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Medical Edge Newspaper Column from Mayo Clinic

OPTIONS FOR TREATING SYMPATHETIC NERVE PAIN

DEAR MAYO CLINIC: In December 2003, I fell and broke my left hip. The doctors put in a new ball. I healed well, but developed another problem. My leg became so painful that I couldn't stand to have the bed sheets touch it. My orthopedic doctor sent me to a pain clinic.

The pain clinic doctor diagnosed sympathetic nerve pain. He gave me a series of epidural nerve blocks in my back. They helped some. I am also taking carbamazepine. However, I'm still in severe pain most of the time. What can you tell me about sympathetic nerve pain and can anything else be done about it? — Antlers, Okla.

ANSWER: Sympathetic nerve pain is now commonly known as complex regional pain syndrome. CRPS can occur after nerve injuries; with medical conditions such as diabetes or lupus; or after orthopedic injuries, even minor ones such as a sprained ankle.

Patients with CRPS are in pain much of the time. Even a light touch can provoke pain. Patients with lower limb pain may have difficulty walking normally. If pain is in the hand, it may be difficult to do normal household activities.

A little history: Silas Weir Mitchell, a Civil War neurologist, first identified this condition. He called it causalgia, taking the Greek roots kausis and algos, which combined mean burning pain. Physicians still look for the symptoms he identified:

— Burning or aching pain.

— Changes in skin color and texture. Skin color can range from white and mottled to red or blue.

— At first, increased hair and nail growth. In later stages, reduced hair growth and nail deterioration.

— Excessive limb sweating.

— Thinning of the bones and muscle stiffness.

— Psychological distress.

Testing to help confirm the diagnosis can include special three-phase bone scans or nerve-function tests.

The reason that the sympathetic nerves start to behave abnormally may be that the nervous system gets, in a sense, wound up. It signifies a chemical change in the central nervous system caused by the ongoing stimulation coming from the area of pain. Once this has occurred, it becomes far more difficult to treat the condition. It’s thought that the nervous system has perhaps permanently been altered.

In your case, it may be that the hip operation irritated the nerves around the hip, or it may be unrelated.

Part of the therapy for CRPS is to begin medications that may seem somewhat unusual for pain, such as antiseizure or antidepressant medicines. Corticosteroids (prednisone) and opioids also are used.

Epidurals, sympathetic nerve blocks and intravenous regional drug infusions are options. They work better when started soon after the problem is identified.

Most importantly, actively try to use the extremity as soon as possible. It helps the person return to normal activities.

In a few selected cases, implantation of a spinal cord stimulator or surgical resection of the sympathetic nerves is recommended.

So you do have more options for treatment. Work with a pain specialist or neurologist to determine treatment for your condition.

— Marc Huntoon, M.D., Pain Medicine, Mayo Clinic, Rochester, Minn.

Additional Resources:
Chronic Pain
Appointment Information
More Information on Sympathetic Nerve Pain

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Medical Edge from Mayo Clinic is an educational resource and doesn’t replace regular medical care. To e-mail a question, go to www.mayoclinic.org, or write: Medical Edge from Mayo Clinic, c/o TMS, 2225 Kenmore Ave., Suite 114, Buffalo, N.Y., 14207. For health information, visit www.mayoclinic.com.