Leitfaden zur Diagnostik des Komplexen regionalen Schmerzsyndroms

 

 Buy Article Permissions and Reprints

Zusammenfassung

Das komplexe regionale Schmerzsyndrom (engl. complex regional pain syndrome; CRPS) tritt nach Traumata v. a. der distalen Extremitäten als Sonderform neuropathischer Schmerzsyndrome auf. Die Symptomatik umfasst Plus- und Minussymptome mit sensiblen, motorischen, vasomotorischen, sudomotorischen und trophischen Veränderungen. Interindividuell und intraindividuell können die jeweiligen Symptome in unterschiedlicher Ausprägung gefunden werden, einzelne auch gänzlich fehlen. Ein diagnostischer „Goldstandard“ konnte bisweilen nicht identifiziert werden, somit gründet die Diagnosestellung auf einer detaillierten Anamnese und klinisch-neurologischen Untersuchung. Durch die Internationale Gesellschaft zum Studium des Schmerzes (IASP) wurden operationale Kriterien zur Diagnosefindung erstellt, validiert und im Jahre 2003 durch eine Konsensusgruppe in Budapest revidiert mit resultierender klinisch wie auch wissenschaftlich zufrieden stellender Sensitivität und Spezifität. Diese klinische Einordnung kann ergänzend durch apparative Diagnostik bestätigt werden – sinnvolle Untersuchungen stellen seitenvergleichende konventionelle Röntgenaufnahmen, eine Kernspintomografie der betroffenen Extremität sowie eine 3-Phasen-Skelettszintigrafie dar. Hilfreich können weiterhin der Nachweis einer Nervenläsion im Zuge elektrophysiologischer Messungen zur Differenzierung zwischen CRPS Typ I und II oder einer Temperaturdifferenz mittels Infrarotthermografie sein. Eine quantitative sensorische Testung kann das Ausmaß der sensorischen Veränderungen erfassen und im Verlauf den Therapieerfolg dokumentieren. Die Initiierung einer Therapie sollte aber, auch bei Vorliegen von Normalbefunden in den ergänzenden apparativen Untersuchungen, von diesen unbeeinflusst bleiben.

Abstract

The complex regional pain syndrome, a special form of neuropathic pain, develops after a minor trauma of the distal limbs. Besides the presentation of pain disproportional to the inciting event, further plus and minus symptoms in the form of sensory, vasomotor, sudomotor-oedematous and motor-trophic changes can be found. Interindividually and intraindividually, occurrence of these symptoms differs widely and single symptoms can be lacking completely. A gold standard in diagnosing CRPS has not been found yet, diagnostics are based on the patients medical history and correlating clinical signs. The International Association for the Study of Pain (IASP) compiled and later on revised operational diagnostic criteria resulting in a satisfactory sensitivity and specificity for both research and clinical needs. Additionally, diagnostic tools can support the clinical suspicion – reasonable tests are conventional X-ray examination comparing sides, magnetic resonance imaging and a 3-phase bone scintigraphy. Moreover, electrophysiological examinations can prove a nerve lesion and differentiate between CRPS type I and II. A temperature difference can be detected via infrared thermography. Furthermore, quantitative sensory testing can verify the magnitude of the sensory disturbance and can be beneficial to objectify therapeutic effects. Use of these diagnostic tools, even after achievement of normal findings, cannot exclude a CRPS and the decision for therapeutic initiation should not be influenced thereby.

