Local anaesthetic sympathetic blockade for complex regional pain syndrome
Abstract
Background
Local anaesthetic blockade of the sympathetic chain is widely used to treat reflex sympathetic dystrophy (RSD) and causalgia. These two pain syndromes are now conceptualized as variants of a single entity: complex regional pain syndrome (CRPS). A recent meta‐analysis of the topic has been published. However, this study only evaluated studies in English language and therefore it could have overlooked some randomized controlled trials.
Objectives
This systematic review had three objectives: to determine the likelihood of pain alleviation after sympathetic blockade with local anesthetics in the patient with CRPS; to assess how long any benefit persists; and to evaluate the incidence of adverse effects of the procedure.
Search methods
We searched the Cochrane Pain, Palliative and Supportive Care Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS, and conference abstracts of the World Congresses of the International Association for the Study of Pain. Bibliographies from retrieved articles were also searched for additional studies.
Selection criteria
We considered for inclusion randomized controlled trials (RCTs) that evaluated the effect of sympathetic blockade with local anesthetics in children or in adult patients to treat RSD, causalgia, or CRPS.
Data collection and analysis
The outcomes of interest were the number of patients who obtained at least 50% of pain relief shortly after sympathetic blockade (30 minutes to 2 hours) and 48 hours or later. We also assessed the presence of adverse effects in each treatment arm. A random effects model was used to combine the studies.
Main results
Two small randomized double blind cross over studies that evaluated 23 subjects were found. The combined effect of the two trials produced a relative risk (RR) to achieve at least 50% of pain relief 30 minutes to 2 hours after the sympathetic blockade of 1.17 (95% CI 0.80‐1.72). It was not possible to determine the effect of sympathetic blockade on long‐term pain relief because the authors of the two studies evaluated different outcomes.
Authors' conclusions
This systematic review revealed the scarcity of published evidence to support the use of local anesthetic sympathetic blockade as the 'gold standard' treatment for CRPS. The two randomized studies that met inclusion criteria had very small sample sizes, therefore, no conclusion concerning the effectiveness of this procedure could be drawn. There is a need to conduct randomized controlled trials to address the value of sympathetic blockade with local anesthetic for the treatment of CRPS.
PICOs
Plain language summary
Local anesthetic sympathetic blockade for complex regional pain syndrome
The efficacy of local anesthetic sympathetic blockade for CRPS is unknown. The sympathetic nervous system has been implicated in the pathophysiology of reflex sympathetic dystrophy (RSD) and causalgia which are now conceptualized as variants of a single entity: complex regional pain syndrome (CRPS). Consequently blockade of the sympathetic nervous system is widely used to treat this pain syndrome. The reviewers sought to evaluate the efficacy of sympathetic blockade with local anesthetic. This systematic review reveals the scarcity of published evidence to support the use of local anesthetic sympathetic blockade as the "gold standard" treatment for CRPS and raises questions as to its usefulness.
