Complex Regional Pain Syndrome To Amputate Or Not Nursing Essay

Complex Regional inconvenience superstarself Syndrome To Amputate Or non Nursing EssayAbstractComplex Regional Pain Syndrome is chafe syndrome confined to one or more step to the foregrowths, usually occurring after trauma. The score of CRPS remains unknown and its diagnosis is base upon a determine of clinical signs and symptoms the Budapest Criteria (figure 1). CRPS is characterised by the presence of limb anguish associated with sensory, motor, autonomic, skin and drum changes. It is often resistant to discourse and its clinic course is difficult to predict. Early diagnosis and treatment from a multidisciplinary team is associated with the high hat outcome. In the UK there has been new-fashioned guidelines published to aid the diagnosis and treatment of CRPS. The mainstay of this treatment is physiotherapy, unhurried program line and the medical exam forethought of bruise in the neck. The patient in this case was schedule to undergo an amputation of the affect ed limb prior to trying either of the to a higher place commission, indeed prior to even being diagnosed with CRPS. Amputation for the treatment of CRPS is controversial. Evidence based guidelines regarding CRPS currently state that there is insufficient evidence to prove that amputation positively contributes to the treatment of the patient. It besides runs the risk of the patient suffering from phantom limb pain or CRPS recurring in the stump or contralateral limb. If indeed CRPS is a sympathetically mediated neuropathic pain, as proposed, surgery to the cranial orbit is likely to aggravate the condition. Tissue damage locally will chair in the release of inflammatory neurokines leading to up regulation of the tolerant and nervous system. Amputation in the presence of CRPS can only therefore be justified in the treatment of therapy-resistant infection after other treatment options become been explored. Even more pertinent to this case was that the patient had never tried m ore conventional treatment options before an amputation was decided upon. encase PresentationReferral InformationPatient JM was referred by Dr FJ, consultant in reformation medicine as a query diagnosis of CRPS of his respectable demean limb. JM was scheduled to have a Symmes amputation, under a Professor MS a consultant orthopaedic surgeon, two weeks after this referral was made.Questionaire ScoresMPSQ 8Mod Zung 21Current ProblemJM complained of gradually worsening pain in ripe(p) ankle and foot over a xxiv month period. He scored his pain from 2-8/10 worse on perch touch, cold weather and at the end of the day. The pain was accompanied by decreased motor function, oedema, an increase in sweating and skin semblance changes in the limb. He described his pain as like a really bad tooth ache especially worse when the limb was bootless and only decreased by rest and elevation. He described a dropping sensation in the foot despite it being amalgamate at the ankle which ca drops such severe pain it has at propagation caused him to vomit.Background HistoryJM was born with a congenitally abnormal serious tibia. As a child he underwent sevenfold operations on his correctly ankle. He has had two osteotomies, a bone graft and Lizorov frame and a triple arthrodesis at this ankle joint.Past Medical HistoryJM has no other medical problems.Drug HistoryDihydrocodine 30mg four times a day. No other medication tried.Family HistoryNo family medical chronicle of note. Mum and Dad alive and well.Social HistoryJM lives with his parents and feats in IT full time from an office at home. He feels that his career promotion has been halted over the last few years as his pain has increase and his function worsened. He has an active social life and close family support. He abuted regular tennis until the pain in his ankle change magnitude a few years ago but hasnt been able to play since 2010. He denies any depression or anxiety although finds his functional limitations frustrating. His draw attended his first clinic appointment and was exceedingly upset and anxious when it was suggested that her son try medical treatment options before resorting to a Symmes amputation. She felt that JM had at rest(p) through a lot of psychological distress coming to legal injury with the prospect of having his leg amputated at the foot and was fully decided this was the best course of action only for that decision to be questioned. JM didnt have any expectations of the pain clinic other than to help him reduce his pain to a habitable level. The main reasons given by the Orthopeadic team for amputation was functional to improve his yard and in the long run reduce possible arthritic changes exploitation ascribable to his poor posture.Examination FindingsJMs right lower limb on inspection was swollen from below the knee, with a pale dis tingeation and multiple operation scars at the ankle. There were noticeable trophic changes in the nails of the right foot but no hair or skin changes locally. His right ankle is fused in fixed dorsi flexion. On palpation it is caller to touch and clammy when compared to the left lower leg and ankle. JM is tender to empty-headed touch over the medial aspect of the right ankle. The right knee has normal and has a good range of movement.Diagnostic FormulationJMs right ankle is positive for the Budapest Diagnostic Criteria for Complex Regional Pain Syndrome.SensoryAllodyniaHyperalgesiaVasomotorTemperature asymmetrySkin colour changesSkin colour asymmetrySudomoter / OedemaOedemaSweating changesSweating asymmetry take / trophicDecreased range of movementMotor dysfunctionTrophic changes (hair/skin/nails)For the patient to be positive for CRPS with the Budapest criteria they must have continuing pain which is disproportionate to the eliciting event and have more than than one sign in two or more of the categories higher up ANDMore than one symptom in three or more of the categories above ANDNo other diagno sis that could better explain their signs and symptoms.JM has all of the italic signs and symptoms above and no other diagnosis that could better explain his symptoms. JM had also undergone a bone density scan of the right leg showing osteopenia and an xray showing arthritic changes to the deformed and fused ankle joint. Therefore a diagnosis of CRPS of his right lower limb was made.Subsequent ManagementJM was started on lignocaine 5% patches. Communications were also made with the other consultants involved in JMs care (orthopaedics and rehabilitation medicine). The orthopaedic team were keen to point out that the benefits of the surgery were functional and that even if JM were to become pain free with buttoned-down treatment then it would not solve his functional problems. At fare up one month after starting the lignocaine 5 % patches JM was managing extremely well. His pain was down to a manageable level and by wearing the patches he could function nearly normally. He is now walking without a stick and had managed to return to playing tennis and had attended a work conference. He had decided against having the amputation and was happy to carry on with the current medical management of his condition. Further treatment options, should his pain flair up again, were discussed. These include IVRA (intravenous regional anaesthesia) and a spinal cord stimulator.DiscussionCRPS is a pain syndrome with an unclear pathophysiology and unpredictable clinical course. The diagnosis of CRPS is based upon a set of signs and symptoms derived from the history and examination of the patient. The treatment of CRPS is aimed at improving function and requires the use of a interdisciplinary team encompassing physiotherapy, psychological therapies and pain management. The management of CRPS depends on prompt diagnosis and early management as rejoinder to treatment is adversely affected by any delays. In the UK novel guidelines have been developed for the diagnosis and managem ent in the context of both primary and secondary care (2). JM in this case had been managed primarily by an orthopaedic team who had not linked his symptoms with a diagnosis of CRPS. CRPSs management requires a multidisciplinary approach based upon the published foursome Pillars of Intervention (3).The Four Pillars of Treatment for CRPSPatient information and educationPatients should be provided with appropriate education about CRPS to support self managementPatients should be reassured the corporeal and occupational therepy are safe and appropriate and engaged in the process of goal setting and reviewPain relief (medication and procedure)No individualist drug can be recommended at current time due to lack of evidence but the following may be considereda)neuropathic pain medicationb)pamidronate 60mg iv single dose in pts with CRPS