Case Scenario

Imrat Sohanpal, MbChB, FRCA, FFPM

Eva, a 53-year-old woman presents to your clinic with a 2-year history of persistent left arm pain. The pain was initially thought to be due to ulnar neuropathy for which she had an ulnar decompression at the elbow. The pain is classically neuropathic in description. Since the operation, the pain actually became worse and has resulted in significant loss of function. As a result, she has endured repeated interventions to help ease her suffering, none of which have been successful. Eva is known to suffer from chronic obstructive pulmonary disease, she smokes 10 cigarettes a day and drinks occasionally.

How would you assess this patient's pain?

The assessment of pain is crucial in establishing the etiology and impact it has on function, quality of life, and psychological well-being. Therefore, a biopsychosocial multidimensional assessment should be utilized, including musculoskeletal examination and assessment of baseline dysfunction.

This patient describes severe allodynia in the region of her elbow down to her hand, including the scar site from surgery over the medial epicondyle. She has hyperhidro-sis of the palm and sporadic shooting electrical pains up her arm. She also complains of neck and shoulder pain on the same side where she has arm pain. Musculoskeletal assessment shows contracted flexion of the left little and ring fingers, swelling of the hand, and weakness of the long flexors. There is also wasting of the hypothenar eminence and decreased pinprick sensation over C6, C7, and C8 sensory dermatomes of the hand. There is also evidence of myofascial pain of the posterior neck and trapezius muscles.

She has been taking slow-release preparation of morphine. Unfortunately, the benefit was limited due to side effects at higher doses. In the past she has tried several anti-neuropathic agents with little effect or stopped them due to anti-cholinergic and over-sedating side effects.

Impact of pain: Eva is unable to work as a cleaner as a result of the disability. She is unable to do simple tasks such as hold a cup of tea or cook. Fear avoidance behaviors are evident. For example, she is very reluctant to the leave home for fear of her arm being bumped, potentially causing severe pain. As a result, she has become socially isolated, leading to a downward spiral in overall function and mood.

Psychological history: Recently Eva has been feeling suicidal and actually visualiszed amputating the arm to ease the pain. She blames the pain as the reason for her separation from her partner of 10 years. In the past Eva received counselling for posttraumatic stress due to an abusive husband.

What is your first impression regarding the diagnosis?

Her symptoms are suggestive of chronic regional pain syndrome following trauma to the nerve, likely a result of surgery.

What is the cause ofher myofascial pain?

This is most certainly related to the compensatory mechanism implemented to reduce load and movement of the affected arm by putting extra strain on the shoulder and neck muscles.

To what types of specialists would you consider referring this patient to help manage her pain?

When treating biopsychosocial disorders, the interventions required must also have biological, psychological, and social dimensions. The psychological information adds a new dimension to the condition and alters the clinical picture significantly. Depression with suicidal urges is a potentially life-threatening condition; therefore an immediate referral to a psychiatrist is warranted.

Functional restoration is key to reducing disability and improving quality of life. In this case a referral to a hand therapist and to nerve injury unit may help achieve this. Regarding her overall pain, a musculoskeletal physiotherapy team may be of benefit.

Cognitive behavioral therapy is another avenue to pursue once the acute depressive phase has been dealt with, to help educate about pain behaviors and pacing.

What intervention could be done to help treat the CRPS?

Repeated stellate ganglion blocks and intravenous regional block with guanethidine or a brachial plexus block can all be tried to bring about pain relief and facilitate active exercise and rehabilitation.

Eva underwent a series of stellate ganglion blocks in conjunction with hand therapy sessions. This combination produced excellent results by reducing disability and achieving the goals set out in the treatment plan.

After successful pain reduction and eradication of the CRPS, Eva was left with ulnar neuropathy that was manageable. However, her main problem was poor mobility of the effective limb and abnormal posture secondary to her myofascial pain.

The above biomechanical issues were reconditioned in an intensive physiotherapy program as well as being entered into a pain management program. Eva was able to integrate the coping skills learnt into her everyday life after the sessions had finished. During this period she was able to stop her morphine and was treated for her depression. Depression was a major factor affecting her compliance and motivation and was preventing her from achieving a reasonable level of function and quality of life.

This case is an example of a situation where without a multidisciplinary approach, a successful outcome would have not been achieved.

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