Complex Regional Pain Syndrome Specialist

What is complex regional pain syndrome?

Complex regional pain syndrome (CRPS) describes a condition that causes chronic pain typically in one limb, such as your arm, leg, foot, or hand. The pain of CRPS lasts longer than six months and usually follows an injury.

The root cause of CRPS pain is likely damage to your peripheral and central nervous systems. The peripheral nervous system travels throughout your body and provides sensations like touch to your arms, legs, and other areas. The central nervous system is made up of the brain and spinal cord.  Damage to these areas can cause the spinal cord to misinterpret signals coming from the nerves and send bad information to the brain. This triggers changes in the brain response. Bad signals can ultimately affect your sympathetic system that controls your body temperature, blood flow, and sensations in your skin.  

Dr. Mukalel likes to say that your body sends information to the spinal cord in English. The brain needs to receive the information in Spanish. The spinal cord (specifically at the dorsal root ganglion, using NMDA receptors as the translator) has to convert that information to Spanish.  In CRPS, the language is converted into French, and the brain has no idea what to do, causing distress, pain and depression.

What are the symptoms of complex regional pain syndrome?

In the early stages of CRPS, you may develop visible changes in your skin color and body temperature. As the condition progresses, you may experience:

• Hair loss
• Brittle skin
• Skin dehydration
• Edema (swelling) in the limbs

Eventually, CRPS can lead to abnormal contractures in the limbs and joints. These issues can lead to damage in the nerve roots that causes chronic pain to develop, even when there are no stimuli to trigger pain. Allodynia and hyperalgesia can also develop, which causes excessive pain even with a gentle touch and pinpricks, respectively.

How is complex regional pain syndrome diagnosed?

To evaluate your symptoms, Dr. Mukalel performs a physical exam of the painful areas and reviews your symptoms. He focuses on confirming whether your symptoms relate to CRPS or another type of chronic pain condition, such as postherpetic neuralgia.

Post-herpetic neuralgia is a painful condition that results from having herpes zoster, or shingles. If you had chickenpox at any point, the virus can remain dormant in your dorsal root ganglion (DRG) and reactivate when you’re older. This can lead to chronic inflammation and pain in the DRG that’s similar to the symptoms of complex regional pain syndrome.  Diabetic peripheral neuropathy in the feet is another similar pain syndrome affecting the DRG and transmitting inappropriate signals to your brain.

How is complex regional pain syndrome treated?

In the early stages of CRPS, Dr. Mukalel may recommend a series of nerve blocks to reset the signaling pathways in your nervous system. He may also recommend:

Medications 

Medication therapies available for treating CRPS include:

• Lyrica®
• Gabapentin
• Antidepressants
• Low-dose naltrexone
• Selective serotonin reuptake inhibitors (SSRIs)

Dr. Mukalel also uses oral and IV vitamins and nutraceuticals to treat early-stage CRPS. Vitamin C, N-Acetyle cisteine, cinnamon, tumeric and Alpha lipoic acid supplementation can be effective.  He can treat postherpetic neuralgia symptoms with medications and steroid injections, much like he does with CRPS. Diabetic peripheral neuropathy however, requires strict diet control and glucose monitoring or more commonly dorsal root ganglion stimulation.

Spinal cord stimulation

For late-stage CRPS, Dr. Mukalel often recommends spinal cord stimulation therapy to target the DRG, the location of the injured neurons.

DRG stimulation helps repair the injured nerves to relieve pain in the long-term, rather than just masking pain signals. Dr. Mukalel offers both spinal cord stimulation and DRG stimulation.

Stimulation of the dorsal root ganglion, where the injured neurons are located, is the most superior and sustainable long-term treatment option for CRPS. Achieving 80-100% total long-term (over 12 months) pain relief in more than 70% of patients studied.

Ketamine fusion therapy

In some cases where DRG stimulation isn’t possible, Dr. Mukalel may recommend infusions of ketamine and lidocaine to relieve inflammation and chronic pain. Ketamine is the only direct inhibitor of the NMDA receptors, and when paired with lidocaine, a potent systemic (whole-body) anti-inflammatory, amazing results can be seen. Dr. Mukalel customizes your dosage based on your unique needs.

Ketamine isn’t a first-line therapy for CRPS, as it’s not a long-term solution like DRG stimulation. However, ketamine may be an option for patients with insurance that doesn’t cover or reimburse for traditional treatments.   

There are certain people who may have failed spinal cord stimulation and have refractory CRPS, or in rare circumstances, have a "traveling" version of CRPS that presents in different limbs or the trunk on either side of the body. For these patients. Dr. Mukalel provides ketamine and lidocaine infusion therapies. 

If you need help with the chronic pain of complex regional pain syndrome, schedule a consultation by calling the office of Jessen Mukalel, MD, or requesting an appointment online today.