J Dent Anesth Pain Med.  2019 Oct;19(5):295-300. 10.17245/jdapm.2019.19.5.295.

Treatment of severe pain in a patient with complex regional pain syndrome undergoing dental treatment under general anesthesia: A case report

• Rhee SH
• Park SH
• Ha SH
• Ryoo SH
• Karm MH
• Kim HJ
• Seo KS

• KMID: 2461246
• DOI: http://doi.org/10.17245/jdapm.2019.19.5.295

Abstract

Complex regional pain syndrome (CRPS) is rare, characterized by pain from diverse causes, and presents as extreme pain even with minor irritation. General anesthesia may be required for dental treatment because the pain may not be controlled with local anesthesia. However, treatment under general anesthesia is also challenging. A 38-year-old woman with CRPS arrived for outpatient dental treatment under general anesthesia. At the fourth general anesthesia induction, she experienced severe pain resulting from her right toe touching the dental chair. Anesthesia was induced to calm her and continue the treatment. After 55 minutes of general anesthesia, the patient still complained of extreme toe pain. Subsequently, two administrations for intravenous sedation were performed, and discharge was possible in the recovery room approximately 5 h after the pain onset. The pain was not located at the dental treatment site. Although the major factor causing pain relief was unknown, ketamine may have played a role.

Keyword

Complex Regional Pain Syndromes; Dental Care; Pain Management

MeSH Terms

Adult
Anesthesia
Anesthesia, General*
Anesthesia, Local
Complex Regional Pain Syndromes
Dental Care
Female
Humans
Ketamine
Outpatients
Pain Management
Recovery Room
Toes
Ketamine

Figure

• 

  Fig. 1 Pillows are placed under the knee and secured to the bed with a restraining band during general anesthesia of a patient with complex regional pain syndrome

• 

  Fig. 2 Time table and drug usage of anesthesia

Reference

1. Marinus J, Moseley GL, Birklein F, Baron R, Maihöfner C, Kingery WS, et al. Clinical features and pathophysiology of complex regional pain syndrome. Lancet Neurol. 2011; 10:637–648.

2. Boas RA. Complex regional pain syndromes: Symptoms, signs, and differential diagnosis. Seattle, WA: IASP Press;1996. p. 79–92.

3. Merskey H. Classification of chronic pain; description of chronic pain syndromes and definitions of pain terms. IASP Task Force on Taxonomy;1994. p. 41–43.

4. Urits I, Shen AH, Jones MR, Viswanath O, Kaye AD. Complex regional pain syndrome, current concepts and treatment options. Curr Pain Headache Rep. 2018; 22:10.

5. Harden RN, Bruehl S, Perez RS, Birklein F, Marinus J, Maihofner C, et al. Validation of proposed diagnostic criteria (the “budapest criteria”) for complex regional pain syndrome. Pain. 2010; 150:268–274.

6. De Mos M, De Bruijn A, Huygen F, Dieleman J, Stricker BC, Sturkenboom M. The incidence of complex regional pain syndrome: A population-based study. Pain. 2007; 129:12–20.

7. Mackey S, Feinberg S. Pharmacologic therapies for complex regional pain syndrome. Curr Pain Headache Rep. 2007; 11:38–43.

8. Okada M, Suzuki K, Hidaka T, Shinohara T, Kataharada K, Takada K, et al. Complex regional pain syndrome type I induced by pacemaker implantation, with a good response to steroids and neurotropin. Intern Med. 2002; 41:498–501.

9. Klega A, Eberle T, Buchholz H-G, Maus S, Maihöfner C, Schreckenberger M, et al. Central opioidergic neurotransmission in complex regional pain syndrome. Neurology. 2010; 75:129–136.

10. Goebel A. Complex regional pain syndrome in adults. Rheumatology. 2011; 50:1739–1750.

11. Turner-Stokes L, Goebel A. Complex regional pain syndrome in adults: Concise guidance. Clin Med (Lond). 2011; 11:596–600.

12. Schwartzman RJ, Grothusen J, Kiefer TR, Rohr P. Neuropathic central pain: Epidemiology, etiology, and treatment options. Arch Neurol. 2001; 58:1547–1550.

13. Sigtermans MJ, Van Hilten JJ, Bauer MC, Arbous MS, Marinus J, Sarton EY, et al. Ketamine produces effective and long-term pain relief in patients with Complex Regional Pain Syndrome Type 1. Pain. 2009; 145:304–311.

14. Massad IM, Mohsen WA, Basha AS, Al-Zaben KR, Al-Mustafa MM, Alghanem SM. A balanced anesthesia with dexmedetomidine decreases postoperative nausea and vomiting after laparoscopic surgery. Saudi Med J. 2009; 30:1537–1541.

15. Azari P, Lindsay DR, Briones D, Clarke C, Buchheit T, Pyati S. Efficacy and safety of ketamine in patients with complex regional pain syndrome. CNS drugs. 2012; 26:215–228.