevent” CRPS. Just my two cents…

 

[bedrock]

Nerve blocks have been implicated as a cause of CRPS so some anesthesiologists will not perform nerve blocks on CRPS patients.

Regarding IV anesthetics, there is some anecdote that ketamine may be helpful.

Best way to prevent an exacerbation of CRPS is to avoid trauma and avoid surgery. That may not be an option for your patient and she should understand that risk. AFAIK, there is nothing that an anesthesiologist can do that will reliably prevent CRPS or prevent an exacerbation of CRPS.

Thank you.
Just to be clear, this patient doesn’t have CRPS. She has mild hyperalgesia to painful stimuli, but definitely doesn’t currently have CRPS, and tolerates normal touch without any pain.

Thank you regarding IV ketamine suggestion during anesthesia.

 

[bedrock]

If she has extreme “concern” or “risk” for CRPS, I wouldn’t even THINK about putting a needle in her, for any blocks. Probably more data out there that would “implicate” them (like Nimbus says) than data that says they “prevent” CRPS. Just my two cents…

I certainly recognize that peripheral nerve blocks have been implicated in some CRPS cases.

However, I thought that in addition to better immediate post op pain control, that regional blocks were thought to decrease the incidence of CRPS/minimize windup?

Am I not understanding that correctly?

 

[deleted875186]

I think it’s been debunked, but people used to do high dose vitamin C preop and postop, you’d have to look it up though. I would do multimodal with ketamine, acetaminophen, NSAID, nerve block although I personally wouldn’t be excited to place a needle in this patient. I would start lyrics or gaba preop, even if she’s failed it, pretty low risk.

 

[bedrock]

I think it’s been debunked, but people used to do high dose vitamin C preop and postop, you’d have to look it up though. I would do multimodal with ketamine, acetaminophen, NSAID, nerve block although I personally wouldn’t be excited to place a needle in this patient. I would start lyrics or gaba preop, even if she’s failed it, pretty low risk.

Happy to do preop lyrica/gabapentin, NSAID. I'll suggest she ask anesthesia regarding ketamine. Is clonidine sometimes used as well for this?

I was looking to educate myself about the rest because I haven't had this question asked of me before as PMR/Pain doc.

I can definitely understand anethesia not being particularly excited to do a block on this patient, but liability aside, say if you were practicing in the VA, etc without any risk of being sued, wouldn't a block, even distal ankle blocks without popliteal cathether, reduce the windup as well as post op pain burden on this patient?

 

[deleted875186]

Happy to do preop lyrica/gabapentin, NSAID. I'll suggest she ask anesthesia regarding ketamine. Is clonidine sometimes used as well for this?

I was looking to educate myself about the rest because I haven't had this question asked of me before as PMR/Pain doc.

I can definitely understand anethesia not being particularly excited to do a block on this patient, but liability aside, say if you were practicing in the VA, etc without any risk of being sued, wouldn't a block, even distal ankle blocks without popliteal cathether, reduce the windup as well as post op pain burden on this patient?

Yes, although nerve blocks and epidurals have not ever proven to decrease incidence of persistent post surgical pain, not sure if it’s every been studied for CRPS.

If I was treating this person, I would offer to try a popliteal block under ultrasound and nerve stimulation for the patient if they sounded reasonable.

 

[bedrock]

Yes, although nerve blocks and epidurals have not ever proven to decrease incidence of persistent post surgical pain, not sure if it’s every been studied for CRPS.

If I was treating this person, I would offer to try a popliteal block under ultrasound and nerve stimulation for the patient if they sounded reasonable.

nerve stimulation, what do you mean by that?

BTW, I did some research on this today and this was the best paper I could find on the topic, though it is from 2004. Right after I finished med school, so maybe this is something I heard on my MS4 anesthesia rotation.

I remember attending a lecture re anesthesia IV meds to decrease post op pain via less windup. I thought regional blocks might have been discussed. However this was 20 years ago and I'm not anesthesia, which is why I asked about it here.

 

[deleted875186]

Sorry, I mean use a traditional nerve stimulator with motor stimulation when doing the block to help identify correct location and make sure I’m not injecting in the nerve if there’s some concern there is scarring in the area.

 

[nimbus]

nerve stimulation, what do you mean by that?

BTW, I did some research on this today and this was the best paper I could find on the topic, though it is from 2004. Right after I finished med school, so maybe this is something I heard on my MS4 anesthesia rotation.

I remember attending a lecture re anesthesia IV meds to decrease post op pain via less windup. I thought regional blocks might have been discussed. However this was 20 years ago and I'm not anesthesia, which is why I asked about it here.

Not saying everything in that review is invalid but it’s quite a coincidence that you found a paper by the infamous Scott Reuben. Probably one of the reasons that paper was not retracted is because it is a review and not original research. Still, several of the papers cited in that review have been retracted because they were made up. I’d say most of the conjectures in that review have not yet been validated. Like some others in academics, he was a guy with an agenda out to make a name for himself and not an impartial or hardworking seeker of truth.

“Reuben was considered to be a prolific and influential researcher in pain management, and his purported findings altered the way millions of patients are treated for pain during and after orthopedic surgeries.[1]Reuben has now admitted that he never conducted any of the clinical trials on which his conclusions were based "in what may be considered the longest-running and widest-ranging cases of academic fraud."

Scott Reuben - Wikipedia

en.wikipedia.org

A Medical Madoff: Anesthesiologist Faked Data in 21 Studies

A pioneering anesthesiologist has been implicated in a massive research fraud that has altered the way millions of patients are treated for pain during and after orthopedic surgeries

www.scientificamerican.com

 

[lobelsteve]

Vit C. 1000mg qd.

2 weeks before and 4 weeks after surgery.