Complex Regional Pain Syndrome: toward a decision making algorithm

In established CRPS, therapeutic goals are threefold and tailored to symptoms and pathophysiology: analgesia, functional recovery of the affected limb, and restoration of quality of life. NSAIDs, paracetamol and weak opioids are not effective. Steroids are useful in case of major inflammatory simptoms. Gabapentin is effective for neuropathic pain. Bisphosphonates (pamidronate) are used by infusion after a prior dental evaluation. Ketamine also shows some degree of efficacy. Autonomic nervous system blocks (intravenous, stellate ganglion, and lumbar plexus) can be performed in specialized centers. Transcutaneous neurostimulation, integrated into the rehabilitation program, is a simple, harmless, and inexpensive therapeutic method. Physical therapy and occupational therapy are key components of management, sometimes including a behavioral aspect (motor imagery, virtual reality, etc.) aimed at correcting the negative effects of cortical reorganization responsible for kinesiophobia. If psychological comorbidities are identified, appropriate management is essential, particularly cognitive behavioral therapy (CBT). In severe forms of CRPS, care requires a multidisciplinary team. Among the most recent therapeutic options are botulinum toxin A, cannabinoids, and repetitive transcranial magnetic stimulation (rTMS). Implanted spinal cord stimulation (posterior cord stimulation) or, more recently, dorsal root ganglion stimulation may be proposed in cases of persistent CRPS resistant to conventional treatments. Limb amputations, after long standing disease with severe, refractory pain often associated with trophic skin and joint disorders, remain exceptional.