Komplexes regionales Schmerzsyndrom

Zusammenfassung

Das komplexe regionale Schmerzsyndrom (CRPS) umschreibt eine Vielzahl von schmerzhaften Zuständen, die charakterisiert sind durch anhaltende Schmerzen, die die Dauer und Intensität des normalerweise zu erwartenden Verlaufs übersteigen. Zwischen zwei Typen kann unterschieden werden: Das CRPS Typ 1 entwickelt sich nach einem Trauma oder einer Fraktur, eine eigentliche Nervenläsion liegt nicht vor. Beim CRPS Typ 2 (Causalgia) liegt eine definierbare Nerven läsion vor. Epidemiologische, genetische und experimentelle Studien lassen darauf schließen, dass die Pathophysiologie des CRPS multifaktoriell ist. Drei Mechanismen sind für die Entwicklung des CRPS verantwortlich: neurogene Entzündung, autonome Dysfunktion und neuroplastische Veränderungen im ZNS. Die Symptomatik des CRPS umfasst autonome, sensorische, motorische und trophische Störungen. Die Hauptsymptome sind spontane Schmerzen, Hyperalgesie, Allodynie, abnormale vasomotorische Aktivität und abnormale sudomotorische Aktivität. Die Diagnose ist klinisch und basiert auf der Anamnese und klinischen Befunden mit Anwendung der diagnostischen Kriterien der Internationalen Gesellschaft zum Studium des Schmerzes (IASP) und kann durch zusätzliche diagnostische Interventionen, wie das konventionelle Röntgenbild, 3-Phasen-Skelett-Szintigrafie und MRI unterstützt werden. Die Therapie ist multidisziplinär. Nicht medikamentöse Therapien umfassen insbesondere Physio-/Ergotherapie, physikalische Maßnahmen und psychologische Betreuung. Medikamentöse Therapien orientieren sich an der individuellen Symptomkonstellation und umfassen Pharmakotherapie der neuropathischen Schmerzen und Substanzen, die in den Knochenstoffwechsel eingreifen. Auch Glukokortikoide und Radikalfänger können zum Einsatz kommen. Zu den invasiven Maßnahmen zählen Sympathikusblockaden, die bei Vorliegen eines sympathisch unterhaltenen Schmerzsyndroms eingesetzt werden können, und die rückenmarksnahe Elektrostimulation.

Summary

Complex-regional pain syndromes (CRPS) belong to the neuropathic pain syndromes. CRPS is characterized by pain out of proportion to the initiating event. CRPS can be divided in two types. In type I, which develops typically after minor trauma or fracture, no overt nerve lesion is detected. In type II (Causalgia), a definable nerve injury is present. Several pathophysiological concepts have been proposed to explain the complex symptoms of CRPS: facilitated neurogenic inflammation, pathological sympatho-afferent coupling, and neuroplastic changes within the CNS. The key features are spontaneous pain, hyeralgesia, allodynia, abnormal vasomotor activity and abnormal sudomotor activity. Diagnosis is mainly based on clinical signs using the diagnostic criteria developed by the International Association for the Study of Pain (IASP). However, additional laboratory and radiological examinations may help to corroborate correct diagnosis. Therapy is based on a multidisciplinary approach. Non-pharmacological approaches include physiotherapy and occupational therapy. Pharmacotherapy is based on individual symptoms and includes treatment of neuropathic pain, agents interfering with bone metabolism, steroids, and eventually free radical scavengers. Invasive therapeutic concepts include sympathetic blocks for the treatment of sympathetically maintained pain and implantation of spinal cord stimulators.

