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Informed Decision-Making Regarding Amputation for Complex Regional Pain Syndrome Type I
Marlies I Bodde1, Pieter U Dijkstra1, Ernst Schrier1
1Department of Rehabilitation Medicine, Center for Rehabilitation (M.I.B., P.U.D., E.S., and J.H.G.), Department of Oral and Maxillofacial Surgery (P.U.D.), Department of Surgery (J.J.v.d.D.), and Department of Pathology and Medical Biology (W.F.d.D.), University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, the Netherlands.
Insights
Amputation for complex regional pain syndrome type I (CRPS-I) involves shared decision-making. While outcomes are unpredictable, amputation is a viable option for therapy-resistant CRPS-I.
Area of Science:
- Pain Medicine
- Surgical Decision-Making
- Patient Outcomes
Background:
- Literature on amputation decisions for complex regional pain syndrome type I (CRPS-I) is limited.
- This study addresses the scarcity of information regarding amputation for CRPS-I.
Purpose of the Study:
- To evaluate the informed decision-making process for amputation in patients with CRPS-I.
- To analyze the factors influencing amputation decisions and the subsequent outcomes.
Main Methods:
- Retrospective study of 36 patients who underwent amputation for CRPS-I between 2000 and 2012.
- Data collected on preceding incidents, reasons for amputation, amputation levels, and post-operative outcomes.
- Therapeutic Level IV evidence.
Main Results:
- Amputation decisions were made collaboratively between the medical team and the patient.
- Factors considered included pain levels, infection, residual limb goals, physical function, and psychological flags.
- No intraoperative complications; 22% postoperative infection rate. High incidence of phantom pain (72% within 3 months, 77% after 1 year).
Conclusions:
- Informed decision-making for CRPS-I amputation is complex, with unpredictable patient-specific outcomes.
- Amputation should be considered a treatment option for long-standing, therapy-resistant CRPS-I.
Background:
Literature on complex regional pain syndrome type I (CRPS-I) discussing the decision to amputate or not, the level of amputation, or the timing of the amputation is scarce. We evaluated informed decision-making regarding amputation for CRPS-I.
Methods:
We describe our findings in a retrospective study of the decision-making process of thirty-six patients who underwent amputation for CRPS-I at our university medical center from 2000 to 2012. Additionally, we present the incidents preceding the CRPS-I, the reasons for and the levels of the amputation, and the outcomes after the amputations.
Results:
Team members and the patient decided together whether or not to amputate and the level of amputation. Issues such as level of pain or allodynia, infection, desired length of the residual limb, joint range of motion, strength of all extremities, ability to use walking aids, and psychological "green, yellow, and red flags" were weighed in this process. There were no complications during the amputation surgery, a 22% rate of complications (infection in all but one patient) immediately postoperatively (reamputation not required), a 72% rate of phantom pain immediately after or within the first three months after the amputation, and a 77% rate of phantom pain more than one year after the amputation.
Conclusions:
Informed decision-making regarding amputation for CRPS-I remains a complex process for which little evidence is available to support patient choices; patient-specific outcomes are not predictable. However, amputation should not be ignored as a treatment option for long-standing therapy-resistant CRPS-I.
Level Of Evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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