Pain
Rebecca Howard, MD
Resident Physician
Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai
Long Island City, New York, United States
Soo Kim, MD
Associate Professor
Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai
New York, New York, United States
Rebecca Howard, MD
Icahn School of Medicine at Mount Sinai
New York, New York, United States
A 67-year-old woman presents with two years of facial pain that started one month after a facelift and dermabrasion procedure. She describes facial allodynia and numbness, hyperhidrosis, and erythema in the lower face and upper neck. Cervical spine and brain imaging was unremarkable. Given that the distribution of pain matched the surgical site, and no localizable nerve injury that could explain her symptoms, the patient was diagnosed with CRPS1.
The patient underwent a variety of pharmacologic and interventional treatments, including gabapentin, amitriptyline, tramadol, morphine, baclofen, marijuana, benzodiazepines, ketamine infusions, botulinum injections, cervical epidural steroid injections and medial branch blocks, and trigeminal nerve blocks. She experienced severe functional impairments and diminished quality of life, including significant weight loss, anxiety and excessive sleep. Patient underwent three right sided stellate ganglion blocks using lidocaine, with significant improvement in facial pain for at least 1 month after each procedure, further confirming the diagnosis.
CRPS1 is a pain syndrome caused by a noxious event without damage to one specific nerve and is characterized by sensory, vasomotor, sudomotor, and trophic changes. Facial and neck CRPS is very rare, with only 13 cases clearly described since 1947. Most etiologies involve dental procedures or trauma from a penetrating injury which caused an identifiable nerve injury. To our knowledge, there have been no published cases of CRPS following a facelift procedure. Diagnosis of chronic facial pain can be challenging with a variety of possible etiologies. When CRPS is highly suspected, stellate ganglion block can be an effective diagnostic and therapeutic option.
This case identifies a cosmetic facial procedure as a possible etiology of CRPS1 and highlights the importance of early diagnosis and multidisciplinary management, as well as the utility of stellate ganglion block as an option for treating facial CRPS1.