Schlüsselwörter

Komplexes regionales Schmerzsyndrom - CRPS - Pathophysiologie - Diagnostik - Therapie

Keywords

Complex regional pain syndrome - CRPS - pathophysioplogy - diagnosis - treatment

• Literatur

• 1 Goebel A. Complex regional pain syndrome in adults. Rheumatology (Oxford) 2011; 50 (10) 1739-1750.
• 2 Marinus J, Moseley GL, Birklein F. et al. Clinical features and pathophysiology of complex regional pain syndrome. Lancet Neurol 2011; 10 (07) 637-648.
• 3 Geusens P, Santen M.. Algodystrophy. Baillieres Best Pract Res Clin Rheumatol 2000; 14 (03) 499-513.
• 4 Albazaz R, Wong YT, Homer-Vanniasinkam S. Complex regional pain syndrome: a review. Ann Vasc Surg 2008; 22 (02) 297-306.
• 5 Maihofner C, Seifert F, Markovic K.. Complex regional pain syndromes: new pathophysiological concepts and therapies. Eur J Neurol 2010; 17 (05) 649-660.
• 6 Stanton-Hicks M, Janig W, Hassenbusch S. et al. Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain 1995; 63 (01) 127-133.
• 7 Harden RN, Bruehl SP.. Diagnosis of complex regional pain syndrome: signs, symptoms, and new empirically derived diagnostic criteria. Clin J Pain 2006; 22 (05) 415-419.
• 8 Sandroni P, Benrud-Larson LM, McClelland RL, Low PA. Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study. Pain 2003; 103 01–02 199-207.
• 9 Hsu ES. Practical management of complex regional pain syndrome. Am J Ther 2009; 16 (02) 147-54.
• 10 Pontell D. A clinical approach to complex regional pain syndrome. Clin Podiatr Med Surg 2008; 25 (03) 361-380.
• 11 Atkins RM, Duckworth T, Kanis JA.. Features of algodystrophy after Colles' fracture. J Bone Joint Surg Br 1990; 72 (01) 105-110.
• 12 Field J, Atkins RM.. Algodystrophy is an early complication of Colles' fracture. What are the implications?. J Hand Surg Br 1997; 22 (02) 178-182.
• 13 de Mos M, de Bruijn AG, Huygen FJ. et al. The incidence of complex regional pain syndrome: a population-based study. Pain 2007; 129 (01) (02) 12-20.
• 14 Bickerstaff DR, Kanis JA.. Algodystrophy: an underrecognized complication of minor trauma. Br J Rheumatol 1994; 33 (03) 240-248.
• 15 de Mos M, Sturkenboom MC, Huygen FJ. Current understandings on complex regional pain syndrome. Pain Pract 2009; 9 (02) 86-99.
• 16 Vaneker M, van der Laan L, Allebes W, Goris JA. Genetic factors associated with complex regional pain syndrome I: HLA DRB and TNFa promoter gene polymorphism. Disabil Med 2002; 2: 69-74.
• 17 Kemler MA, van de Vusse AC, van den Berg-Loonen EM. et al. HLA-DQ1 associated with reflex sympathetic dystrophy. Neurology 1999; 53 (06) 1350-1351.
• 18 Huhne K, Leis S, Schmelz M. et al. A polymorphic locus in the intron 16 of the human angiotensinconverting enzyme (ACE) gene is not correlated with complex regional pain syndrome I (CRPS I). Eur J Pain 2004; 8 (03) 221-225.
• 19 Veldman PH, Reynen HM, Arntz IE, Goris RJ.. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet 1993; 342 8878 1012-1016.
• 20 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 (03) 235-239.
• 21 Birklein F, Schmelz M.. Neuropeptides, neurogenic inflammation and complex regional pain syndrome (CRPS). Neurosci Lett 2008; 437 (03) 199-202.
• 22 Blair SJ, Chinthagada M, Hoppenstehdt D. et al. Role of neuropeptides in pathogenesis of reflex sympathetic dystrophy. Acta Orthop Belg 1998; 64 (04) 448-451.
• 23 de Mos M, Huygen FJ, Stricker BH. et al. The association between ACE inhibitors and the complex regional pain syndrome: Suggestions for a neuro-inflammatory pathogenesis of CRPS. Pain 2009; 142 (03) 218-224.
