Local anaesthetic sympathetic blockade for complex regional pain syndrome

Neil E O'Connell; Benedict M Wand; William Gibson; Daniel B Carr; Frank Birklein; Tasha R Stanton

doi:10.1002/14651858.CD004598.pub4

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Summary of findings 1. LASB for pain intensity and duration of pain relief in adults with CRPS

Comparison	Studies	No of participants (studies)	Result (effect estimates reported where available from study report)	Quality of the evidence (GRADE)
Patient or population: adults with CRPS Setting: secondary care Intervention/comparison: LASB vs various comparisons Outcome: pain intensity 0‐10 (VAS or NRS)
LASB vs placebo	Aydemir 2006; Price 1998	23 (2)	No significant between‐group difference	⊕⊕⊕⊝ Moderate^a
Thoracic LASB + steroid vs subcutaneous local anaesthetic+ steroid	Rocha 2014	36 (1)	Favours LASB Mean difference (0‐10 scale) One month −1.25 (95% CI −3.2 to 0.7) One year −2.39 (95% CI −4.72 to −0.06)	⊕⊝⊝⊝ Very low^b
LASB vs ultrasound block	Aydemir 2006	18 (1)	No significant between‐group difference	⊕⊕⊝⊝ Low^c
LASB vs IVRB guanethidine	Bonelli 1983	19 (1)	No significant between‐group difference	⊕⊝⊝⊝ Very low^b
LASB lumbar plexus vs pulsed radiofrequency lumbar plexus	Freitas 2013	40 (1)	No significant between‐group difference	⊕⊝⊝⊝ Very low^b
LASB (lidocaine + clonidine) vs IVRB (lidocaine + clonidine)	Nascimento 2010	43 (1)	No significant between‐group difference	⊕⊝⊝⊝ Very low^b
LASB + PT+ pharmacological vs PT + pharmacological	Rodriguez 2005	82 (1)	Favours SGB group	⊕⊝⊝⊝ Very low^b
LASB + PT vs PT	Zeng 2003	60 (1)	No significant between‐group difference	⊕⊝⊝⊝ Very low^b
Continuous LASB vs continuous brachial plexus block	Toshniwal 2012	33 (1)	Favours brachial plexus block	⊕⊕⊝⊝ Low^c
Image‐guided LASB vs nonimage‐guided LASB	Yoo 2012	42 (1)	Mean difference 2 weeks postinjection −0.58 (95% CI −1.51 to 0.35) 4 weeks postinjection −0.74 (95% CI −1.36 to −0.12)	⊝⊝⊝⊝ Very low^d
Outcome: hand pain 0‐3 scale
LASB vs oral corticosteroids	Lim 2007	38 (1)	15 day follow‐up, no significant between‐group difference at 30 day follow‐up 0.4 (95% CI −0.69 to −0.11), favours LASB with steroid	⊝⊝⊝⊝ Very low^d
Outcome: duration of pain relief
LASB bupivacaine + BTA vs LASB bupivacaine	Carroll 2009	9 (1)	Increased duration of relief with BTA Median time to analgesic failure (days): LASB bupivacaine + BTA 71 (95% CI 12 to 253) LASB bupivacaine 10 (95%CI 0 to 12)	⊕⊕⊝⊝ Low^c
^a Downgraded once for imprecision. ^b Downgraded three times for limitations, inconsistency, and imprecision. ^cDowngraded twice for inconsistency and imprecision. ^dDowngraded four times for limitations, inconsistency, indirectness, and imprecision.

Summary of findings 1. LASB for pain intensity and duration of pain relief in adults with CRPS

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Table 1. Budapest criteria: diagnostic criteria for complex regional pain syndrome

To make the clinical diagnosis, the following criteria must be met:

1. Continuing pain, which is disproportionate to any inciting event

2. Must report at least one symptom in three of the four following categories.

Sensory: reports of hyperaesthesia, allodynia, or both.
Vasomotor: reports of temperature asymmetry, skin colour changes, skin colour asymmetry, or a combination of these.
Sudomotor/oedema: reports of oedema, sweating changes, sweating asymmetry, or a combination of these.
Motor/trophic: reports of decreased range of motion, motor dysfunction (weakness, tremor, dystonia), trophic change (hair, nail, skin), or a combination of these.

3. Must display at least one sign at time of evaluation in two or more of the following categories:

Sensory: evidence of hyperalgesia (to pinprick), allodynia (to light touch, temperature sensation, deep somatic pressure, or joint movement), or both
Vasomotor: evidence of temperature asymmetry (> 1° C), skin colour changes, asymmetry, or a combination of these.
Sudomotor/oedema: evidence of oedema, sweating changes, sweating asymmetry, or a combination of these.
Motor/trophic: evidence of decreased range of motion, motor dysfunction (weakness, tremor, dystonia), trophic changes (hair, nail, skin), or a combination of these.

4. There is no other diagnosis that better explains the signs and symptoms

For research purposes, diagnostic decision rule should be at least one symptom in all four symptom categories and at least one sign (observed at evaluation) in two or more sign categories. A sign is counted only if it is observed at time of diagnosis.

Table 1. Budapest criteria: diagnostic criteria for complex regional pain syndrome

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