Spinal Treatment Useful for Painful Syndrome in Children?

CRPS-I is a painful and debilitating disease that affects both children and adults. There exists many treatments that can be used to treat patients affected by CRPS-I. SCS is an established therapy used as a last resort for patients who are resistant to all other treatments however it has currently only been tested for use on adults. This study tested whether SCS is an effective treatment for children and adolescents with CRPS-I.

In a recent issue of the European Journal of Pain, spinal cord stimulation (SCS) was tested as a treatment for complex regional pain syndrome type I (CRPS-I) in adolescents resistant to normal treatment. CRPS-I is quite prevalent in children, particularly in adolescent girls between 11-14 years of afge. The condition is characterized by spontaneous pain, tactile allodynia and dysautonomic signs. It commonly involves a foot, and usually occurs locally around an injury. Sometimes no reasonable cause can be identified, and CRPS-I occurs with no sign of persistent tissue injury giving rise to normal continuing pain. Typical treatment includes active movements and physical therapy, drugs such as gabapentin and amitriptyline, psychological therapy (including cognitive behaviour therapy) and sympathetic blocks. For the small number of patients resistant to these treatments, SCS may be tried as a last resort.

SCS is an established therapy, but its use has only been studied on adult patients. The research looked at whether SCS is a suitable treatment for children and adolescents with CRPS-I.

This study retrospectively examined seven girls 11-14 years of age with CRPS-I treated with SCS. The girls were all selected for SCS from 1994 to 2004 after failing to respond to intensive treatment trials. Testing revealed that their conditions were not caused by any other inflammatory disease. Prior to SCS, these girls were treated with physiotherapy, analgesics, sympathetic blocks and amitriptyline without success. After SCS surgery, the patients were examined and interviewed.

The researchers measured the outcome by evaluating spontaneous pain, allodynia, ability to bear weight, pain at bearing weight, dysautonomic signs, sensitivity to cold, analgesic consumption, and school attendance. A final follow up interview was conducted by telephone in the spring of 2006.

All patients benefited from the treatment. Five patients had complete pain relief, while the other two had partial but useful pain reduction. The length of time between developing CRPS-I and treating it with SCS did not affect the outcome. Patients stayed at home during the trial, and failed to comply with instructions to self-evaluate spontaneous and evoked pain. Therefore, the researchers relied on patient and parent unstructured evaluations. This information included whether or not they were able to put load on the affected foot and/or resume walking with or without crutches, as well as their ability to resume school attendance.

Pain reduction was felt after 1-2 weeks, with complete pain suppression after another 2-3 weeks. The level of touch allodynia was initially difficult to assess as the hypersensitivity felt by patients was so extremely severe that they refused examination.

The patients in this study had extreme and severe forms of CRPS-I which were resistant to any other treatment. As such, spontaneous remission of symptoms was considered to be less likely than normal. Late in the study, the researchers discovered that two cases had major psychological/psychosocial problems that were important in the generation and maintenance of the pain condition. Nevertheless, both cases benefited from the SCS treatment.

As previously mentioned, SCS has not previously been tried in children. From the experience of this study it is believed that SCS can also be a useful treatment for severely incapacitated paediatric cases that are otherwise resistant to standard therapy. As this study was small and non-control designed, further studies are required to confirm that SCS can be recommended for both children and adolescents.

(Source: Olsson GL, Meyerson BA, Linderoth B. Spinal cord stimulation in adolescents with complex regional pain syndrome type I (CRPS-I). European Journal of Pain 2007. : December 2007)