Leitfaden zur Diagnostik des Komplexen regionalen Schmerzsyndroms

Zusammenfassung

Das komplexe regionale Schmerzsyndrom (engl. complex regional pain syndrome; CRPS) tritt nach Traumata v. a. der distalen Extremitäten als Sonderform neuropathischer Schmerzsyndrome auf. Die Symptomatik umfasst Plus- und Minussymptome mit sensiblen, motorischen, vasomotorischen, sudomotorischen und trophischen Veränderungen. Interindividuell und intraindividuell können die jeweiligen Symptome in unterschiedlicher Ausprägung gefunden werden, einzelne auch gänzlich fehlen. Ein diagnostischer „Goldstandard” konnte bisweilen nicht identifiziert werden, somit gründet die Diagnosestellung auf einer detaillierten Anamnese und klinisch-neurologischen Untersuchung. Durch die Internationale Gesellschaft zum Studium des Schmerzes (IASP) wurden operationale Kriterien zur Diagnosefindung erstellt, validiert und im Jahre 2003 durch eine Konsensusgruppe in Budapest revidiert mit resultierender klinisch wie auch wissenschaftlich zufrieden stellender Sensitivität und Spezifität. Diese klinische Einordnung kann ergänzend durch apparative Diagnostik bestätigt werden – sinnvolle Untersuchungen stellen seitenvergleichende konventionelle Röntgenaufnahmen, eine Kernspintomografie der betroffenen Extremität sowie eine 3-Phasen-Skelettszintigrafie dar. Hilfreich können weiterhin der Nachweis einer Nervenläsion im Zuge elektrophysiologischer Messungen zur Differenzierung zwischen CRPS Typ I und II oder einer Temperaturdifferenz mittels Infrarotthermografie sein. Eine quantitative sensorische Testung kann das Ausmaß der sensorischen Veränderungen erfassen und im Verlauf den Therapieerfolg dokumentieren. Die Initiierung einer Therapie sollte aber, auch bei Vorliegen von Normalbefunden in den ergänzenden apparativen Untersuchungen, von diesen unbeeinflusst bleiben.

Abstract

The complex regional pain syndrome, a special form of neuropathic pain, develops after a minor trauma of the distal limbs. Besides the presentation of pain disproportional to the inciting event, further plus and minus symptoms in the form of sensory, vasomotor, sudomotor-oedematous and motor-trophic changes can be found. Interindividually and intraindividually, occurrence of these symptoms differs widely and single symptoms can be lacking completely. A gold standard in diagnosing CRPS has not been found yet, diagnostics are based on the patients medical history and correlating clinical signs. The International Association for the Study of Pain (IASP) compiled and later on revised operational diagnostic criteria resulting in a satisfactory sensitivity and specificity for both research and clinical needs. Additionally, diagnostic tools can support the clinical suspicion – reasonable tests are conventional X-ray examination comparing sides, magnetic resonance imaging and a 3-phase bone scintigraphy. Moreover, electrophysiological examinations can prove a nerve lesion and differentiate between CRPS type I and II. A temperature difference can be detected via infrared thermography. Furthermore, quantitative sensory testing can verify the magnitude of the sensory disturbance and can be beneficial to objectify therapeutic effects. Use of these diagnostic tools, even after achievement of normal findings, cannot exclude a CRPS and the decision for therapeutic initiation should not be influenced thereby.

Schlüsselwörter

Komplex regionales Schmerzsyndrom - Diagnosekriterien - neuropathischer Schmerz - CRPS - Morbus Sudeck

Key words

complex regional pain syndrome - diagnostic criteria - neuropathic pain - CRPS - Sudeck's atrophy

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