SLR - January 2012 - Sidharth Reddy
Reference: Bodde, M. (2011), Dijkstra, P., den Dunnen, W., Geertzen (2011). Therapy-Resistant Complex Regional Pain Syndrome Type I: To Amputate or Not? Journal of Bone & Joint Surgery (93) 19; 799-805.
Scientific Literature Review
Reviewed by: Sidharth Reddy, DPM
Residency Program: Bethesda Memorial Hospital, Boynton Beach, FL
Podiatric Relevance:
Complex regional pain syndrome type I is commonly encountered in the podiatric setting, and it is important to understand methods of conservative vs. surgical treatment for such a problematic, recalcitrant condition.
Methods:
A thorough literature review was performed of the online databases, PubMed and EMBASE, and included original studies published prior to January 2010 discussing amputation as a treatment for CRPS-I. Other parameters were also evaluated within these studies, including criteria used to diagnose CRPS-I, rationale for amputation, surgical decision-making, phantom pain, prosthesis fitting and patient satisfaction, functional ability, and quality of life following surgery.
Results:
One hundred and sixty total articles were identified, of which twenty-six studies with Level-IV evidence were included. These studies involved 111 total amputations in 107 patients. Diagnostic criteria proposed by the International Association for the Study of Pain were applied to four of the studies, while the remainder of the studies did not discuss or implement the use of any diagnostic criteria. The primary reasons cited for amputation were pain (80%) and loss of limb function (72%). Recurrence was common, in 31 of 65 patients, while phantom pain occurred in 15 patients. Thirty-six of 49 patients were fitted with a prosthesis, of which only 14 used the prosthesis. Thirteen of 43 patients had paid employment after the amputation. Eight of the studies reported patient satisfaction, although it was unclear how it was measured. Changes in patient quality of life were reported on 15 patients reported over three studies. These studies reported an improvement of the quality of life in five patients and the joy of life in another six patients.
Conclusions:
The literature review does not favor amputation vs. limb salvage as a result of poor overall research design and poor reporting regarding the benefits vs. adverse effects of amputation in patients with CRPS-I. Overall, amputation is still a viable option in longstanding, therapy resistant CRPS-I as long as conservative methods, such as physical therapy, have failed. However, there is no solid foundation on which to support or deny that it will be successful as an end-stage treatment modality. Controlled studies, ones with more uniform diagnostic criteria and measured outcomes, must be performed to fully elucidate the viability of this treatment option.