Challenges and Controversies in Complex Regional Pain Syndrome (CRPS) Treatment

Management of complex regional pain syndrome (CRPS) is challenging and controversial. We discuss sympathetic block, intravenous (IV) ketamine infusion, and peripheral nerve stimulation (PNS) in CRPS treatment. Stellate ganglion or lumbar sympathetic blocks provide a clinically significant pain reduction in some CRPS patients with sympathetically maintained pain in the upper or lower extremities, respectively. Patients not responding to sympathetic block may still benefit from other treatment modalities such as spinal cord stimulation. Use of sympathetic neurolysis to treat CRPS remains controversial. With low to moderate evidence, IV ketamine infusion has been reported to be effective in managing refractory pain in some CRPS patients. The optimal infusion protocol remains controversial. The long-term effects of IV ketamine infusion are unknown. PNS may help patients with CRPS pain limited to single nerve distributions. There is Level I evidence for dorsal root ganglion (DRG) stimulation in patients with CRPS in lower extremities.