CRPS II Following a Cervical Epidural Steroid Injection: A Case Report
Majid Saleem, MD, Ahmed Ghaleb MD, Carmelita Pablo MD
Dept. of Anesthesiology, Univ. of Arkansas for Med. Sciences, Little Rock, Arkansas

INTRODUCTION:
Complex Regional Pain Syndromes (CRPS) I and II are significant health problems in US with high rate of treatment failure. The pathophysiology and natural course of CPRS remains obscure and management contentious. The features of CRPS type I include an initiating noxious event or immobilization, allodynia or hyperalgesia with pain disproportionate to any inciting event, presence of edema, vasomotor and sudomotor changes. CRPS II shares the same symptomatology of CRPS I but follows an injury to a peripheral nerve. CRPS has two components i.e., sympathetically and non- sympathetically mediated pain. We report a case in which the patient developed CRPS II following an attempted epidural steroid injection.
CASE REPORT:
A 48 year-old woman was referred to our pain clinic for complaints of chronic pain in the neck and the right upper extremity for several months. A diagnosis of right C5-C6 radiculitis was made and she was scheduled for right translaminar cervical epidural steroid injection. Due to technical difficulty a translaminar C6-7 epidural steroid injection was done during the second clinic visit. With the patient in prone position, C6-C7 interspace was identified fluoroscopically. The skin and the deep tissues were anesthetized with 6 cc of 1% lidocaine. A 20-gauge Tuohy introduced and advanced under fluoroscopy. During the attempt to locate the epidural space the patient developed paresthesia radiating to the right hand. The symptoms were not relieved by withdrawing the needle. After discussion with the patient, it was decided to postpone the procedure. She was given midazolam 2 mg and meperidine 25 mg intravenously for anxiolysis and pain relief with fair results. She was discharged home. She was advised to take hydrocodone 5 mg every 4-6 hrs as needed for breakthrough pain and was scheduled to return to the pain clinic in four days or earlier if required. She returned to the pain clinic the next day stating that the pain was getting worse. She described the pain as “burning and at times alternating with electrical shooting”, present in the right fourth and fifth digits, unrelieved by pain medications. On examination, the patient had allodynia, hyperalgesia to pin prick and localized swelling and sweating of the fourth and fifth digit. However, there was no motor weakness and sensory loss. A diagnosis of CRPS II was made. She was then scheduled for right stellate ganglion block. Immediately after the procedure she reported that the pain had totally disappeared. The temperature in the right hand also increased by three degree centigrade. Follow up
with her for the next 2 weeks revealed that she was pain free and the sweating and swelling had disappeared. However there was some residual mild paresthesia in the middle, ring and little finger, which was also improving.
CONCLUSION:
CRPS has been reported following various nerve injuries and trivial procedures. To our knowledge, CRPS II has not been reported following an epidural steroid injection. Every year millions of epidural, spinal anesthesia and nerve blocks, spinal taps are performed worldwide. Paresthesia which disappears after repositioning the needle is a common occurrence. However caution must be exercised in those situations when the paresthesia does not disappear even after repositioning the needle tip. CRPS following an attempt
to locate the epidural space is a rare. However every physician should be aware of the possibility. Staging of the disease presents a critical window of opportunity for optimal therapeutic results. Therefore, it is commonly advocated that a limited trial of interventions that interrupt sympathetic function should be instituted early in the course of CRPS. Sympathetic blockade by mean of stellate ganglion block appeared to be most promising approach in our patient. The success of stellate ganglion block in our patient suggests
that this approach may be optimal in early stages of CRPS.
REFFERENCES:

1. SN Raja et al. CRPS I. Anesthesiology 2002; 96.

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