Leitfaden zur Diagnostik des Komplexen regionalen Schmerzsyndroms

Zusammenfassung

Das komplexe regionale Schmerzsyndrom (engl. complex regional pain syndrome; CRPS) tritt nach Traumata v. a. der distalen Extremitäten als Sonderform neuropathischer Schmerzsyndrome auf. Die Symptomatik umfasst Plus- und Minussymptome mit sensiblen, motorischen, vasomotorischen, sudomotorischen und trophischen Veränderungen. Interindividuell und intraindividuell können die jeweiligen Symptome in unterschiedlicher Ausprägung gefunden werden, einzelne auch gänzlich fehlen. Ein diagnostischer „Goldstandard“ konnte bisweilen nicht identifiziert werden, somit gründet die Diagnosestellung auf einer detaillierten Anamnese und klinisch-neurologischen Untersuchung. Durch die Internationale Gesellschaft zum Studium des Schmerzes (IASP) wurden operationale Kriterien zur Diagnosefindung erstellt, validiert und im Jahre 2003 durch eine Konsensusgruppe in Budapest revidiert mit resultierender klinisch wie auch wissenschaftlich zufrieden stellender Sensitivität und Spezifität. Diese klinische Einordnung kann ergänzend durch apparative Diagnostik bestätigt werden – sinnvolle Untersuchungen stellen seitenvergleichende konventionelle Röntgenaufnahmen, eine Kernspintomografie der betroffenen Extremität sowie eine 3-Phasen-Skelettszintigrafie dar. Hilfreich können weiterhin der Nachweis einer Nervenläsion im Zuge elektrophysiologischer Messungen zur Differenzierung zwischen CRPS Typ I und II oder einer Temperaturdifferenz mittels Infrarotthermografie sein. Eine quantitative sensorische Testung kann das Ausmaß der sensorischen Veränderungen erfassen und im Verlauf den Therapieerfolg dokumentieren. Die Initiierung einer Therapie sollte aber, auch bei Vorliegen von Normalbefunden in den ergänzenden apparativen Untersuchungen, von diesen unbeeinflusst bleiben.

Abstract

The complex regional pain syndrome, a special form of neuropathic pain, develops after a minor trauma of the distal limbs. Besides the presentation of pain disproportional to the inciting event, further plus and minus symptoms in the form of sensory, vasomotor, sudomotor-oedematous and motor-trophic changes can be found. Interindividually and intraindividually, occurrence of these symptoms differs widely and single symptoms can be lacking completely. A gold standard in diagnosing CRPS has not been found yet, diagnostics are based on the patients medical history and correlating clinical signs. The International Association for the Study of Pain (IASP) compiled and later on revised operational diagnostic criteria resulting in a satisfactory sensitivity and specificity for both research and clinical needs. Additionally, diagnostic tools can support the clinical suspicion – reasonable tests are conventional X-ray examination comparing sides, magnetic resonance imaging and a 3-phase bone scintigraphy. Moreover, electrophysiological examinations can prove a nerve lesion and differentiate between CRPS type I and II. A temperature difference can be detected via infrared thermography. Furthermore, quantitative sensory testing can verify the magnitude of the sensory disturbance and can be beneficial to objectify therapeutic effects. Use of these diagnostic tools, even after achievement of normal findings, cannot exclude a CRPS and the decision for therapeutic initiation should not be influenced thereby.

Komplex regionales Schmerzsyndrom - Diagnosekriterien - neuropathischer Schmerz - CRPS - Morbus Sudeck

complex regional pain syndrome - diagnostic criteria - neuropathic pain - CRPS - Sudeck's atrophy

