Complex Regional Pain Syndrome

Complex Regional Pain Syndrome (CPRS) is a chronic neurological disorder characterized by disabling pain, swelling, vasomotor instability, sudomotor abnormality, and impairment of motor function. Complex Regional Pain Syndrome (CPRS) generally affects legs and arms. CRPS develops after an injury, a surgery, a stroke or a heart attack. The pain is prolonged and far more intense than that of the initial injury. CRPS is also known as Reflex Sympathetic Dystrophy (RSD or CRPS-Type I) and Causalgia (CRPS-Type II).

Majority of CRPS conditions are the result of improper function of the peripheral C-fiber nerve fibers that carry pain messages to the brain. Their excessive firing triggers inflammation that leads to burning sensation, swelling and pain.

Symptoms

Symptoms change over time and vary from person to person. Patients who suffer CRPS may exhibit the following symptoms:

Diagnosis

Most often CRPS is triggered by nerve trauma or injury to the affected limb that damages the thinnest sensory and autonomic nerve fibers. Fractures, surgery, sprains/strains, burns or cuts, poor circulation etc. are some of the common reasons why people develop CRPS. CRPS develops only in the limbs because circulation is constrained there.

Currently, no single, specific test can identify CRPS. Diagnosis includes a detailed examination by a neurologist, nerve conduction studies, imaging nerves by ultrasound or magnetic resonance imaging (MRI) and triple-phase bone scans.

Treatment

Oftentimes, most mild cases recover on their own. General treatment options include the following.

Rehabilitation and physical therapy is the single most important treatment for CRPS. Patients who develop post-traumatic stress disorder can benefit from psychotherapy. Graded motor imagery and pain medications also help. Spinal cord stimulation or other types of neural stimulation (peripheral nerve stimulation and motor cortex stimulation) via implantation of a neuro-stimulator device is an effective option for some. Transcranial Magnetic Stimulation (rTMS) and stimulation at the peroneal nerve at the knee has proven effective in some cases.

Implantation of spinal-fluid drug pumps to deliver pain-relieving medications directly into the fluid can be an option in severe cases. Some patients can benefit from medical marijuana, behavior modification, acupuncture, relaxation techniques and other similar alternative therapies. In certain clinical settings, intravenously given ketamine has been shown to be useful in treating pain that does not respond well to other treatments.

Sympathetic nerve block, surgical sympathectomy, severing injured nerves or nerve roots and amputating the painful limb are a few rare treatments that are not as frequently used as other remedies.

Dr. Samadani is a world renowned expert on nerve and spinal injuries. Consult Dr. Samadani for thorough evaluation and seek eraly treatment.

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Spinal Tumors

Spinal tumors can develop around the spinal column, within the spinal cord or around the nerves. Tumors can occur on multiple places in or around spine. Just like any other tumor, these can be benign (i.e. non-cancerous) or malignant (i.e. cancerous). Sometimes, the tumors originate within the spine (primary tumors) or spread to spine due to some other form of cancer (secondary tumor). Majority, up to 70%, of malignant spine tumors are secondary tumors.

Spinal tumors are categorized based on their locaton – cervical, thoracic, lumbar, intradural, extradural, intramedullary or extramedullary. Extradural tumors are generally cancerous while others are benign.

Symptoms

Spinal tumors certainly show discernable symptoms. Each type of tumor presents itself differently. Symptoms include:

Diagnosis

A thorough physical examination and radiological imaging such as X-Rays, CT scans, MRIs will reveal the presence of spinal tumors. A bone scan using Technectium-99 will be helpful in detecting primary bone tumors, infection and bone abnormalities. Sometimes, a biopsy might also be needed for further analysis of the tumor.

Treatment

Treatment for spinal tumors depends on the stage, location and type of tumor. Generally, an inter-disciplinary team of oncologists, radiologists and spinal surgeons will evaluate and determine the correct course of action.

