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Fortschr Neurol Psychiatr 2007; 75(6): 331-342
DOI: 10.1055/s-2006-944310
Übersicht
© Georg Thieme Verlag Stuttgart · New York

Komplex regionale Schmerzsyndrome: Neues zu Pathophysiologie und Therapie

Complex Regional Pain Syndromes: New Aspects on Pathophysiology and TherapyC.  Maihöfner1, 2 , F.  Birklein3
  • 1Neurologische Klinik mit Poliklinik (Direktor: Prof. Dr. S. Schwab)
  • 2Institut für Physiologie und Experimentelle Pathophysiologie (Leiter: Prof. Dr. Dr. h.c. H. O. Handwerker) der Friedrich-Alexander-Universität Erlangen-Nürnberg
  • 3Neurologische Universitätsklinik Mainz (Direktorin: Prof. Dr. M. Dieterich)
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Publication History

Publication Date:
17 November 2006 (online)

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Zusammenfassung

Die Komplex-Regionalen Schmerzsyndrome (complex regional pain syndrome; CRPS) wurden früher als Morbus Sudeck oder Kausalgie bezeichnet. Sie sind Sonderformen neuropathischer Schmerzsyndrome. Ein CRPS kann sich als Komplikation nach Frakturen und Verletzungen der Extremitäten, aber auch nach Nerven- oder ZNS-Läsionen entwickeln. Selten tritt ein CRPS spontan auf. Als klinisches Bild findet sich eine relativ charakteristische Trias, die autonome (u. a. Hauttemperaturstörungen, Hautverfärbungen, Schwitzstörungen), sensorische (Schmerz und Hyperalgesie) und motorische (Paresen, Tremor, Dystonie) Störungen umfasst. Die Diagnose wird in erster Linie anhand klinischer Merkmale gestellt, apparative Zusatzuntersuchungen können die Diagnose aber unterstützen. Pathophysiologisch werden eine gesteigerte neurogene Entzündung, eine pathologische sympathiko-afferente Kopplung und in jüngster Zeit auch neuroplastische Veränderungen im ZNS diskutiert. Daneben mehren sich Anhaltspunkte für eine genetische Disposition. Die Therapie des CRPS ist multidisziplinär. Zu den nicht-medikamentösen Therapiekonzepten zählen insbesondere Physio/Ergotherapie, physikalische Maßnahmen und die transkutane elektrische Nervenstimulation. Medikamentöse Therapien orientieren sich an der individuellen Symptomkonstellation und umfassen Glukokortikoide, Radikalfänger, die Pharmakotherapie der neuropathischen Schmerzen, und Substanzen, die in den Knochenstoffwechsel eingreifen (Calcitonin und Biphosphonate). Sympathikusblockaden können bei Vorliegen eines sympathisch-unterhaltenen Schmerzsyndroms eingesetzt werden. Zu den invasiven Maßnahmen zählt vor allem die rückenmarksnahe Elektrostimulation („spinal cord stimulator”). Diese Arbeit stellt neue Aspekte von Pathophysiologie und Therapie des CRPS vor.

Abstract

Complex-regional pain syndromes (CRPS), formerly known as Sudeck's dystrophy and causalgia, belong to the neuropathic pain syndromes. CRPS may develop following fractures, limb trauma or lesions of the peripheral or central (CNS) nervous system. Occasionally, CRPS may also develop spontaneously. The clinical picture comprises a characteristic clinical triade of symptoms including autonomic (disturbances of skin temperature, colour, presence of sweating abnormalities), sensory (pain and hyperalgesia) and motor (paresis, tremor, dystonia) disturbances. Diagnosis is mainly based on clinical signs. However, additional laboratory, neurophysiological and radiological examinations may help to corroborate correct diagnosis. Several pathophysiological concepts have been proposed to explain the complex symptoms of CRPS: 1, facilitated neurogenic inflammation; 2, pathological sympatho-afferent coupling; 3, neuroplastic changes within the CNS. Furthermore, there is accumulating evidence that genetic factors may predispose for CRPS. Therapy is based on a multidisciplinary approach. Non-pharmacological approaches include physiotherapy and occupational therapy. Pharmacotherapy is based on individual symptoms and includes steroids, free radical scavengers, treatment of neuropathic pain, and finally agents interfering with bone metabolism (calcitonin, biphosphonates). Sympathetic blocks are useful for the treatment of sympathetically maintained pain. Invasive therapeutic concepts include implantation of spinal cord stimulators. This review covers new aspects of pathophysiology and therapy of CRPS.

Schlüsselwörter

Komplex regionales Schmerzsyndrom - CRPS - Morbus Sudeck - Kausalgie - neuropathischer Schmerz - sympathische Reflexdystrophie - sympathisch unterhaltener Schmerz - Therapie

Key words

complex regional pain syndrome - CRPS - Sudeck's dystrophy - reflex sympathetic dystrophy - causalgia - neuropathic pain - sympathetically maintained pain - therapy

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Priv. Doz. Dr. med. Christian Maihöfner

Neurologische Klinik mit Poliklinik der Universität Erlangen Nürnberg

Schwabachanlage 6

91054 Erlangen

Email: christian.maihoefner@uk-erlangen.de

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