Effect of Co-Morbid Conditions on Persistent Neuropathic Pain after Brachial Plexus Injury in Adult Patients

BACKGROUND AND PURPOSE: Neuropathic pain (NeuP) associated with traumatic brachial plexus injury (BPI) can be severe, persistent, and resistant to treatment. Moreover, comorbidity associated with NeuP may worsen the pain and quality of life. This study compared persistent NeuP after BPI between patients with and without co-morbid conditions (psychiatric dysfunction and other painful conditions) and tramadol usage as a second-line agent in combination with an antiepileptic and/or antidepressant during a 2-year follow-up. METHODS: The medical records of patients diagnosed with BPI referred to a pain center between 2006 and 2010 were reviewed for 2 years retrospectively. Data regarding patient demographics, injury and surgical profiles, characteristics of NeuP and its severity, and treatment received were compared between patients with and without manifesting co-morbid conditions. The NeuP and pain intensity assessments were based on the DN4 questionnaire and a numerical rating scale, respectively. RESULTS: Of the 45 patients studied, 24 patients presented with one of the following co-morbid conditions: myofascial pain (21%), psychiatric disorder (17%), phantom limb pain (4%), complex regional pain syndrome (21%), and insomnia (37%). Tramadol was required by 20 patients with co-morbidity and, 9 patients without co-morbidity (p<0.001). The mean pain score after 2 years was higher in patients with co-morbidity than in those without co-morbidity (p<0.05). CONCLUSIONS: Persistent pain following BPI was more common in patients manifesting other painful conditions or psychiatric co-morbidity. A higher proportion of the patients in the co-morbid group required tramadol as a second-line of agent for pain relief.

Complex Regional Pain Syndrome (CRPS type-1) in an Adolescent Following Extravasation of Dextrose Containing Fluid-an Underdiagnosed Case

Due to its complex pathophysiology and wide spectrum of clinical manifestations, the diagnosis of CRPS is often missed in the early stage by primary care physicians. After being treated by a primary care physician for 5 months for chronic cellulitis, a 16-year-old girl was referred to our hospital with features of type-1 CRPS of the right upper extremity. Inability to diagnose early caused prolonged suffering to the girl with all the consequence of CRPS. The patient responded well with marked functional recovery from multimodal therapy. Ability to distinguish CRPS from other pain conditions, referral for specialty care at the appropriate time and full awareness of this condition and its clinical features among various healthcare professionals are essential in reducing patient suffering and stopping its progression towards difficult-to-treat situations.