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Complex Regional Pain Syndrome Type II (CRPS II) with sympathetic ganglion blockade and electrodiagnostic confirmation: a case report

      A 53 y/o Caucasian female who presented in February, 2012 - six months after a total hip arthroplasty with complaints of pain and instability in her left hip. Imaging studies were performed at that time which showed that the femoral component of her hip prosthesis had loosened. Her total hip arthroplasty was revised one month later. Immediately after the revision, she was noted to have left foot drop, allodynia, and hyperalgesia in the dorsum of her left foot. Her physical exam was remarkable for 0/5 in Left ankle dorsiflexion and 0/5 in Left great toe extension. Nerve Conduction Studies showed absent left peroneal nerve CMAPs as well as positive sharp waves and fibrillation potentials in the left tibialis anterior, peroneus longus and the short head of the biceps femoris. The patient underwent a series of four lumbar sympathetic ganglion blocks at the L3 level with moderate pain relief for 2-3 weeks after each block. The patient also was prescribed gabapentin, an ankle-foot orthotic and physical therapy as adjuncts to her ganglion blockade. The patient had significant pain relief following the sympathetic blocks and has not yet regained dorsiflexion in her Left ankle nor extension in her great toe. The patient is currently in physical therapy and wears an AFO at all times. This is a unique case involving a combination of electrodiagnostics and interventional pain modalities to aid in the diagnosis and treatment of CRPS Type II. The electrodiagnostic studies aided in the localization of the peroneal nerve lesion, and the sympathetic ganglion blocks helped to improve the patient’s quality of life and also helped to confirm that her pain was sympathetically mediated. Type II CRPS may occur after surgical manipulation and electrodiagnostic studies can be an invaluable tool to localize the lesion, provide diagnostic confirmation, and guide therapeutic modalities.