Intraoperative Pain Management for Treatment-Resistant Complex Regional Pain Syndrome: A Case Report.

Complex regional pain syndrome (CRPS) is a chronic neuropathic pain disorder often following trauma, associated with severe pain and autonomic disturbances in the affected limbs. Managing CRPS is challenging due to the lack of FDA-approved medications, often requiring off-label treatments. Traditional options like nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids show limited efficacy, while adjunctive treatments such as gabapentin, antidepressants, and bisphosphonates are increasingly favored. Surgical interventions, including nerve blocks and spinal cord stimulation, may help in refractory cases but have varying success rates. Recent discussions highlight intraoperative ketamine, which targets N-methyl-D-aspartate (NMDA) pathways linked to CRPS. This case study illustrates the complexity of CRPS management, particularly how psychosocial factors and secondary trauma can exacerbate or alleviate symptoms. The case centers on a treatment-resistant flare-up of CRPS, managed through revision neurolysis of the sciatic, tibial, and perineal nerves, along with the release of the right tibial nerve and intraoperative ketamine. Trauma's impact is evident, as the patient initially went into remission after nerve decompression, only for symptoms to return severely following a subsequent trauma. This emphasizes the need for a multipronged treatment approach. Intraoperative ketamine provides rapid pain relief during and after surgery, benefiting patients with severe chronic pain while reducing post-surgery opioid needs and minimizing dependency risks. Patients typically achieve improved functional recovery and better rehabilitation engagement. Research suggests ketamine may offer long-lasting pain relief and psychological benefits, positively impacting mood and anxiety.
Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.
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