(Kiosk 1) Onabotulinumtoxina as a Successful Treatment Option for Complex Regional Pain Syndrome in a Patient with Spastic Hemiparesis: A Case Report

Case Diagnosis: OnabotulinumtoxinA as Treatment for Complex Regional Pain Syndrome

Case Description or Program Description: 55 year old female with right MCA stroke in 2014 sustaining left spastic hemiparesis who presents with intractable pain due to Complex Regional Pain Syndrome (CRPS). CRPS diagnosed after experiencing characteristic changes within her left upper limb. Patient was unable to participate in therapy early in course due to pain. Typical first-line agents were offered. Prednisone 50mg, NSAIDs, SNRI, muscle relaxants and anti-spasmodics were ineffective. Oxycodone 15mg and gabapentin 1200mg provided mild relief. Stellate ganglion block was performed and provided moderate relief for months. Repeat ganglion block 6 months later was ineffective. Patient was unwilling to repeat ganglion block. Per patient, pain was unrelenting and escalated to point that patient willing to accept amputation of left arm.

Setting: Outpatient PM&R clinic

Assessment/Results: OnabotulinumtoxinA injections completed to spastic muscles at roughly 9 months from stroke, providing highly effective pain relief and improvement in quality of life.

Discussion (relevance): CRPS remains a debilitating condition that can significantly impair functional recovery and lead to long-term complications. There is growing evidence that CRPS displays subgroup phenotypes in its response to treatment. Clinicians have adopted a trial-and-error approach towards managing this syndrome due to the severity of illness and lack of successful single treatment. The majority of studies evaluating novel approaches have been restricted to case series or small pilot studies. Emerging agents include hyperbaric oxygen therapy, immunomodulation agents, plasma exchange, and botulinum toxin, among others. In 2011, a retrospective chart review of 37 patient with CRPS, found that botulinum toxin was effective for pain relief.

Conclusions: This case report adds to the growing evidence that botulinum toxin injection may be an effective treatment for CRPS, a notoriously difficult condition to treat.