Complex regional pain syndrome: medical and legal ramifications of clinical variability and experience and perspective of a practicing clinician

OBJECTIVE The aim of this study was to demonstrate the ramifications of clinical variability of complex regional pain syndrome (CRPS) and how they can affect the various aspects of this condition, favorably or unfavorably, for both patients and participating medical and legal professionals. METHODS Twelve patients diagnosed with CRPS at different times in the past 25 years were followed up, and their signs and symptoms were reviewed for variability. None had preexisting or ongoing medical disorders and prior injury to the peripheral nerves or musculoskeletal tissues. None had been involved in litigation. Physical traumas that triggered CRPS were job-related, vehicular accidents, and personal injuries. The presence of vasomotor symptoms (eg, swelling, skin discoloration, and temperature changes) and allodynia in the affected extremity was the basis for clinical diagnosis in all the patients. The need for imaging studies was precluded in some patients owing to the presence of vasomotor symptoms, which either fluctuated or were steady. Seven of the patients had type 1 CRPS, and five patients had type 2 CRPS. RESULTS Most patients encountered delay in diagnosis and treatment and legal obstacles owing to the lack of "typical" objective signs of CRPS. The patients' symptoms fluctuated at different times of the day. Eight patients experienced spread of vasomotor symptoms and varying degree of allodynia in the opposite extremity. One patient, who developed signs and symptoms of rheumatoid arthritis, 2 months after the injury, continued to have CRPS symptoms in the injured hand. Treatment modalities administered in all the patients were essentially ineffective. All the patients, except one, were unable to return to their original line of work, and their symptoms persisted regardless of the outcome of their legal claims. CONCLUSION It is likely that patients who continue to complain of pain and vasomotor symptoms followed by a physical injury have CRPS. The complex interaction between the peripheral, autonomic, and central nervous system in this condition makes it challenging to diagnose, treat, and prognosticate.