Steve -
I strongly recommend that you follow Sandy's advice and make an appointment to see Dr. Getson as soon as possible.
Alternatively, you may which to seek out the services of an anesthesiologist in your area who is board certified by the American Board of Pain Medicine, the organization that supervises all pain management fellowships in the U.S. Its search engine can be found at:
http://www.association-office.com/ab...dir/search.cfm In light of the urgency of your situation, I would seek out - under the heading "Demographics" - someone with a background in anesthesiology, although a neurologist who has completed a pain management fellowship would be fine too. (For CRPS, I avoid physiatrists as a matter of principle, as great as they may be for lower back pain.)
Quite simply, each new "spread" to a previously unaffected limb is, in effect, a fresh case of RSD. See generally, Intravenous Immunoglobulin Treatment of the Complex Regional Pain Syndrome - A Randomized Trial, Goebel A, Baranowski A, Maurer K, Ghial A, McCabe C, Ambler G,
Ann Intern Med. 2010;152:152-158, FULL TEXT @
http://www.rsds.org/2/library/articl...rnMed_2010.pdf:
There is evidence, however, for immune activation in the affected limb, peripheral blood, and cerebrospinal fluid (8 –10). This suggests that modulating the immune system may alleviate CRPS. In keeping with this possibility and stimulated by a chance observation, we examined the benefit of treating CRPS with intravenous immunoglobulin (IVIG).
* * *
The study physician judged whether eligible patients had stable CRPS of 6 to 30 months’ duration. Patients with a longer duration of disease were eligible if they reported that disease had spread to a previously uninvolved limb within the past 30 months. [Citations partially omitted.]
Notes
8. Huygen FJ, De Bruijn AG, De Bruin MT, Groeneweg JG, Klein J, Zijlstra
FJ. Evidence for local inflammation in complex regional pain syndrome type 1.
Mediators Inflamm. 2002;11:47-51. [PMID: 11930962] [FULL TEXT @ http://www.ncbi.nlm.nih.gov/pmc/arti...f/11930962.pdf]
9. Uçeyler N, Eberle T, Rolke R, Birklein F, Sommer C. Differential expression
patterns of cytokines in complex regional pain syndrome. Pain. 2007;132:195-205. [PMID: 17890011] [ABSTRACT @ http://www.ncbi.nlm.nih.gov/pubmed/17890011]
10. Alexander GM, van Rijn MA, van Hilten JJ, Perreault MJ, Schwartzman
RJ. Changes in cerebrospinal fluid levels of pro-inflammatory cytokines in CRPS. Pain. 2005;116:213-9. [PMID: 15964681] [ABSTRACT @ http://www.ncbi.nlm.nih.gov/pubmed/15964681]
Translation: After 30 months CRPS is no longer a function of the immune system, except in the case of spread to a previously unaffected limb, in which case the clock is reset.
Unfortunately, the results with IVIG are not terribly spectacular, indeed they are subject to open doubt. See, IVIG Shown to Relieve Complex Regional Pain Syndrome But Study Has Limitations, Experts Say, Valeo T,
Neurology Today. 2010 March 14. FULL TEXT @
http://www.rsds.org/2/library/articl..._IVIG_2010.pdf
To the best if my understanding, by far and away the best odds for knocking out a fresh case of CRPS in the upper extremities lies in a Stellate Ganglion Block. But there (as with the lumbarsympathetic block for lower extremities) time is absolutely of the essence. See, Efficacy of Stellate Ganglion Blockade for the Management of Type 1 Complex Regional Pain Syndrome, Ackerman WE, Zhang JM,
South Med J. 2006;99:1084-1088, FULL TEXT @
http://www.rsds.org/2/library/articl...lion_block.pdf:
Abstract
INTRODUCTION: The purpose of this study was to examine the efficacy of stellate ganglion blockade (SGB) in patients with complex regional pain syndromes (CRPS I) of their hands.
METHODS: After IRB approval and patient informed consent, 25 subjects, with a clinical diagnosis of CRPS I of one hand as defined by the International Association for the Study of Pain (IASP) criteria, had three SGB's performed at weekly intervals. Laser Doppler fluxmetric hand perfusion studies were performed on the normal and CRPS I hands pre- and post-SGB therapy. No patient was included in this study if they used tobacco products or any medication or substance that could affect sympathetic function. The appropriate parametric and nonparametric data analyses were performed and a p value <0.05 was used to reject the null hypothesis.
RESULTS: Symptom onset of CRPS I until the initiation of SGB therapy ranged between 3 to 34 weeks. Following the SGB series, patient pain relief was as follows: group I, 10/25 (40%) had complete symptom relief; group II, 9/25 (36%) had partial relief and group III, 6/25 (24%) had no relief. The duration of symptoms until SGB therapy was: group I, 4.6 +/- 1.8 weeks, group II, 11.9 +/- 1.6 weeks and group III, 35.8 +/- 27 weeks. Compared with the normal control hand, the skin perfusion in the CRPS I affected hand was greater in group I and decreased in groups II and III.
DISCUSSION: The results of our study demonstrate that an inverse relationship exists between hand perfusion and the duration of symptoms of CRPS I. On the other hand, a positive correlation exists between SGB efficacy and how soon SGB therapy is initiated. A duration of symptoms greater than 16 weeks before the initial SGB and/or a decrease in skin perfusion of 22% between the normal and affected hands adversely affects the efficacy of SGB therapy. [Emphasis added.]
PMID: 17100029 [PubMed - indexed for MEDLINE]
http://www.ncbi.nlm.nih.gov/pubmed/17100029
See, also, Complex regional pain syndrome type I: efficacy of stellate ganglion blockade, Istemi Yucel, Yavuz Demiraran, Kutay Ozturan, Erdem Degirmenci,
J Orthopaed Traumatol (2009) 10:179–183, FULL TEXT @
http://www.ncbi.nlm.nih.gov/pmc/arti...Article_71.pdf
Bottom line: time is not on your side if you wait to have PT. And in that regard, I wouldn't rule out surgery if properly performed with something called continuous regional anesthesia, which Dr. Getson or another specialist can explain to you. Frankly, it would be my guess that you stand the best chance in the long run of avoiding CRPS spread with surgery using continuous regional anesthesia, than in spending the rest of your life being subject to irritation from bone chips. I know one lady on this board who, with more or less chronic CRPS, was nevertheless considerably relieved when a loose orthopedic screw from a prior procedure was surgically removed using continuous regional anesthesia.
In any event, an ASAP consultation can't hurt.
Good luck!
Mike
PS And as a general rule, beware immobilization.