Clinical experience using intrathecal (IT) bupivacaine infusion in three patients with complex regional pain syndrome type I (CRPS-I)

Background and aim: To date, there is no reliable method for treating the s evere pain and for modifying the natural evolution of CRPS-I. Therefore, we explored the effect of long-term IT bupivacaine infusion (with or without buprenorphine) on this syndrome. Patients and methods: (a) Patients: two women and one man, 25, 31 and 42 ye ars old, with CRPS-I of the lower (n = 2) or upper (n = 1) extremity lastin g for 4 and 5 months, and 14 years. (b) Interventions: insertion of externa lized IT catheters; IT infusion of buprenorphine 0.015 mg/ml and bupivacain e 4.75 mg/ml (n = 1), or only bupivacaine 5 mg/ml (n = 2) from external ele ctronic pumps. Results: The IT treatment lasted for 172, 282 and 668 days. The mean/maxima l daily doses of the IT bupivacaine were 39/66, 55/80 and 69/125 mg, respec tively. The pain intensity decreased from VAS(mean) = 7 +/- 1 to VAS(mean) = 2 +/- 2. None of the patients had regression of allodynia, edema, and tro phic disturbances in the affected extremities. Ln 2 patients, the IT treatm ent did not prevent spread of the disease to the opposite extremity or the occurrence of phantom pain and stump allodynia after amputation. The IT cat heters were withdrawn as being no longer needed: in 2 patients 56 and 458 d ays after amputation of the involved extremity, and in another one before r eplacement of the IT bupivacaine infusion with epidural dorsal column stimu lation (EDCS). After termination of the IT treatment, the patients were obs erved for 1437, 1575, and 2689 days (until September 1, 1998). At that date , all the patients were alive, and still affected by their CRPS-I, either i n the amputation stump (n = 2), and/or in the opposite or remote extremitie s (n = 2); further, two were unemployed and one worked for 75% of the time. One of them was taking up to 1500 mg of slow-release morphine to cope with pain. Conclusion: The IT pain treatment with bupivacaine (with or without bupreno rphine) alleviated the "refractory" pain, but affected neither the associat ed symptoms and signs of the CRPS-I, nor its natural evolution. Thus, the I T treatment cannot be recommended in preference to other pain treatment reg imens for CRPS-I.