A substantial proportion of patients with complex regional pain syndrome do not achieve sufficient pain relief with first-line pharmacological and interventional treatment. When that threshold is not met, a defined next-line protocol applies. This page describes that escalation step.
The prior treatment programme — which included agents such as tricyclic antidepressants (nortriptyline, amitriptyline, doxepin, or desipramine), gabapentin or pregabalin, calcitonin, and NSAIDs, combined with cognitive behavioural therapy, relaxation training with biofeedback, graded exposure therapy, and sympathetic nerve block at the stellate ganglion or lumbar sympathetic chain — did not achieve a reduction of at least 2 points on the 0–10 Numeric Rating Scale or meaningful improvement in specific functional activities.
When more intensive conservative and first-line interventional management has not met pain targets, the next step involves advanced interventional procedures targeting the nervous system. A structured trial phase is required before any permanent intervention proceeds. Additional infusion-based approaches may also be considered in appropriate patients. The complete protocol — including which specific procedures apply, the trial criteria, the sequencing, and the conditions for advancing — is accessible via the link below.
At least 50% reduction in pain intensity on the Visual Analog Scale.
DOI: 10.1093/pm/pnac046
Failure to progress in an interdisciplinary model/functional restoration algorithm and more intensive non-invasive therapies may warrant consideration of treatment with spinal cord stimulation or dorsal root ganglion stimulation.
Conventional SCS stimulation offers an opportunity to inhibit the nociceptive pathways at the level of the dorsal column of the spinal cord, while DRG stimulation modulates pain signal pathways at the level of the dorsal root.
Patients with a successful trial, which was defined by at least a 50% reduction in VAS for lower limb pain relief and freedom from any new neurological complaints, were implanted with a permanent device.
Intravenous administration of sub-anesthetic doses has been shown effective in two CRPS RCTs (level 2) assessing either 10 consecutive outpatient infusion treatments, or a 4.5 day inpatient treatment with slowly escalating doses.
Data demonstrates pain reduction, improved quality of life and function, as well as a reduction in opioid pharmaceuticals when spinal cord stimulation is employed in the setting of failed conservative therapy.