Peripheral Nerve Surgery in Patients with a Label of Complex Regional Pain Syndrome in the Extremities

The management of complex regional pain syndrome (CRPS) is challenging, and the optimal treatment pathway for these patients remains unclear. We describe the treatment trajectory for patients referred with a label of CRPS.

We retrospectively analyzed 53 patients referred with a label of CRPS in the extremities at a tertiary care center from 2017 to 2024. Three clinicians conducted a retrospective Budapest criteria assessment to classify patients into 3 categories: (1) Budapest-confirmed CRPS, (2) inconclusive CRPS, or (3) Budapest-confirmed non-CRPS. Data on injury and treatment characteristics were recorded from chart review. Outcomes were recorded, defined as reported improvement in pain and/or function at the most recent visit.

The median treatment duration was 3.9 years (interquartile range 2.2 to 6.6). Common treatment modalities included neuromodulators (91%), opioids (77%), and peripheral nerve surgery in 66% of patients. The overall rate of clinical improvement was 55%, with 67% of patients undergoing surgery reporting benefit. No statistically significant differences in treatments were observed across the 3 CRPS groups. Exploratory bivariate analysis identified factors associated with improvement: absence of emotional events affecting symptoms (p = 0.022), no opioid use (p = 0.024), no cannabinoid use (p = 0.019), surgery after referral (p < 0.001), and major limb amputation with primary targeted muscle reinnervation (p = 0.047).

More than half of patients referred with a label of CRPS underwent surgical intervention, with 67% of surgical patients reporting improvement. With a median treatment duration of more than 3 years and frequent clinic visits, our findings underscore the need for an interdisciplinary, personalized approach and the importance of considering peripheral nerve surgery for select patients.