Some tumors can be effectively treated with radiation and chemo-therapy, especially where surgery is either not possible due to location and size of the tumor or because the tumors are asymptomatic.

Complete en bloc resection could potentially be adequate in some surgical cases. Generally metastatic tumors are good candidates for surgery, especially when they don't respond well to radiation or chemo therapy. Intractable pain, spinal cord compression and fractures are also indications for surgical intervention.

Thoracic and lumbar spinal tumors that affect both posterior and anterior vertebrae pose a special surgical challenge. As is in with any major surgery, spinal tumor surgery presents certain complications and risks which need to be carefully evaluated based on patient's overall health, condition and location of the tumor and the prognosis.

Dr. Samadani is a leader in the treatment of rare and complex spinal tumor cases that require expert skills and groundbreaking technology.

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Spinal Cord Injury

Damage to the spinal cord or nerves within the spinal canal is considered spinal cord injury. A traumatic spinal cord injury happens due to a sudden blow or cut to the spine as is when a person is an automobile accident. A spinal cord injury causes permanent loss of strength, sensation and function below the site of the injury.

Complete or partial paralysis occurs in the areas of the body that are controlled by the nerves associated with the damaged vertebrae and those below. The higher the injury, the more paralysis there is. For example, damage in the cervical segment can result in paralysis of the chest, arms, and legs (tetraplegia, or quadriplegia). Damage in thoracic, lumbar, or sacral segments can result in paralysis of the legs and lower body (paraplegia). Breathing is affected only by injuries high on the spinal cord. But bowel and bladder control can be affected no matter where the spinal cord is injured.

Spinal cord injuries are divided into two types: incomplete and complete. An incomplete spinal cord injury is one in which there is some motor or sensory function below the affected area. A complete spinal cord injury is one in which all ability to control movement (motor function) are lost below the injury. There are three types of complete spinal cord injuries: Tetraplegia, Paraplegia and Triplegia. The most severe type of complete spinal cord injury is Tetraplegia. This causes paralysis and can affect every limb.

There are three common types of incomplete spinal injuries: Anterior Cord Syndrome, Central Cord Syndrome and Brown-Sequard Syndrome. Incomplete spinal cord injuries are more common than complete injuries.

Symptoms

Your neurologist will examine you to determine the neurological level and completeness of your injury. Given below are some of the symptoms:

Diagnosis

A quick test for sensory function and movement can indicate spinal cord injury. A definitive diagnosis of spinal cord injuries requires a CT scan, MRI or X-ray. These tests help the doctors determine the abnormalities within the spinal cord, injury location, level and completeness.

Treatment

Unfortunately, spinal cord injury cannot be reversed and is permanent. Treatment focuses on preventing further injury and empowering people with a spinal cord injury to return to an active and productive life.

Treatments include medications, immobilization and surgery to remove fragments of bones, foreign objects, herniated disks or fractured vertebrae. Experimental treatments to stop cell death, control inflammation and promote nerve regeneration are being actively researched and being tested but not yet mainstream treatment options.

Research is underway in developing sophisticated, functional electrical stimulation devices, that use electrical stimuli to control arm and leg muscles to allow people with spinal cord injuries to stand, walk, reach and grip.

Please consult Dr. Samadani to find out how she can help you.

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Hydrocephalus

Cerebrospinal fluid (CSF) keeps the brain buoyant allowing the brain to float within the skull. It functions to cushion the brain to prevent injury, remove waste products of metabolism and maintain a constant pressure within the brain.

Abnormal accumulation of cerebrospinal fluid in the brain causes the cavities (ventricles) of the brain to fill & swell casuing a condition known as hydrocephalus. Swelling increases the cerebral pressure that can lead to tissue damage in the brain and loss of function.

Hydrocephalus occurs mostly in infants and older people (over 60 years of age). Some infants are born with the condition and it progresses gradually as they age.

Symptoms

Symptoms vary depending on age. Older people show very different symptoms than infants. Other brain related conditions mimic hydrocephalus and therefore, symptoms must be carefully evaluated by a trained neurologist.

