http://www3.interscience.wiley.com/j...TRY=1&SRETRY=0

CNS Measures of Pain Responses Pre- and Post-Anesthetic Ketamine in a Patient with Complex Regional Pain Syndrome
L. Becerra, PhD,* R. J. Schwartzman, MD, † R. T. Kiefer, MD, ‡ P. Rohr, M MD, ‡ E. A. Moulton, PhD,* D. Wallin, BS,* G. Pendse, MA, MS,* S. Morris, BA,* and David Borsook, MD, PhD*
*Pain/Analgesia Imaging Neuroscience (PAIN) Group, Brain Imaging Center, McLean Hospital, Harvard Medical School, Belmont, Massachusetts; † Drexel University College of Medicine, Department of Neurology, Philadelphia, Pennsylvania, USA; and ‡ Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tuebingen, Germany
Correspondence to David Borsook, MD, PhD, Pain/Analgesia Imaging Neuroscience (P.A.I.N.) Group, Brain Imaging Center, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA. Tel: 617-855-2691; Fax: 617-855-3772; E-mail: dborsook@partners.org
Copyright © 2009 American Academy of Pain Medicine
KEYWORDS
CRPS • Neuropathic Pain • Imaging • Clinical • fMRI • Ketamine Coma

ABSTRACT
Background. Previous reports have indicated that ketamine anesthesia may produce significant improvement if not complete recovery of patients with complex regional pain syndrome (CRPS).

Aims. Here we report on a patient who had CRPS affecting mainly the right side of her body who underwent functional magnetic resonance imaging (fMRI) scans prior to and in the months following apparent successful treatment with anesthetic doses of ketamine.

Materials and Methods. The patient underwent two imaging sessions: one during her pain state (CRPS+) and 1 month after her ketamine treatment in her pain-free state (CRPS-).

Both spontaneous and evoked (brush, cold, and heat) pain scores decreased from 7–9/10 on a visual analog scale prior to the treatment to 0–1 immediately following and for months after the treatment. For each imaging session, the identical mechanical (brush) and thermal (cold and heat) stimuli were applied to the same location (the skin of the dorsum of the right hand).

Results. Comparison of CRPS+ vs CRPS- for the three stimuli showed significant changes throughout the cerebral cortex (frontal, parietal, temporal, cingulate, and hippocampus), in subcortical regions such as caudate nucleus, and in the cerebellum. In addition, resting state network analysis showed a reversal of brain network state, and the recovered state paralleled specific default networks in healthy volunteers.

Discussion. The observed changes in brain response to evoked stimuli provide a readout for the subjective response.

Conclusion. Future studies of brain function in these patients may provide novel insight into brain plasticity in response to this treatment for chronic pain.

They have also seen this reversal in people who have recovered using mirror therapy, ECT, and PT. They have even seen this reversal in people with phantom limb pain.

Dear IT,

Thanks very much for sharing your experiences and information. It is very informative. I went to Dr. K's site and he has done quite a bit since I last visited it a few years ago.

My pain is primarily in my left foot where I still have one screw left after a failed bunion surgery. I had 2 of the screws removed last year but this 3rd one had so much new bone growth around it and was so deeply embedded that they didn't want to monkey around with it. I get deep sharp shooting nerve pain directly from that area and a recent bonce scan showed inflammation in my foot directly under the area where the screw resides. The swelling of my foot increases with activity and stress. I think something has changed inside structurally very slightly and the metal is literally getting on my nerves.

I have burning and deep bone pain that moves around the left side of my body, primarily my joint areas and it comes and goes. My bones turn ice cold. If I don't stay on top of my RSD pain in my foot these other areas become overly sensitized, that completely exhausts me and I crash. You are probably right that it is like referred pain.

What is strange is that the bone scan also revealed more degenerative changes in my right foot, more so than the left side. While I do experience occasional pain in the right foot too it was never the nerve pain of RSD. Since I realized that my doctors were all concerned about my right foot too I became a bit anxious about potential spread but no one thinks I have spread there. I think the mild burning I'm feeling in that area is simply a psychosomatic response to reading the report. I keep telling myself that and it seems to calm down.

I've always believed that the 3 metal screws were the real source of my pain and I was so deeply disappointed when I was informed that they couldn't take out the 3rd. The surgeon is a very well respected head of the department for trauma surgery at that hospital and I think he did what was best at that time. There is no doubt that I benefited from the removal of the other screws as they were working their way out on their own with each step I took. I'm working toward a plan to see what else can be done.

I'm so happy to hear you are doing better following your infusions. Do you plan to have any more in the future?

You are right, there is always hope. Thanks for the inspiration.

MsL

Hey MsL,

You are very welcome!

Your story is very intriguing. I am so glad to hear you got relief after they removed the other 2 screws (great news)! Did the doctor feel that the pain would lessen over time? Did he have any other suggestions? Did, the surgery to remove the other 2 screws cause you any additional RSD pain or any spreading of your RSD symptoms?

I like to think of doctors as health advisors. But the decision ultimately lies with the patient (after all, it is us going through the pain - but we also have to deal with the consequences of our decisions too).

I sought counsel of a few different doctors and PT's and I got mixed reviews on whether or not to get the 1st surgery. I did a ton of research on the internet too. I had to make the final decision.

I know 2 people who had the same surgery done on their spine within weeks of each other (by 2 different doctors, same area of specialty). One was instructed to wear a collar and the other not (his doctor told him that was old information). I thought that was very curious. The one who did not wear the collar faired much better.

Do you see an RSD specialist who can give you some insight? Have you seen a neurosurgeon? Sometime getting information from different sources can help.

I think you are on the right path to continue to pursue your options. Gather as much information as possible. Good luck on your quest for health and let us know what you decide.

Yes, I believe I will continue on with the infusions, as I need them. I know it is a process and it takes time.

With God, all things are possible!