Literatur

• 1 Veldman PH, Reynen HM, Arntz IE. et al . Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients.  Lancet. 1993;  342 1012-1016
  Google Scholar
• 2 Stanton-Hicks M, Janig W, Hassenbusch S. et al . Reflex sympathetic dystrophy: changing concepts and taxonomy.  Pain. 1995;  63 127-133
  Google Scholar
• 3 Atkins RM, Duckworth T, Kanis JA. Features of algodystrophy after Colles’ fracture.  J Bone Joint Surg Br. 1990;  72 105-110
  Google Scholar
• 4 Bickerstaff DR, Kanis JA. Algodystrophy: an under-recognized complication of minor trauma.  Br J Rheumatol. 1994;  33 240-248
  Google Scholar
• 5 Schurmann M, Gradl G, Andress HJ. et al . Assessment of peripheral sympathetic nervous function for diagnosing early post-traumatic complex regional pain syndrome type I.  Pain. 1999;  80 149-159
  Google Scholar
• 6 Gibbons JJ, Wilson PR. RSD score: criteria for the diagnosis of reflex sympathetic dystrophy and causalgia.  Clin J Pain. 1992;  8 260-263
  Google Scholar
• 7 Kozin F, Ryan LM, Carerra GF. et al . The reflex sympathetic dystrophy syndrome (RSDS). III. Scintigraphic studies, further evidence for the therapeutic efficacy of systemic corticosteroids, and proposed diagnostic criteria.  Am J Med. 1981;  70 23-30
  Google Scholar
• 8 Janig W. Experimental approach to reflex sympathetic dystrophy and related syndromes.  Pain. 1991;  46 241-245
  Google Scholar
• 9 Zyluk A. A new clinical severity scoring system for reflex sympathetic dystrophy of the upper limb.  J Hand Surg Br. 2003;  28 238-241
  Google Scholar
• 10 van de Beek WJ, Schwartzman RJ, van Nes SI. et al . Diagnostic criteria used in studies of reflex sympathetic dystrophy.  Neurology. 2002;  58 522-526
  Google Scholar
• 11 Harden RN, Bruehl S, Stanton-Hicks M. et al . Proposed new diagnostic criteria for complex regional pain syndrome.  Pain Med. 2007;  8 326-331
  Google Scholar
• 12 Brunner F, Lienhardt SB, Kissling RO. et al . Diagnostic criteria and follow-up parameters in complex regional pain syndrome type I – a Delphi survey.  Eur J Pain. 2008;  12 48-52
  Google Scholar
• 13 Harden RN, Bruehl SP. Diagnosis of complex regional pain syndrome: signs, symptoms, and new empirically derived diagnostic criteria.  Clin J Pain. 2006;  22 415-419
  Google Scholar
• 14 Galer BS, Bruehl S, Harden RN. IASP diagnostic criteria for complex regional pain syndrome: a preliminary empirical validation study. International Association for the Study of Pain.  Clin J Pain. 1998;  14 48-54
  Google Scholar
• 15 Bruehl S, Harden RN, Galer BS. et al . External validation of IASP diagnostic criteria for Complex Regional Pain Syndrome and proposed research diagnostic criteria. International Association for the Study of Pain.  Pain. 1999;  81 147-154
  Google Scholar
• 16 Harden RN, Bruehl S, Galer BS. et al . Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive?.  Pain. 1999;  83 211-219
  Google Scholar
• 17 Perez RS, Collins S, Marinus J. et al . Diagnostic criteria for CRPS I: differences between patient profiles using three different diagnostic sets.  Eur J Pain. 2007;  11 895-902
  Google Scholar
• 18 Birklein F, Riedl B, Sieweke N. et al . Neurological findings in complex regional pain syndromes – analysis of 145 cases.  Acta Neurol Scand. 2000;  101 262-269
  Google Scholar
• 19 Drummond PD, Finch PM, Skipworth S. et al . Pain increases during sympathetic arousal in patients with complex regional pain syndrome.  Neurology. 2001;  57 1296-1303
  Google Scholar
• 20 Wasner G, Schattschneider J, Heckmann K. et al . Vascular abnormalities in reflex sympathetic dystrophy (CRPS I): mechanisms and diagnostic value.  Brain. 2001;  124 587-599
