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Complex Regional Pain Syndrome Type 1 of the Breast after Reduction Mammoplasty: A Case Report

Pollock, Stephenie MS3 Papay, Frank M.D Stanton-Hicks, Michael M.D
Florida State College of Medicine
2012-01-21

Presenter: Stephenie Pollock

Affidavit:
I certify that the material proposed for presentation in this abstract has not been published in any scientific journal or previously presented at a major meeting. The case report represents the original work of Stephenie Pollock, a year 3 medical student from the Florida State College of Medicine. The case report is an original manuscript which was written using hte combined efforts of all the authors.

Director Name: Frank A. Papay

Author Category: Student
Presentation Category: Clinical
Abstract Category: Breast (Aesthetic and Recon.)

How does this presentation meet the established conference educational objectives?
We report bilateral breast CRPS with extension to the upper chest and shoulders after reduction mammoplasty in a 54 year old patient with a previous history of lower extremity CRPS. Prophylactic epidural anesthesia should be considered for all patients with a history of CRPS who are to undergo breast surgery. Complex Regional Pain Syndrome has been described as a complex set of symptoms diagnosed using various criteria. Therapies are usually prolonged, intensive and determined on a case by case basis. While approaches to treatment are numerous, little thought has been devoted to the preventative treatment of patients who opt to undergo elective surgery. Case reports of CRPS developing after surgical trauma are frequent, but little is known about its prevalence in patients who have already developed the syndrome at another site. While considerable progress has been made to better diagnose, treat, and prevent CRPS, only eight studies touch on the secondary prevention of the syndrome. Extension of CRPS to another site following surgery is most commonly reported in patients having orthopedic intervention. Few cases have been reported in the literature that described secondary spread to the chest after aesthetic procedures. While there is considerable interest in the risk factors and perioperative treatment strategies that should be used in patients with pre-existing or active CRPS, one technique that is prophylactic, and in most cases prevents exacerbation of CRPS, is the use of regional anesthesia. This should certainly be standard practice when surgery on the same or another extremity is contemplated. One question that should be asked: Should patients with a known history of CRPS, whether familial or directly diagnosed, be exposed to the risk of an elective surgical procedure? While there are no current studies that have been developed to evaluate this question, the use of prophylactic measures such as regional anesthetic procedures and a more conservative approach have been shown effective in preventing the exacerbation of CRPS in such patients. Preventative measures like regional anesthesia are extremely effective in preventing either a recurrence or exacerbation of CRPS in the ipsilateral extremity or its development in a remote extremity. Although in general, surgery is avoided on an extremity either ipsilateral to the syndrome of CRPS or when there has been a prior history of the syndrome. In conclusion, patients with a known history of CRPS should be well informed that spread of the syndrome to any location may occur after an elective surgical procedure. Perioperative prophylaxis should be undertaken and the usual precautions such as waiting until the syndrome is in remission should be the standard of care. More research is needed to determine whether elective surgical procedures can be safely carried out in patients with a history of CRPS. Certainly, surgeries on the chest wall or trunk are amendable to continuous regional anesthetic procedures either alone or in conjunction with general anesthesia. Such measures are capable of reducing the inflammatory response, relieving surgical pain and prophylactically reducing the possibility of secondary expression of CRPS from a primary site in the body. In patients having limb surgery this form of prophylaxis is standard of care. One could argue that this should be the standard of care in all patient with a primary limb CRPS whether in remission or active for all patients having breast surgery.

How will your presentation be used by practicing physicians in the audience?
Despite increasing research interest, little is known regarding which patients are at greater risk for development of postoperative CRPS. Even less is known about the prevention of CRPS in those that undergo elective or emergent procedures with a known history of the syndrome. We now know that waiting for remission, minimizing the use of a tourniquet, administering vasodilators and providing a sympathetic block encourage the circulation and decrease postoperative extension, however, these actions still may not affect the development of secondary CRPS. Different studies have shown that using preventative measures such as vitamin C, and pre- and post-operative calcitonin have improved outcomes and prevented the secondary spread of the syndrome. Reports also indicate that performing a perioperative stellate ganglion block in a patient with a history of CRPS can reduce the recurrence rate of the disease. However, the most valuable method of prevention seems to be the use of regional anaesthetic techniques. It has proven extremely effective in preventing either a recurrence or exacerbation of CRPS in the ipsilateral extremity or its development in a remote extremity. However, when considering an elective procedure on a patient with a history of CRPS, surgeons and patients should be alert that CRPS exacerbation and extension may occur even with surgical and medical prophylaxis.

Complex regional pain syndrome (CRPS) is a disorder of inflammation, sweating, autonomic and sensory dysfunction accompanied by pain disproportionate to the inciting event.

We report bilateral breast CRPS with extension to the upper chest and shoulders after reduction mammoplasty in a 54 year old patient with a previous history of lower extremity CRPS. The patient suffered post-surgical complication of bilateral cellulitis with persistent symptoms of pain, redness, allodynia, and continued heat that persisted after treatment. Because of a previous history of CRPS, she presented to the Pain Management Department with possible extension of CRPS to the breast. Both inflammation and allodynia improved when the maintenance dose of Topiramate, that the patient was already taking due to the lower extremity CRPS, was doubled. Remission was spontaneous at three months.
Prophylactic epidural anesthesia should be considered for all patients with a history of CRPS who are to undergo breast surgery.

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