Infants

Other symptoms include headache, blurred or double vision, problems with balance, loss of developmental progress like walking or talking, poor appetite and coordination, frequent urination and loss of cognition including memory.

Adults

Diagnosis

A neurological exam and brain imaging is required to diagnose the condition. Neurological exam includes age appropriate evaluation of memory, coordination, movement, muscle strength, reflexes and cognition. Imaging tests may include CT, MRI and Ultrasound. A spinal tap (lumbar puncture), fundoscopic examination and intracranial pressure monitoring (ICP) may also be done.

Treatment

Hydrocephalus is generally treated surgically. Dr. Samadani treats adult onset Hydrocephalus. She performs the following surgical treatments. Parents of infants who are affected by Hydrocephalus may contact a pediatric neurosurgeon.

Shunt

A shunt is a flexible tube inserted into the brain to drain excess fluid into abdomen or chest so it can be absorbed by the body. A shunt does not treat the underlying cause of the condition but certainly provides significant relief.

Endoscopic Third Ventriculostomy (ETV)

A small hole is made at the bottom of the third ventricle to divert CSF and relieve pressure. Sometimes, this is done along with choroid plexus cauterization (burning off some tissue that produces CSF) to reduce CSF production.

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Arteriovenous Malformation

An arteriovenous malformation (AVM) is an abnormal connection between groups of arteries and veins. The capillaries between arteries and veins get unusually tangled forming direct connections and start abnormal blood flow. Such abnormal connectivity disrupts normal blood flow and oxygen circulation leading to hemorrhage, stroke, brain damage and occassionally death. It is currently unknown how and why AVM's form.

When AVM's form, the capillaries disappear, blood does not slow down, doesn't deliver oxygen and nutrients to the tissues and flows too fast directly from an artery to a vein.

Tissues surrounding AVM don't get enough blood supply leading to tissue damagae that could be permanent. AVM's can occur in any part of the body, including brain. AVM's in the brain or close to the spinal cord, are called neurological AVMs, and are most likely to cause long-term problems. AVM's in brain can be successfully treated, if diagnosed early. The greatest potential danger of AVMs is hemorrhage which remains undetected because it is not significant or large enough.

Symptoms

The symptoms vary depending on where AVM occurs. Most people with AVM's don't show any symptoms and won't experience any problems for long time. AVM's are often discovered when they rupture or cause significant symptoms.

Diagnosis

History and physical exam are two initial means of diagnosis. Imaging tests such as ultrasound, MRI or CT might be required to make a final determination. Magnetic resonance angiography captures the pattern, speed and distance of blood flow through the vascular abnormalities to aid in final diagnosis. However, cerebral angiography is the gold standard of detecting AVMs and may be required to get better understanding of the structure of the blood vessels.

Treatment

Size, location and stage (pain or loss of function) guide the course of treatment. Currently there are no medicines to treat an AVM, although some medicines are in experimental stage. However, there are medicines to help manage symptoms such as seizures, headaches and back pain.

Endovascular embolization and sclerotherapy are common treatments for AVM that are currently available. Embolization and sclerotherapy can reduce the size and symptoms but are not cures for AVM. Stereotactic radiosurgery is also an option to treat AVMs.

For some AVMs, surgery is an option, especially if there is a high risk of bleeding and if it is in a part of the brain that can be safely operated on.

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Chiari Malformation

Chiari malformation occurs when part of the brain expands into the spinal canal.Common reason for this condition is misshaped skull or smaller than usual skull which pushes the brain down into the canal.

Depending on the area of the brai that is pushed downward, Chiari is classified into Type 1, Type 2 or Type 3. Generally, Type 2 and Type 3 are congenital (i.e. present at birth) while Type 1 develops as the person grows into adulthood. Type 3 malformation is more problematic than the rest since the cerebellum is pushed through the back of the skull. Hence, it is associated with higher mortality and may cause neurological problems. Chiari can lead to complications such as Hydrocephalus, Spina bifida, Syringomyelia and Tethered Cord syndrome as well.