  Google Scholar
• 21 van der Laan L, Veldman PH, Goris RJ. Severe complications of reflex sympathetic dystrophy: infection, ulcers, chronic edema, dystonia, and myoclonus.  Arch Phys Med Rehabil. 1998;  79 424-429
  Google Scholar
• 22 Albazaz R, Wong YT, Homer-Vanniasinkam S. Complex regional pain syndrome: a review.  Ann Vasc Surg. 2008;  22 297-306
  Google Scholar
• 23 de Rooij AM, Florencia Gosso M, Haasnoot GW. et al . HLA-B62 and HLA-DQ8 are associated with Complex Regional Pain Syndrome with fixed dystonia.  Pain. 2009;  145 82-85
  Google Scholar
• 24 Melzack R. The McGill Pain Questionnaire: major properties and scoring methods.  Pain. 1975;  1 277-299
  Google Scholar
• 25 Bennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs.  Pain. 2001;  92 147-157
  Google Scholar
• 26 de Mos M, Sturkenboom MC, Huygen FJ. Current understandings on complex regional pain syndrome.  Pain Pract. 2009;  9 86-99
  Google Scholar
• 27 Beerthuizen A, van ’t Spijker A, Huygen FJ. et al . Is there an association between psychological factors and the Complex Regional Pain Syndrome type 1 (CRPS1) in adults? A systematic review.  Pain. 2009;  145 52-59
  Google Scholar
• 28 Galer BS, Jensen MP. Development and preliminary validation of a pain measure specific to neuropathic pain: the Neuropathic Pain Scale.  Neurology. 1997;  48 332-338
  Google Scholar
• 29 Krause SJ, Backonja MM. Development of a neuropathic pain questionnaire.  Clin J Pain. 2003;  19 306-314
  Google Scholar
• 30 Stein C, Mendl G. The German counterpart to McGill Pain Questionnaire.  Pain. 1988;  32 251-255
  Google Scholar
• 31 Birklein F, Riedl B, Neundorfer B. et al . Sympathetic vasoconstrictor reflex pattern in patients with complex regional pain syndrome.  Pain. 1998;  75 93-100
  Google Scholar
• 32 Livingstone JA, Field J. Algodystrophy and its association with Dupuytren's disease.  J Hand Surg Br. 1999;  24 199-202
  Google Scholar
• 33 Schurmann M, Zaspel J, Lohr P. et al . Imaging in early posttraumatic complex regional pain syndrome: a comparison of diagnostic methods.  Clin J Pain. 2007;  23 449-457
  Google Scholar
• 34 Fournier RS, Holder LE. Reflex sympathetic dystrophy: diagnostic controversies.  Semin Nucl Med. 1998;  28 116-123
  Google Scholar
• 35 Krumova EK, Frettloh J, Klauenberg S. et al . Long-term skin temperature measurements – a practical diagnostic tool in complex regional pain syndrome.  Pain. 2008;  140 8-22
  Google Scholar
• 36 Chemali KR, Gorodeski R, Chelimsky TC. Alpha-adrenergic supersensitivity of the sudomotor nerve in complex regional pain syndrome.  Ann Neurol. 2001;  49 453-459
  Google Scholar
• 37 Baron R, Maier C. Reflex sympathetic dystrophy: skin blood flow, sympathetic vasoconstrictor reflexes and pain before and after surgical sympathectomy.  Pain. 1996;  67 317-326
  Google Scholar
• 38 Schwartzman RJ, Kerrigan J. The movement disorder of reflex sympathetic dystrophy.  Neurology. 1990;  40 57-61
  Google Scholar
• 39 van Rijn MA, Marinus J, Putter H. et al . Onset and progression of dystonia in complex regional pain syndrome.  Pain. 2007;  130 287-293
  Google Scholar
• 40 Zyluk A. The usefulness of quantitative evaluation of three-phase scintigraphy in the diagnosis of post-traumatic reflex sympathetic dystrophy.  J Hand Surg Br. 1999;  24 16-21
  Google Scholar
• 41 Zyluk A, Birkenfeld B. Quantitative evaluation of three-phase bone scintigraphy before and after the treatment of post-traumatic reflex sympathetic dystrophy.  Nucl Med Commun. 1999;  20 327-333
  Google Scholar
• 42 Holder LE, Mackinnon SE. Reflex sympathetic dystrophy in the hands: clinical and scintigraphic criteria.  Radiology. 1984;  152 517-522
