Multiple Sclerosis and other Neurological Conditions
John Defant, MD
Resident
The Ohio State University
Johnstown, Ohio, United States
Michelle Miller, MD
Physician
Nationwide Children's Hospital
Columbus, Ohio, United States
Shelby Lewis, n/a
Medical Student
Ohio University Heritage College of Osteopathic Medicine
Athens, Ohio, United States
jOHN DEFANT, MD
The Ohio State University
Johnstown, Ohio, United States
Complex regional pain syndrome with severe focal dystonia of the right upper extremity
Case Description:
A 12-year-old male with a complex neuromuscular history was admitted for T2-L3 posterior fusion for kyphoscoliosis. Postoperatively, he developed fevers and right arm swelling, tremors, allodynia, and erythema. An ultrasound showed non-occlusive thrombi in the cephalic and subclavian veins. Despite therapeutic anticoagulation, the swelling worsened. An MRI showed tenosynovitis in the wrist flexor and extensor compartments and osteitis of distal radius, capitate, and metacarpals. He was treated with broad spectrum antibiotics for presumed cellulitis/osteomyelitis. He eventually developed severely fixed dystonia of the wrist and finger flexors. Upon PM&R assessment, CRPS was suspected. Warm water bath indicated vasomotor dysfunction. He had mild improvement with prednisone. Botulinum toxin injections to the wrist and finger flexor muscles (FCR, FCU, FDS, FDP, FPL, lumbricals) were performed but with minimal improvement given dystonic contractures. Serial casting and splinting were attempted but the patient was unable to tolerate. He underwent surgical correction and had significant improvement.
Discussions:
Complex regional pain syndrome is regarded as generalized regional pain disproportionate to known trauma or pathology in a distal to proximal predominance and can have abnormal sensory, motor, sudomotor, or vasomotor function. Clinical presentations can appear like other inflammatory conditions such as cellulitis and osteomyelitis. Imaging can show a spectrum of nonspecific findings such as bone marrow edema and subcutaneous soft tissue enhancement, which are neither sensitive nor pathognomonic for CRPS and can be seen in a host of inflammatory conditions. Early recognition of CRPS with appropriate pharmacologic interventions, bracing, physical therapy, and/or injection therapies can limit dystonia prior to contracture development.
Conclusions:
Cases of focal dystonia can resemble many inflammatory conditions. Earlier recognition of CRPS with appropriate treatment can improve patient outcomes and prevent complications.
