Hello RUReady -

I did a fair amount of investigation regarding a far less drastic procedure of the torso - hernia repair - before the issue stopped bothering me and I was able to place it on the back burner. I learned two things though: even outside of the extremities, precautions such as the use of nerve blocks must be taken. For something as serious as cracking one's chest open, it would appear that continuous regional anesthesia would be the way to go.

For what is perhaps the best piece out there, check out the following Open Access article, "distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/2.0 which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited":

Evidence based guidelines for complex regional pain syndrome type 1, Roberto S Perez, Paul E Zollinger, Pieter U Dijkstra et al, BMC Neurology 2010, 10:20, http://www.biomedcentral.com/1471-2377/10/20

Secondary prevention

Various interventions or combinations of interventions aimed at preventing relapse of CRPS-I have been described, but little adequate research has been carried out. Relapse rates up to 13% (of 47 patients) have been reported despite combined interventions aimed at preventing relapse of CRPS-I (waiting until the symptoms of CRPS-I had abated, minimizing the use of tourniquet, administering vasodilators to encourage circulation, sympathetic blockades and mannitol) [98]. Six percent of patients with a history of CPRS-I (n = 18) treated with calcitonin (100 IU a day s.c. for four weeks) had a relapse of CRPS-I, against 28% of the patients in a historic control group (n = 74) [99]. A retrospective study (n = 50) found that peri-operative stellate ganglion blockade carried out to prevent a relapse of CRPS-I to be unsuccessful in 10% of cases. The relapse rate in an untreated control group was 72% [100].

A retrospective study (n = 1200) found that 1% of the patients undergoing anterior cruciate ligament surgery receiving pre-emptive analgesia (comprising administration of paracetamol and NSAIDs before surgery) combined with multimodal analgesia experienced a relapse of CPRS-I. The CRPS-I relapse rate for a control group, taking painkillers only as required after surgery, was 4% [101].

In a randomized double-blind study in 84 patients with a history of CRPS-I in the hand or arm scheduled for hand or arm surgery, intravenous regional blockade with lidocaine and clonidine (1 μg/kg) showed a relapse rate for clonidine of 10% against 74% in the group receiving only lidocaine [100]. Case studies point to a possible beneficial effect of regional anaesthesia, such as brachial plexus block and epidural anaesthesia [101].

Despite lack of evidence, the task force is of the opinion that operations are preferably postponed until CRPS-I signs are minimal. Preferably, regional anaesthetic techniques such as brachial plexus blockade and epidural anaesthesia should be used (level 4)

There are indications that stellate blocks and intravenous regional anaesthesia using clonidine (not guanethidine) offer protection (level 3: Reuben et al. (A2)).

There are indications that the use of multimodal analgesia offers protection (level 3: Reuben (A2).

There are indications that daily administration of 100 IU of salmon calcitonin s.c. (peri-operatively for four weeks) can prevent a relapse of CRPS-I (level 3: Kissling et al. (B)).

Notes
98. Veldman PH, Goris RJ: Surgery on extremities with reflex sympathetic dystrophy. Unfallchirurg 1995, 98:45-48.
99. Kissling RO, Bloesch AC, Sager M, Dambacher MA, Schreiber A: Prevention of recurrence of Sudeck's disease with calcitonin. Rev Chir Orthop Reparatrice Appar Mot 1991, 77:562-567.
100. Reuben SS, Rosenthal EA, Steinberg RB, Faruqi S, Kilaru PA: Surgery on the affected upper extremity of patients with a history of complex regional pain syndrome: the use of intravenous regional anesthesia with clonidine. J Clin Anesth 2004, 16:517-522.
101. Reuben SS: Preventing the development of complex regional pain syndrome after surgery. Anesthesiology 2004, 101:1215-1224.

Complicating the literature, however, is that fact that the professional articles of Scott S. Reuben, MD have been largely retracted due to a persistant patter of admitted fraud on his part. See, Fraud Case Rocks Anesthesiology Community, Anesthesiology News, MARCH 2009 VOLUME: 35:3 http://www.anesthesiologynews.com/in...12634&ses=ogst However, his fraud seems to have centered around the "peri-operative" effectiveness of certain medications, where Dr. Reuben may of had undisclosed financial dealings with the manufacturers. As such, there may well be is less reason to doubt the effectiveness of interventions such as continuous regional anesthesia, where its effectiveness has been well documented elsewhere. See, e.g., Pain following battlefield injury and evacuation: a survey of 110 casualties from the wars in Iraq and Afghanistan, Buckenmaier CC 3rd, Rupprecht C, McKnight G, et al, Pain Med. 2009 Nov;10(8):1487-96. Epub 2009 Oct 14.

Abstract
OBJECTIVE: Advances in regional anesthesia, specifically continuous peripheral nerve blocks (CPNBs), have greatly improved pain outcomes for wounded soldiers in Iraq and Afghanistan. pain management practice variations, however, do exist, depending on the availability of pain-trained military professionals deployed to combat support hospitals. an exploratory study was undertaken to examine pain and other outcomes during evacuation and at landstuhl regional medical center (lrmc), germany. DESIGN: a mixed-methods, semistructured interview survey design was conducted on a convenience sample of wounded u.s. soldiers evacuated from iraq and afghanistan to lrmc. setting and patients. a total of 110 wounded soldiers evacuated from IRAQ and Afghanistan from July 2007 to February 2008 completed a pain survey at LRMC. Data were collected on demographics, injury mechanism, last 24-hour average, least, and worst, and pain now by using a 0-10 scale, and percent pain relief (from 0% [No relief] to 100% [Complete relief]). Similar items and measures of anxiety, distress, and worry during flight transport were measured (from 0 [None] to 10 [Extreme]). Responses were analyzed by using descriptive and correlational statistics, multiple linear regression, Mann-Whitney U-tests, and t-tests. The Walter Reed Army Medical Center, Human Use Committee approved this investigation. RESULTS: Participants were typically male (99.1%), Caucasian (80%), and injured from improvised explosive devices (60%) and gunshots (21.8%). Average and worst pain scores were inversely correlated with pain relief during transport (r = -0.58 and r = -0.46, respectively; P < 0.001), and low to moderately positively correlated with increased anxiety, distress, and worry during transport (P < 0.05). Average percent pain relief achieved was 45.2% +/- 26.6% during transport and 64.5% +/- 23.5% while at LRMC (P < 0.001). Participants with CPNB catheters placed at LRMC reported significantly less pain right now (P = 0.031) and better pain relief (P = 0.029) than soldiers without CPNBs. CONCLUSIONS: Our findings underscore the value of early aggressive pain management after major combat injuries. Increased pain was associated with increased anxiety, distress, and worry during transport, suggesting the need for psychological management along with analgesia. Regional anesthesia techniques while at LRMC contributed to better pain outcomes.

PMID: 19843233 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/20399593

That said, I have been repeatedly advised that none of this will make a difference unless you can have this done in a (typically university) hospital where you can get a pre-operative consultation with the anesthesiologist. Without that, it is almost impossible to assure that special precautions will be taken, by someone who knows how to employ them.

Hope this is useful.

Mike