Literatur

• 1 Veldman PH, Reynen HM, Arntz IE. et al . Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients.  Lancet. 1993;  342 1012-1016
• 2 Stanton-Hicks M, Janig W, Hassenbusch S. et al . Reflex sympathetic dystrophy: changing concepts and taxonomy.  Pain. 1995;  63 127-133
• 3 Atkins RM, Duckworth T, Kanis JA. Features of algodystrophy after Colles’ fracture.  J Bone Joint Surg Br. 1990;  72 105-110
• 4 Bickerstaff DR, Kanis JA. Algodystrophy: an under-recognized complication of minor trauma.  Br J Rheumatol. 1994;  33 240-248
• 5 Schurmann M, Gradl G, Andress HJ. et al . Assessment of peripheral sympathetic nervous function for diagnosing early post-traumatic complex regional pain syndrome type I.  Pain. 1999;  80 149-159
• 6 Gibbons JJ, Wilson PR. RSD score: criteria for the diagnosis of reflex sympathetic dystrophy and causalgia.  Clin J Pain. 1992;  8 260-263
• 7 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 23-30
• 8 Janig W. Experimental approach to reflex sympathetic dystrophy and related syndromes.  Pain. 1991;  46 241-245
• 9 Zyluk A. A new clinical severity scoring system for reflex sympathetic dystrophy of the upper limb.  J Hand Surg Br. 2003;  28 238-241
• 10 van de Beek WJ, Schwartzman RJ, van Nes SI. et al . Diagnostic criteria used in studies of reflex sympathetic dystrophy.  Neurology. 2002;  58 522-526
• 11 Harden RN, Bruehl S, Stanton-Hicks M. et al . Proposed new diagnostic criteria for complex regional pain syndrome.  Pain Med. 2007;  8 326-331
• 12 Brunner F, Lienhardt SB, Kissling RO. et al . Diagnostic criteria and follow-up parameters in complex regional pain syndrome type I – a Delphi survey.  Eur J Pain. 2008;  12 48-52
• 13 Harden RN, Bruehl SP. Diagnosis of complex regional pain syndrome: signs, symptoms, and new empirically derived diagnostic criteria.  Clin J Pain. 2006;  22 415-419
• 14 Galer BS, Bruehl S, Harden RN. IASP diagnostic criteria for complex regional pain syndrome: a preliminary empirical validation study. International Association for the Study of Pain.  Clin J Pain. 1998;  14 48-54
• 15 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;  81 147-154
• 16 Harden RN, Bruehl S, Galer BS. et al . Complex regional pain syndrome: are the IASP diagnostic criteria valid and sufficiently comprehensive?.  Pain. 1999;  83 211-219
• 17 Perez RS, Collins S, Marinus J. et al . Diagnostic criteria for CRPS I: differences between patient profiles using three different diagnostic sets.  Eur J Pain. 2007;  11 895-902
• 18 Birklein F, Riedl B, Sieweke N. et al . Neurological findings in complex regional pain syndromes – analysis of 145 cases.  Acta Neurol Scand. 2000;  101 262-269
• 19 Drummond PD, Finch PM, Skipworth S. et al . Pain increases during sympathetic arousal in patients with complex regional pain syndrome.  Neurology. 2001;  57 1296-1303
• 20 Wasner G, Schattschneider J, Heckmann K. et al . Vascular abnormalities in reflex sympathetic dystrophy (CRPS I): mechanisms and diagnostic value.  Brain. 2001;  124 587-599
• 21 van der Laan L, Veldman PH, Goris RJ. Severe complications of reflex sympathetic dystrophy: infection, ulcers, chronic edema, dystonia, and myoclonus.  Arch Phys Med Rehabil. 1998;  79 424-429
• 22 Albazaz R, Wong YT, Homer-Vanniasinkam S. Complex regional pain syndrome: a review.  Ann Vasc Surg. 2008;  22 297-306
• 23 de Rooij AM, Florencia Gosso M, Haasnoot GW. et al . HLA-B62 and HLA-DQ8 are associated with Complex Regional Pain Syndrome with fixed dystonia.  Pain. 2009;  145 82-85
• 24 Melzack R. The McGill Pain Questionnaire: major properties and scoring methods.  Pain. 1975;  1 277-299
• 25 Bennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs.  Pain. 2001;  92 147-157
• 26 de Mos M, Sturkenboom MC, Huygen FJ. Current understandings on complex regional pain syndrome.  Pain Pract. 2009;  9 86-99
• 27 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 52-59
• 28 Galer BS, Jensen MP. Development and preliminary validation of a pain measure specific to neuropathic pain: the Neuropathic Pain Scale.  Neurology. 1997;  48 332-338
• 29 Krause SJ, Backonja MM. Development of a neuropathic pain questionnaire.  Clin J Pain. 2003;  19 306-314
• 30 Stein C, Mendl G. The German counterpart to McGill Pain Questionnaire.  Pain. 1988;  32 251-255
• 31 Birklein F, Riedl B, Neundorfer B. et al . Sympathetic vasoconstrictor reflex pattern in patients with complex regional pain syndrome.  Pain. 1998;  75 93-100
• 32 Livingstone JA, Field J. Algodystrophy and its association with Dupuytren's disease.  J Hand Surg Br. 1999;  24 199-202