  Google Scholar
• 43 Kozin F, Soin JS, Ryan LM. et al . Bone scintigraphy in the reflex sympathetic dystrophy syndrome.  Radiology. 1981;  138 437-443
  Google Scholar
• 44 Park SA, Yang CY, Kim CG. et al . Patterns of three-phase bone scintigraphy according to the time course of complex regional pain syndrome type I after a stroke or traumatic brain injury.  Clin Nucl Med. 2009;  34 773-776
  Google Scholar
• 45 Atkins RM, Tindale W, Bickerstaff D. et al . Quantitative bone scintigraphy in reflex sympathetic dystrophy.  Br J Rheumatol. 1993;  32 41-45
  Google Scholar
• 46 Crozier F, Champsaur P, Pham T. et al . Magnetic resonance imaging in reflex sympathetic dystrophy syndrome of the foot.  Joint Bone Spine. 2003;  70 503-508
  Google Scholar
• 47 Schweitzer ME, Mandel S, Schwartzman RJ. et al . Reflex sympathetic dystrophy revisited: MR imaging findings before and after infusion of contrast material.  Radiology. 1995;  195 211-214
  Google Scholar
• 48 Graif M, Schweitzer ME, Marks B. et al . Synovial effusion in reflex sympathetic dystrophy: an additional sign for diagnosis and staging.  Skeletal Radiol. 1998;  27 262-265
  Google Scholar
• 49 Rommel O, Malin JP, Zenz M. et al . Quantitative sensory testing, neurophysiological and psychological examination in patients with complex regional pain syndrome and hemisensory deficits.  Pain. 2001;  93 279-293
  Google Scholar
• 50 Rolke R, Magerl W, Campbell KA. et al . Quantitative sensory testing: a comprehensive protocol for clinical trials.  Eur J Pain. 2006;  10 77-88
  Google Scholar
• 51 Rolke R, Baron R, Maier C. et al . Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values.  Pain. 2006;  123 231-243
  Google Scholar
• 52 Sethna NF, Meier PM, Zurakowski D. et al . Cutaneous sensory abnormalities in children and adolescents with complex regional pain syndromes.  Pain. 2007;  131 153-161
  Google Scholar
• 53 Baron R. Mechanisms of disease: neuropathic pain – a clinical perspective.  Nat Clin Pract Neurol. 2006;  2 95-106
  Google Scholar
• 54 Schinkel C, Gaertner A, Zaspel J. et al . Inflammatory mediators are altered in the acute phase of posttraumatic complex regional pain syndrome.  Clin J Pain. 2006;  22 235-239
  Google Scholar
• 55 Uceyler N, Eberle T, Rolke R. et al . Differential expression patterns of cytokines in complex regional pain syndrome.  Pain. 2007;  132 195-205
  Google Scholar
• 56 Birklein F, Schmelz M, Schifter S. et al . The important role of neuropeptides in complex regional pain syndrome.  Neurology. 2001;  57 2179-2184
  Google Scholar
• 57 Kohr D, Tschernatsch M, Schmitz K. et al . Autoantibodies in complex regional pain syndrome bind to a differentiation-dependent neuronal surface autoantigen.  Pain. 2009;  143 246-251
  Google Scholar
• 58 Goebel A, Vogel H, Caneris O. et al . Immune responses to Campylobacter and serum autoantibodies in patients with complex regional pain syndrome.  J Neuroimmunol. 2005;  162 184-189
  Google Scholar
• 59 Turton AJ, McCabe CS, Harris N. et al . Sensorimotor integration in Complex Regional Pain Syndrome: a transcranial magnetic stimulation study.  Pain. 2007;  127 270-275
  Google Scholar
• 60 van de Beek WJ, Vein A, Hilgevoord AA. et al . Neurophysiologic aspects of patients with generalized or multifocal tonic dystonia of reflex sympathetic dystrophy.  J Clin Neurophysiol. 2002;  19 77-83
  Google Scholar

Korrespondenzadresse

PD Dr. Christian Maihöfner

University of Erlangen

Department of Neurology

Schwabachanlage 6

91054 Erlangen

Phone: + 49/091/31 8533 001

Fax: + 49/091/31 8522 497

Email: christian.maihoefner@uk-erlangen.de