Symptoms

Chiari doesn't generally cause any serious symptoms and hence is diagnosed during tests that are unrelated to this condition.

Type 1 Chiari can show the following symptoms:

Type 2 Chiari can show the following symptoms:

Diagnosis

Chiari is generally diagnosed using several imaging methods such as MRI, X-Rays (CT) or Ultrasound. All of these are non-invasive, simple, painless procedures.

Treatment

Treatment is dependent on type of Chiari, severity of the condition and perhaps, even age. Asymptomatic patients are monitored long term and no treatment is generally recommended.

However, in severe cases with pronounced symptoms, surgery is generally performed to stop or slow the progression of the condition and relieve the pressure on the brain and spinal canal.

Please contact Dr. Samadani's office for evaluation.

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Spondylolisthesis & Spondylolysis

These two are related conditions but not same. Spondylolysis is a stress fracture or crack in spine bones. Most commonly, this fracture occurs in the fifth vertebra of the lumbar spine, although it sometimes occurs in the fourth lumbar vertebra. Fracture can occur on one side or both sides of the bone. Spondylolisthesis is when a vertebra slips out of place, resting on the bone below it. Vertebra may slip out of place due to a degenerative condition. Spondylolysis and spondylolisthesis occur in the lumbar spine. Both cause low back pain.

Spondylolisthesis can be either low grade or high grade, depending upon the amount of slippage. A high-grade slip occurs when more than 50% of the width of the fractured vertebra slips forward on the vertebra below it. Patients with high-grade slips are more likely to experience significant pain and nerve injury needing surgery to relieve their symptoms and prevent further deterioration.

Types of Spondylolisthesis

Congenital Spondylolisthesis

Congenital spondylolisthesis occurs when a baby’s spine doesn’t form the way it should before birth. The misaligned vertebrae put the person at risk for slippage later in life.

Isthmic Spondylolisthesis

Isthmic spondylolisthesis happens as a result of spondylolysis. The crack or fracture weakens the bone.

Degenerative Spondylolisthesis

Aging causes the disks that cushion the vertebrae lose water over time. As the disks thin, they are more likely to slip out of place.

Pathogenic Spondylolisthesis

Due to bone disease such as metastatic disease, tumor, osteoporosis.

Traumatic spondylolisthesis

Caused because of a fracture of the neural arch

Post-surgical spondylolisthesis

A vertebra slips out of place after spinal surgery.

Symptoms

Lower back pain is the most common symptom of spondylolysis. It usually gets worse during exercise or other physical activity, especially when someone leans back a lot. Spondylolysis also can cause buttock and leg pain, and tight hamstrings. The pain may extend to the buttocks and down the thighs.

The following are other symptoms:

Diagnosis

Evaluation of this condition includes a review of the medical history and a physical exam followed by several imaging methods such as MRI, X-Rays (CT) or Ultrasound. A bone scan can be used for early detection of a stress fracture of the pars.

Sophisticated imaging techniques such as single-photon emission computed tomography (SPECT) bone scans and magnetic resonance imaging (MRI) scans of the spine can help in evaluating the physiological changes associated with spondylolysis and help distinguish between active and inactive spondylolysis.

Treatment

The grade is based on how severe the spondylolisthesis is. Low-grade (I or II) is less serious and usually doesn’t need surgery. High-grade (III and IV) is more serious. You may need surgery, especially if you’re in a lot of pain.

Spondylolisthesis is treated with the strengthening of supportive abdominal and back muscles through physical therapy. Other treatments include:

If you continue to have severe pain and disability after physical therapy, surgery may be an option.

Untreated and severe spondylolisthesis may lead to a condition called cauda equina syndrome. This is a serious condition where nerve roots in the lower back called the cauda equina are compressed leading to loss of feeling in the legs and also can affect the bladder and cause paralysis.

Please contact Dr. Samadani's office for evaluation.

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