• 24 Huygen FJ, de Bruijn AG, De Bruin MT. et al. Evidence for local inflammation in complex regional pain syndrome type 1. Mediators Inflamm 2002; 11 (01) 47-51.
• 25 Uceyler N, Eberle T, Rolke R. et al. Differential expression patterns of cytokines in complex regional pain syndrome. Pain 2007; 132 (01) [phone].
• 26 Borsook D, Sava S. Pain. Do ACE inhibitors exacerbate complex regional pain syndrome?. Nat Rev Neurol 2009; 5 (06) 306-308.
• 27 Blaes F, Tschernatsch M, Braeu ME. et al. Autoimmunity in complex-regional pain syndrome. Ann N Y Acad Sci 2007; 1107: 168-173.
• 28 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 (03) 246-251.
• 29 Kohr D, Singh P, Tschernatsch M. et al. Autoimmunity against the beta(2) adrenergic receptor and muscarinic-2 receptor in complex regional pain syndrome. Pain 2011; 152 (12) 2690-2700.
• 30 Birklein F. Complex regional pain syndrome. J Neurol 2005; 252 (02) 131-138.
• 31 Janig W, Baron R.. Complex regional pain syndrome: mystery explained?. Lancet Neurol 2003; 2 (11) 687-697.
• 32 Maihofner C, Handwerker HO, Neundorfer B, Birklein F.. Patterns of cortical reorganization in complex regional pain syndrome. Neurology 2003; 61 (12) 1707-1715.
• 33 Maihofner C, Handwerker HO, Neundorfer B, Birklein F.. Cortical reorganization during recovery from complex regional pain syndrome. Neurology 2004; 63 (04) 693-701.
• 34 Maihofner C, Baron R, DeCol R. et al. The motor system shows adaptive changes in complex regional pain syndrome. Brain 2007; 130 (10) 2671-2687.
• 35 Kuner R. Central mechanisms of pathological pain. Nat Med 2010; 16 (11) 1258-1266.
• 36 Bruehl S, Harden RN, Galer BS. et al. Complex regional pain syndrome: are there distinct subtypes and sequential stages of the syndrome?. Pain 2002; 95 (01) [phone].
• 37 Bruehl S. Complex regional pain syndrome: outcomes and subtypes. Clin J Pain 2009; 25 (07) 598-599.
• 38 Harden RN, Bruehl S, Stanton-Hicks M, Wilson PR.. Proposed new diagnostic criteria for complex regional pain syndrome. Pain Med 2007; 8 (04) 326-331.
• 39 Harden RN, Bruehl S, Galer BS. et al. Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive?. Pain 1999; 83 (02) 211-219.
• 40 Harden RN, Bruehl S, Perez RS. et al. Validation of proposed diagnostic criteria (the “Budapest Criteria”) for Complex Regional Pain Syndrome. Pain 2010; 150 (02) 268-274.
• 41 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 (01) 23-30.
• 42 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 (04) 327-333.
• 43 Nitzsche EU. Nuclear medicine imaging for diagnosis of CRPS I. Handchir Mikrochir Plast Chir 2011; 43 (01) 20-24.
• 44 Sintzoff S, Sintzoff Jr S, Stallenberg B, Matos C. Imaging in reflex sympathetic dystrophy. Hand Clin 1997; 13 (03) 431-442.
• 45 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 (05) 262-265.
• 46 Deutsche Gesellschaft Neurologie. Diagnostik und Therapie komplexer regionaler Schmerzsyndrome (CRPS). AWMF-Leitlinien-Register Nr. 030/116 2008; 1-22.
• 47 Hugle C, Geiger M, Romann C, Moppert C.. Die Behandlung des CRPS I aus ergotherapeutischer Sicht. Handchir Mikrochir Plast Chir 2011; 43 (01) 32-38.
• 48 Werner GT, Beyer A, Berliner S. et al. Therapierichtlinien der Deutschen Gesellschaft für Physikalische Medizin und Rehabilitation – Behandlung beim komplexen regionalen Schmerzsyndrom. Phys Med Rehab Kuror 2002; 12: 208-210.
