J Brachial Plex Peripher Nerve Inj 2008; 03(01): e80-e85
DOI: 10.1186/1749-7221-3-22
Case study
Sunder et al; licensee BioMed Central Ltd.

Ketamine as an adjuvant in sympathetic blocks for management of central sensitization following peripheral nerve injury[*]

Rani A Sunder
1   Asst Professor, Dept of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
,
Gokul Toshniwal
2   Former Resident, Dept of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
,
GP Dureja
3   Ex-Professor Dept of Anaesthesiology, All India Institute of Medical Sciences, Currently, Director – Delhi Pain Management Centre, New Delhi, India
› Author Affiliations

Subject Editor:
Further Information

Publication History

01 July 2008

25 October 2008

Publication Date:
17 September 2014 (online)

Abstract

Proliferation of NMDA receptors and role of glutamate in producing central sensitization and ’wind up’ phenomena in CRPS [complex regional pain syndrome] forms a strong basis for the use of Ketamine to block the cellular mechanisms that initiate and maintain these changes. In this case series, we describe 3 patients of CRPS Type II with debilitating central sensitization, heat/mechano allodynia and cognitive symptoms that we termed ’vicarious pain’. Each of these patients had dramatic relief with addition of Ketamine as an adjuvant to the sympathetic blocks after conventional therapy failed.

Case Reports All 3 patients suffered gunshot wounds and developed characteristic features of CRPS Type II. Within 2–3 weeks they developed extraterritorial symptoms typical of central sensitization. The generalized mechanical allodynia and debilitating heat allodynia described to be rare in human subjects had life altering affect on their daily life. Case 2 and 3 also described an unusual cognitive phenomenon i.e. visual stimuli of friction would evoke severe pain in the affected limb that we have termed as ’vicarious pain’. They responded positively to sympathetic blocks but the sympatholysis did not bring relief to the heat and mechanical allodynia. Addition of Ketamine 0.5 mg/kg to the sympathetic blocks elicited resulted in marked relief in the allodynia.

Conclusion Ketamine has a special role in patients with debilitating heat allodynia and positive cognitive symptoms via its action on central pain pathway. As an adjuvant in sympatholytic blocks it has a targeted action without significant neuropsychiatric side effects.

