Amputation for complex regional pain syndrome: A systematic review

Complex regional pain syndrome (CRPS) is a disabling pain condition, usually confined to a single limb. Amputation of the affected limb is sometimes performed to improve pain and function for treatment-resistant CRPS. This systematic review evaluated the benefits and harms of amputation for CRPS. Primary studies of adults with CRPS that reported the outcomes of amputation of a CRPS-affected limb were included. Primary outcomes were pain intensity and adverse events. The following databases were searched from inception to 23 September 2024: PubMed, EMBASE, Scopus, CENTRAL, CINAHL, and PsycINFO for published literature, and BASE, Web of Science, OpenMD and MedNar for grey literature. Study methodological quality was assessed using Joanna Briggs Institute critical appraisal tools. Data were synthesised using systematic review without meta-analysis guidance. The review included 67 studies, comprising one comparative study, 24 case series and 42 case studies. Studies included 249 patients who received 263 amputations. Amputation indications included pain relief, functional improvement, infection, fracture, and prosthetic complications. The heterogeneous designs of included studies precluded quantitative estimation of treatment effects. The only included comparative study reported that CRPS patients had lower mean pain intensity scores post-amputation than non-amputated, non-matched control patients. The four studies that assessed pain intensity scores before amputation and at least 6 months post-operatively reported reductions in average pain post-amputation. Adverse events in assessed patients included phantom pain (67%), residual limb pain (66%), and recurrence of CRPS (47%). The critically low quality of included evidence and incomplete reporting greatly reduced confidence in the results. This review found no clear evidence that amputation of a CRPS-affected limb offers greater pain relief than no amputation. High-quality, controlled prospective studies with embedded qualitative research are needed to determine the benefits and harms of amputation for CRPS, as well as the factors that drive patients to seek this permanent intervention that does not guarantee improvement. PERSPECTIVE: This article presents a systematic review of the benefits and harms of amputation for complex regional pain syndrome. The unclear benefits and likely harms can help inform individuals and clinicians considering amputation of the potential outcomes of this intervention.