• 49 Oerlemans HM, Oostendorp RA, de BT, Goris RJ.. Pain and reduced mobility in complex regional pain syndrome I: outcome of a prospective randomised controlled clinical trial of adjuvant physical therapy versus occupational therapy. Pain 1999; 83 (01) 77-83.
• 50 Oerlemans HM, Oostendorp RA, de Boo T. et al. Adjuvant physical therapy versus occupational therapy in patients with reflex sympathetic dystrophy/complex regional pain syndrome type I. Arch Phys Med Rehabil 2000; 81 (01) 49-56.
• 51 Lee BH, Scharff L, Sethna NF. et al. Physical therapy and cognitive-behavioral treatment for complex regional pain syndromes. J Pediatr 2002; 141 (01) 135-140.
• 52 Bruehl S, Chung OY.. Psychological and behavioral aspects of complex regional pain syndrome management. Clin J Pain 2006; 22 (05) 430-437.
• 53 Turner JA, Mancl L, Aaron LA.. Short-and longterm efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: a randomized, controlled trial. Pain 2006; 121 (03) 181-194.
• 54 Turner JA, Holtzman S, Mancl L.. Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain. Pain 2007; 127 (03) 276-286.
• 55 Lesky J. Die “Sudeck-Persönlichkeit”: Mythos und Fiktion. Z Orthop Unfall 2010; 148 (06) 716-722.
• 56 Janig W, Baron R.. Is CRPS I a neuropathic pain syndrome?. Pain 2006; 120 (03) 227-229.
• 57 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 (01) (02) 52-59.
• 58 Perez RS, Zollinger PE, Dijkstra PU. et al. Evidence based guidelines for complex regional pain syndrome type 1. BMC Neurol 2010; 10: 20.
• 59 Maihofner C, Birklein F.. Complex regional pain syndromes: new aspects on pathophysiology and therapy. Fortschr Neurol Psychiatr 2007; 75 (06) 331-342.
• 60 Sindrup SH, Bach FW, Madsen C. et al. Venlafaxine versus imipramine in painful polyneuropathy: a randomized, controlled trial. Neurology 2003; 60 (08) 1284-1289.
• 61 Adami S, Fossaluzza V, Gatti D. et al. Bisphosphonate therapy of reflex sympathetic dystrophy syndrome. Ann Rheum Dis 1997; 56 (03) 201-204.
• 62 Manicourt DH, Brasseur JP, Boutsen Y. et al. Role of alendronate in therapy for posttraumatic complex regional pain syndrome type I of the lower extremity. Arthritis Rheum 2004; 50 (11) 3690-3697.
• 63 Varenna M, Zucchi F, Ghiringhelli D. et al. Intravenous clodronate in the treatment of reflex sympathetic dystrophy syndrome. A randomized, double blind, placebo controlled study. J Rheumatol 2000; 27 (06) 1477-1483.
• 64 Robinson JN, Sandom J, Chapman PT.. Efficacy of pamidronate in complex regional pain syndrome type I. Pain Med 2004; 5 (03) 276-280.
• 65 Yanow J, Pappagallo M, Pillai L.. Complex regional pain syndrome (CRPS/RSD) and neuropathic pain: role of intravenous bisphosphonates as analgesics. Scientific World Journal 2008; 8: 229-236.
• 66 Kingery WS, Guo T, Agashe GS. et al. Glucocorticoid inhibition of neuropathic limb edema and cutaneous neurogenic extravasation. Brain Res 2001; 913 (02) 140-148.
• 67 Guo TZ, Wei T, Kingery WS.. Glucocorticoid inhibition of vascular abnormalities in a tibia fracture rat model of complex regional pain syndrome type I. Pain 2006; 121 (01) [phone].
• 68 Eisenberg E, Shtahl S, Geller R. et al. Serum and salivary oxidative analysis in complex regional pain syndrome. Pain 2008; 138 (01) 226-232.
• 69 Goris RJ, Dongen LM, Winters HA.. Are toxic oxygen radicals involved in the pathogenesis of reflex sympathetic dystrophy?. Free Radic Res Commun 1987; 3 (01) (05) 13-18.
• 70 Geertzen JH, de Bruijn H, de Bruijn-Kofman AT, Arendzen JH. Reflex sympathetic dystrophy: early treatment and psychological aspects. Arch Phys Med Rehabil 1994; 75 (04) 442-446.
