Complex regional pain syndrome (CRPS) is a condition that afflicts patients with chronic pain in the affected area. Often, the affected area is a limb such as an arm or leg. CRPS may affect other areas as well. CRPS progresses through four main stages. However, stage four of CRPS is often debated by researchers and medical professionals. Furthermore, CRPS may be difficult to categorize. Many CRPS patients do not progress sequentially and distinctly through each stage.
For those who recognize stage four, it is the most advanced stage of CRPS. It is suggested that many patients who receive CRPS treatment will never advance to CRPS stage four. In stage four of CRPS, the condition becomes resistant to most types of treatment. Additionally, the patient’s internal organs may become affected by the condition.
Stage Four Amputation
During stage four of CRPS, damage to the affected limb may be so critical that a medical professional may recommend amputation. However, it is highly recommended to avoid amputation unless it is performed out of medical necessity. For example, gangrene in the affected limb is considered a medical necessity that requires amputation in order to prevent the spread of deadly infection. While CRPS amputation is infrequent, it still occurs.
Many researchers and medical professionals believe that the costs of amputation strongly outweigh the benefits. Amputees undergo severe physical and mental destruction. Additionally, evidence does not support that amputation is an effective cure for CRPS pain. Amputation may even exacerbate the rate at which CRPS pain spreads throughout the affected limb and the body.
Stage Four Symptoms
The symptoms of stage four CRPS are generally similar to the symptoms in the prior three stages of CRPS. As indicated by the name of the condition, all four stages are characterized by severe and often debilitating pain. Similarly to stage one, stage four CRPS patients will experience stinging or burning sensations in the affected limb. CRPS pain is constant, but may vary in intensity throughout the course of the condition. Stage four may exhibit a plateau in pain.
As seen in stage three, stage four CRPS patients typically experience atrophy in the affected areas. Decreased use and tightness of the muscles and tissue contribute to the wasting away of the skin, tissues, and bone in the affected area. Patients may show marked signs of osteoporosis.
Prognosis and Treatment
Due to the severity of stage four CRPS, prognosis is generally poor. While certain treatments may help to alleviate pain, most patients in stage four will not fully recover from CRPS. Furthermore, a number of patients are resistant to various forms of treatment, which can make treatment difficult. Stage four CRPS treatment is generally more aggressive for these reasons.
Treatment for stage four CRPS may include dorsal column stimulation (DCS) or spinal cord stimulation (SCS). These treatments involve the use of electrodes which are implanted near the patient’s spinal cord. Small electrical currents are delivered from the electrodes, which can result in relief from CRPS pain symptoms.
Ketamine infusion may be used for CRPS pain reduction. Ketamine is an analgesic drug which shows promising evidence in relieving CRPS pain. Ketamine is believed to have particular benefit for CRPS patients as it is currently the only available drug that blocks N-methyl-D-aspartate (NMDA) receptors. NMDA receptors play a significant role in the reception of pain.
Ketamine infusion may be administered in three main ways:
• A low-dose inpatient procedure, also called the “awake” technique. This technique typically involves a continuous dose administered over the course of five days.
• Several outpatient procedures which may occur over several days, weeks, or months. Treatments may last for five hours at first, after which time the duration and dosage are decreased until treatment is complete.
• A high-dose inpatient procedure called the “coma” technique. During this technique, the patient is given a very high dosage of ketamine after entering a medically-induced coma. This method is not currently available in the United States.
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