• 33 Schurmann M, Zaspel J, Lohr P. et al . Imaging in early posttraumatic complex regional pain syndrome: a comparison of diagnostic methods.  Clin J Pain. 2007;  23 449-457
• 34 Fournier RS, Holder LE. Reflex sympathetic dystrophy: diagnostic controversies.  Semin Nucl Med. 1998;  28 116-123
• 35 Krumova EK, Frettloh J, Klauenberg S. et al . Long-term skin temperature measurements – a practical diagnostic tool in complex regional pain syndrome.  Pain. 2008;  140 8-22
• 36 Chemali KR, Gorodeski R, Chelimsky TC. Alpha-adrenergic supersensitivity of the sudomotor nerve in complex regional pain syndrome.  Ann Neurol. 2001;  49 453-459
• 37 Baron R, Maier C. Reflex sympathetic dystrophy: skin blood flow, sympathetic vasoconstrictor reflexes and pain before and after surgical sympathectomy.  Pain. 1996;  67 317-326
• 38 Schwartzman RJ, Kerrigan J. The movement disorder of reflex sympathetic dystrophy.  Neurology. 1990;  40 57-61
• 39 van Rijn MA, Marinus J, Putter H. et al . Onset and progression of dystonia in complex regional pain syndrome.  Pain. 2007;  130 287-293
• 40 Zyluk A. The usefulness of quantitative evaluation of three-phase scintigraphy in the diagnosis of post-traumatic reflex sympathetic dystrophy.  J Hand Surg Br. 1999;  24 16-21
• 41 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;  20 327-333
• 42 Holder LE, Mackinnon SE. Reflex sympathetic dystrophy in the hands: clinical and scintigraphic criteria.  Radiology. 1984;  152 517-522
• 43 Kozin F, Soin JS, Ryan LM. et al . Bone scintigraphy in the reflex sympathetic dystrophy syndrome.  Radiology. 1981;  138 437-443
• 44 Park SA, Yang CY, Kim CG. et al . Patterns of three-phase bone scintigraphy according to the time course of complex regional pain syndrome type I after a stroke or traumatic brain injury.  Clin Nucl Med. 2009;  34 773-776
• 45 Atkins RM, Tindale W, Bickerstaff D. et al . Quantitative bone scintigraphy in reflex sympathetic dystrophy.  Br J Rheumatol. 1993;  32 41-45
• 46 Crozier F, Champsaur P, Pham T. et al . Magnetic resonance imaging in reflex sympathetic dystrophy syndrome of the foot.  Joint Bone Spine. 2003;  70 503-508
• 47 Schweitzer ME, Mandel S, Schwartzman RJ. et al . Reflex sympathetic dystrophy revisited: MR imaging findings before and after infusion of contrast material.  Radiology. 1995;  195 211-214
• 48 Graif M, Schweitzer ME, Marks B. et al . Synovial effusion in reflex sympathetic dystrophy: an additional sign for diagnosis and staging.  Skeletal Radiol. 1998;  27 262-265
• 49 Rommel O, Malin JP, Zenz M. et al . Quantitative sensory testing, neurophysiological and psychological examination in patients with complex regional pain syndrome and hemisensory deficits.  Pain. 2001;  93 279-293
• 50 Rolke R, Magerl W, Campbell KA. et al . Quantitative sensory testing: a comprehensive protocol for clinical trials.  Eur J Pain. 2006;  10 77-88
• 51 Rolke R, Baron R, Maier C. et al . Quantitative sensory testing in the German Research Network on Neuropathic Pain (DFNS): standardized protocol and reference values.  Pain. 2006;  123 231-243
• 52 Sethna NF, Meier PM, Zurakowski D. et al . Cutaneous sensory abnormalities in children and adolescents with complex regional pain syndromes.  Pain. 2007;  131 153-161
• 53 Baron R. Mechanisms of disease: neuropathic pain – a clinical perspective.  Nat Clin Pract Neurol. 2006;  2 95-106
• 54 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;  22 235-239
• 55 Uceyler N, Eberle T, Rolke R. et al . Differential expression patterns of cytokines in complex regional pain syndrome.  Pain. 2007;  132 195-205
• 56 Birklein F, Schmelz M, Schifter S. et al . The important role of neuropeptides in complex regional pain syndrome.  Neurology. 2001;  57 2179-2184
• 57 Kohr D, Tschernatsch M, Schmitz K. et al . Autoantibodies in complex regional pain syndrome bind to a differentiation-dependent neuronal surface autoantigen.  Pain. 2009;  143 246-251
• 58 Goebel A, Vogel H, Caneris O. et al . Immune responses to Campylobacter and serum autoantibodies in patients with complex regional pain syndrome.  J Neuroimmunol. 2005;  162 184-189
• 59 Turton AJ, McCabe CS, Harris N. et al . Sensorimotor integration in Complex Regional Pain Syndrome: a transcranial magnetic stimulation study.  Pain. 2007;  127 270-275
• 60 van de Beek WJ, Vein A, Hilgevoord AA. et al . Neurophysiologic aspects of patients with generalized or multifocal tonic dystonia of reflex sympathetic dystrophy.  J Clin Neurophysiol. 2002;  19 77-83

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