Name: Dr Thuya Win E-mail: thuya.win@nhs.net
Occupation: Consultant Rehabilitation
Medicine
Affiliation: Birmingham
Community Healthcare NHS Foundation Trust, UK
Other authors): Dr Poornashree Ramamurthy
ABSTRACT
Complex regional pain syndrome
(CRPS) is a chronic neurologic condition with multiple disabling symptoms -
severe neuropathic pain, vasomotor dysfunction, skin ulceration, infection
and autonomic instability. Treatment modalities include medication,
physical therapy, psychological therapy, and neuromodulation but it is very
difficult to treat, and outcomes are usually unsatisfactory. Amputation is
often requested by patients in refractory cases but there are concerns of
recurrence of CRPS, residual/phantom pain and worsening disability. The
chances of functional ambulation with prosthesis as well as the success
with pain relief seem to be limited. Hence, many believe that amputation
for CRPS is unlikely to have a better outcome.
Recent RCP guidelines
suggest amputation may be considered in a selected group of patients
following a thorough multidisciplinary assessment and evaluation of all
risk factors. Amputation of the diseased segment of the limb offers the
patient the unique prospect to turn around the natural history. It may put
an end to the recurrent intractable infections and septicaemia. Patient can
regain functional ability including ambulation and quality of life though
it does not guarantee pain relief. It is crucial to have a pre-amputation
consultation with the multidisciplinary amputation rehabilitation team to
have an open discussion of the caveats and risks associated with amputation
and set realistic functional goals and a clear plan for rehabilitation from
the start.
West Midlands Rehabilitation centre is a regional tertiary
Prosthetic and Amputee Rehabilitation Centre which provides complex
rehabilitation to people with amputation including those with CRPS.
The aim
is to evaluate outcomes of our patient cohort at West Midlands
Rehabilitation Centre and establish references for future consultations. It
is a retrospective study. Electronic and paper medical records were
reviewed. Inclusion criteria – Patient with formal diagnosis of CRPS who
had undergone lower limb amputation and were referred to WMRC and its
satellite clinics during February 2016 – March 2022. We reviewed 12
patients – Age (19 - 65 years), Gender (Male=5, Female=7), Level of
amputation (transfemoral=5, through knee= 2, transtibial=5) and sides
(unilateral= 10, bilateral= 1). The event leading to CRPS varied from
surgery, crush injury to nerve damage. 8 had pre-amputation consultation
with us. Primary goals for amputation were wound complications=4, pain
relief=3, specific physical activities=2, walking=2 and dystonia=1. 11 out
of 12 achieved primary goals. 2 from 5 wheelchair bound patients progressed
to prosthetic mobility.
Those who were walking before amputation either
improved or maintained ambulation, but one chose to be a non-prosthetic
user. No recurrence of CRPS was noted at their last follow-ups. Pain at 1
year after amputation was phantom (3), and stump (3). Most people with CRPS
who have undergone lower limb amputation achieved their primary goal of
having amputation. The key to this achievement is setting realistic
functional goals other than just pain relief, and frank discussion at
comprehensive pre-amputation consultation with MDT support through the
different stages of rehabilitation.
Amputation is a life changing surgery
and can be considered as a positive intervention in selected cases of
refractory CRPS.
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