• 71 Zuurmond WW, Langendijk PN, Bezemer PD. et al. Treatment of acute reflex sympathetic dystrophy with DMSO 50 % in a fatty cream. Acta Anaesthesiol Scand 1996; 40 (03) 364-367.
• 72 Perez RS, Zuurmond WW, Bezemer PD. et al. The treatment of complex regional pain syndrome type I with free radical scavengers: a randomized controlled study. Pain 2003; 102 (03) 297-307.
• 73 van Dieten HE, Perez RS, van Tulder MW. et al. Cost effectiveness and cost utility of acetylcysteine versus dimethyl sulfoxide for reflex sympathetic dystrophy. Pharmacoeconomics 2003; 21 (02) 139-148.
• 74 Decramer M, Rutten-van MM, Dekhuijzen PN. et al. Effects of N-acetylcysteine on outcomes in chronic obstructive pulmonary disease (Bronchitis Randomized on NAC Cost-Utility Study, BRONCUS): a randomised placebo-controlled trial. Lancet 2005; 365 9470 1552-1560.
• 75 Ali Z, Raja SN, Wesselmann U. et al. Intradermal injection of norepinephrine evokes pain in patients with sympathetically maintained pain. Pain 2000; 88 (02) 161-168.
• 76 Baron R, Schattschneider J, Binder A. et al. Relation between sympathetic vasoconstrictor activity and pain and hyperalgesia in complex regional pain syndromes: a case-control study. Lancet 2002; 359 9318 1655-1660.
• 77 Cepeda MS, Lau J, Carr DB.. Defining the therapeutic role of local anesthetic sympathetic blockade in complex regional pain syndrome: a narrative and systematic review. Clin J Pain 2002; 18 (04) 216-233.
• 78 Cepeda MS, Carr DB, Lau J.. Local anesthetic sympathetic blockade for complex regional pain syndrome. Cochrane Database Syst Rev 2005; 4: CD004598.
• 79 Mailis A, Furlan A.. Sympathectomy for neuropathic pain. Cochrane Database Syst Rev 2003; 2: CD002918.
• 80 Forouzanfar T, Kemler MA, Weber WE. et al. Spinal cord stimulation in complex regional pain syndrome: cervical and lumbar devices are comparably effective. Br J Anaesth 2004; 92 (03) 348-353.
• 81 Kemler MA, de Vet HC, Barendse GA. et al. The effect of spinal cord stimulation in patients with chronic reflex sympathetic dystrophy: two years' follow-up of the randomized controlled trial. Ann Neurol 2004; 55 (01) 13-18.
• 82 Kemler MA, de Vet HC, Barendse GA. et al. Effect of spinal cord stimulation for chronic complex regional pain syndrome Type I: five-year final followup of patients in a randomized controlled trial. J Neurosurg 2008; 108 (02) 292-298.
• 83 Kemler MA, Raphael JH, Bentley A, Taylor RS.. The cost-effectiveness of spinal cord stimulation for complex regional pain syndrome. Value Health 2010; 13 (06) 735-742.
• 84 Hassenbusch SJ, Stanton-Hicks M, Schoppa D. et al. Long-term results of peripheral nerve stimulation for reflex sympathetic dystrophy. J Neurosurg 1996; 84 (03) 415-423.
• 85 Turner JA, Loeser JD, Deyo RA, Sanders SB.. Spinal cord stimulation for patients with failed back surgery syndrome or complex regional pain syndrome: a systematic review of effectiveness and complications. Pain 2004; 108 (01) [phone].
• 86 Tronnier V, Baron R, Birklein F. et al. Epidural spinal cord stimulation for therapy of chronic pain. Summary of the S3 guidelines. Schmerz 2011; 25 (05) 484-492.
• 87 Kemler MA, de Vet HC, Barendse GA. et al. Spinal cord stimulation for chronic reflex sympathetic dystrophy – five-year follow-up. N Engl J Med 2006; 354 (22) 2394-2396.
• 88 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 (01) [phone].
• 89 Meier B, Budak K, Brunner F.. Komplexes regionales Schmerzsyndrom Typ 1 (CRPS 1). Praxis 2011; 100 (04) 191-198.