Pain
Christopher Lee, DO
Resident Physician
JFK Medical Center
West Orange, New Jersey, United States
Shirley Shen, MD
Pain Fellow
JFK Medical Center
Edison, New Jersey, United States
Laurent Delavaux, MD
Physician
JFK Medical Center
Edison, New Jersey, United States
Craig Vandien, MD
Physician
JFK Medical Center
Edison, New Jersey, United States
Christopher Lee, DO
JFK Medical Center
West Orange, New Jersey, United States
CRPS-II secondary to superficial radial nerve injury from radial artery harvesting
Case Description:
Patient presented with persisting pain in her left arm following coronary bypass surgery two months prior. Exam revealed reduced mobility in left elbow flexion and extension, wrist extension, and grip strength due to pain. She also exhibited allodynia from her left thumb to the ventral surface of her forearm. Symptoms were refractory to conservative management with physical therapy, analgesics, gabapentinoids, and steroids. Radiographic and magnetic resonance imaging revealed chronic degenerative changes. In light of these findings, complex regional pain syndrome (CRPS) was suspected. The patient subsequently underwent a stellate ganglion block without relief. Dynamic ultrasound imaging revealed superficial radial nerve (SRN) injury parallel to her incisional scar, and a nerve block was performed using dexamethasone and lidocaine. A referral was made for surgical evaluation, and follow up is planned for ongoing management.
Discussions:
Iatrogenic SRN injury has been described as a rare complication of endoscopic radial artery harvesting (RAH), but development of CRPS type 2 from SRN injury has never been reported in the United States. In this case, the patient developed increased pain, sensitivity, weakness, skin changes, and reduced mobility exceeding the expected territory of the injured nerve. The Budapest criteria was utilized to facilitate diagnosis, but is limited by poor specificity. CRPS is a challenging and complex clinical diagnosis made upon exclusion of other pathologies, and careful consideration of the patient’s medical history.
Conclusions:
It is important to investigate SRN injuries as a complication of RAH. The exact pathophysiology of CRPS is unknown, and is likely heterogeneously contributed by classic and neurogenic inflammation, autonomic dysregulation, and psychological factors. Advanced imaging and sonographic visualization may help to elucidate nerve injury and targeted treatments. Symptoms from CRPS can be debilitating, but early diagnosis and treatment can improve patient outcomes.
