PAINClinician Case Study: Ketamine for the Treatment of Complex Regional Pain Syndr
Joshua P. Prager, MD, MS
Director, Center for Rehabilitation of Pain Syndromes (CRPS)
University of California, Los Angeles
Los Angeles, California
This is the second of two parts
Since the publication of randomized controlled studies in peer reviewed journals regarding the use of ketamine infusions to treat complex regional pain syndromes (CRPS) the use of this therapy has markedly increased. This case study provides a glimpse of the experience of this treatment.
Dr Joshua Prager has been performing ketamine infusions for the treatment of CRPS since 2005. Dr. Prager, a faculty member in the departments of Anesthesiology and Internal Medicine at the David Geffen School of Medicine at UCLA. He was recently reelected as chair of the Pain and Sympathetic Nervous System (CRPS) Group of the International Association for the Study of Pain (IASP), the largest organization of pain clinicians and researchers in the world. He has received the Bounty of Hope Award from the Reflex Sympathetic Dystrophy Syndrome Association (RSDSA) for clinical care and Contributions to the RSD community.
Elizabeth was involved in a car accident 12 years ago, resulting in a cracked rib, broken tailbone, sacroiliac injuries to both right and left pelvic regions, and damage to the sciatic nerve. A small break in the right cessmoid bone was unrecognized before a second break in the same area 2 years later prompted additional x-ray imaging. Her foot was cast twice over the next 16 weeks, and symptoms of complex regional pain syndrome (CRPS) were immediately apparent when the second cast was removed. Although physical therapy was helpful, a trip to a ski resort at an elevation of 10,000 feet above sea level exacerbated the symptoms, causing redness and burning pain to spread in her right leg and jump to her left leg. For the next 4 to 5 years, Elizabeth often slept with ice packs and beach towels under one or both legs in an attempt to alleviate the pain and prevent her skin from blistering. Following a third broken bone in her right foot, Elizabeth experienced hemarthrosis, and began to note hypersensitivity to noises, bright lights, and certain tactile stimuli as well as impaired depth perception and night vision. A subsequent fall on her crutches resulted in a dislocated collarbone and torn brachial plexus nerves, which precipitated widespread tactile and thermal allodynia. She was told she had "suicide disease" and that nothing could be done. She was referred by a friend to Dr. Prager's clinic approximately 5 years ago, and began a full functional rehabilitation program, including physical therapy, coping strategies, and more recently ketamine infusions. Here, Dr. Prager and Elizabeth discuss her medical history and the use of ketamine as one component of a multimodal treatment regimen for CRPS.
References
Harden RN, Bruehl S, Perez RS, et al. Validation of proposed diagnostic criteria (the "Budapest Criteria") for Complex Regional Pain Syndrome. Pain. 2010;150(2):268-274.
Schwartzman RJ, Alexander GM, Grothusen JR, et al. Outpatient intravenous ketamine for the treatment of complex regional pain syndrome: a double-blind placebo controlled study. Pain. 2009;147(1-3):107-115.
Ben-Ari A, Lewis MC, Davidson E. Chronic administration of ketamine for analgesia. J Pain Palliat Care Pharmacother. 2007;21(1):7-14.
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