*This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


 
  • References

  • 1 Stanton-Hicks M, Janig W, Hassenbusch S et al.: Reflex sympathetic dystrophy: Changing concepts and taxonomy. Pain 1995; 63: 127-33 10.1016/0304-3959(95)00110-E 8577483
  • 2 Hocking Graham, Cousins MJ. Ketamine in Chronic Pain Management: An evidence- based review. Anesth Analg 2003; 97: 1730-9 10.1213/01.ANE.0000086618.28845.9B 14633551
  • 3 Correll GE, Maleki J, Harbut RE. Subanesthetic ketamine infusion therapy: A retrospective analysis of a novel therapeutic approach to complex regional pain syndrome. Pain Medicine 2004; 5: 263-275 10.1111/j.1526-4637.2004.04043.x 15367304
  • 4 Harbut RE, Correll GE. Successful treatment of a nine -year old case of Complex Regional Pain syndrome Type I [Reflex Sympathetic Dystrophy] with intravenous Ketamine – Infusion therapy in a warfarin anticoagulated adult female patient. Pain Medicine 2002; 3: 147-155 10.1046/j.1526-4637.2002.02029.x 15102163
  • 5 Wilson P, Harden RN, Stanton-Hicks M. Eds: CRPS: Current Diagnosis and Therapy, Progress in Pain Research and Management. IASP Press; Seattle: 2005. 32.
  • 6 Hartrick CT. Mechanism-based treatment for Complex Regional Pain Syndrome: Back to basics. Pain Practice 2004; 4: 69-73 10.1111/j.1533-2500.2004.04201.x 17166189
  • 7 Bridges D, Thompson SW, Rice ASC. Mechanism of neuropathic pain. Br J Anaesth 2001; 87: 12-26 10.1093/bja/87.1.12 11460801
  • 8 Torhild W, Audun S, Ellen J. Ketamine, an NMDA receptor anatagonist, suppresses spatial and temporal properties of burn-induced secondary hyperalgesia in man: a double blinded, cross over comparison with morphine and placebo. Pain 1997; 72: 99-106 10.1016/S0304-3959(97)00006-7 9272793
  • 9 Maleki J, LeBel AA, Bennett GJ, Schwartzman RJ et al.: Patterns of spread in complex regional pain syndrome, type I (reflex sympathetic dystrophy). Pain 2000; 88 (3) 259-266 10.1016/S0304-3959(00)00332-8 11068113
  • 10 Milligan ED, Twining C, Chacur M. Spinal glia and proinflammatory cytokines mediate mirror-image neuropathic pain in rats. The Journal of Neuroscience 2003; 23 (3) 1026 12574433
  • 11 McCabe CS, Mosley LG. Functional strategies of restoration of Complex regional pain syndrome. In: Justins DM. Pain 2005- An updated review: Refresher course syllabus. IASP press; Seattle:
  • 12 Lorenz J, Cross D, Minoshima S, Morrow T, Paulson P, Casey K. A unique representation of heat allodynia in the human brain. Pain 1993; 54 (3) 365-6 10.1016/0304-3959(93)90044-P 8233557
  • 13 Arner S, Meyerson BA. Lack of analgesic effect of opioids in neuropathic pain and idiopathic forms of pain. Pain 1988; 33: 11-23 10.1016/0304-3959(88)90198-4 2454440
  • 14 Gottrup H, Hansen PO, Arendt-Nielsen L, Jensen TS. Differential effects of systemically administered ketamine and lidocaine on dynamic and static hyperalgesia induced by intradermal capsacin in humans. Br J Anaesth 2000; 84: 155-62 10743446
  • 15 Devor M, Jaing W, Michaelis M. Modulation of activity in dorsal root ganglion neurons by sympathetic activation in nerve injured rats. J Neurophysiol 1994; 71: 38-47 8158237
  • 16 Hartrick CT. Outcome prediction following sympathetic block for complex regional pain syndrome. Pain Practice 2002; 98: 321
  • 17 Shirani P, Salamone AR, Schulz P. Ketamine Treatment for Intractable Pain in a Patient with Severe Refractory Complex Regional Pain Syndrome: A Case Report. Pain Physician 2008; 11 (3) 339-342 18523505
  • 18 Fisher K, Hagen NA. Analgesic effect of oral ketamine in chronic neuropathic pain of spinal origin: a case report. J Pain Symptom Manage 1999; 18: 61-6 10.1016/S0885-3924(99)00018-4 10439575
  • 19 Ushida T, Tani T, Kanbara T, Zinchuk VS et al.: Analgesic effects of ketamine ointment in patients with complex regional pain syndrome type1. Reg Anesth Pain Med 2002; 27 (5) 524-8 10.1053/rapm.2002.35517 12373705
  • 20 Kiefer R, Rohr P, Ploppa A, Dieterich H et al.: Efficacy of Ketamine in Anesthetic Dosage for the Treatment of Refractory Complex Regional Pain Syndrome: An Open-Label Phase II Study. Pain Med 2008;
  • 21 Kiefer R, Rohr P, Ploppa A, Nohe B, Dieterich H et al.: A Pilot Open-Label Study of the Efficacy of Subanesthetic Isomeric S(+)-Ketamine in Refractory CRPS Patients. Pain Medicine 2008; 9 (1) 44-54 10.1111/j.1526-4637.2006.00223.x 18254766
  • 22 Koffler SP, Hampstead BM, Irani F et al.: The neurocognitive effects of 5 day anesthetic ketamine for the treatment of refractory complex regional pain syndrome. Archives of Clinical Neuropsychology 2007; 22: 719-729 10.1016/j.acn.2007.05.005 17611073
  • 23 Cruccu G, Anand P, Attal N, Garcia-Larrea L et al.: EFNS guidelines on neuropathic pain assessment. European Journal of Neurology 2004; 11: 153-162 10.1111/j.1468-1331.2004.00791.x 15009162