Post-Traumatic Complex Regional Pain Syndrome Type I in an Elderly Diabetic Female Following Early Carpal Tunnel Syndrome and Trigger Finger: A Case Report from Rural Nepal

Post-Traumatic Complex Regional Pain Syndrome Type I in an Elderly Diabetic Female Following Early Carpal Tunnel Syndrome and Trigger Finger: A Case Report from Rural Nepal | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Post-Traumatic Complex Regional Pain Syndrome Type I in an Elderly Diabetic Female Following Early Carpal Tunnel Syndrome and Trigger Finger: A Case Report from Rural Nepal Sahaj Poudel, Shirish Prasad Amatya, Suresh Bishokarma, Jeevan Gyawali This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8123027/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : Complex Regional Pain Syndrome (CRPS) is a challenging neuropathic pain disorder often following trauma or surgery, with disproportionate pain and autonomic changes. Early identification is essential, particularly in elderly diabetic patients, where overlapping neuropathies can obscure diagnosis. Case Presentation : We report a case of a 74-year-old woman from rural Nepal presenting with chronic left-hand pain initially diagnosed as trigger finger and early carpal tunnel syndrome, which evolved into CRPS Type I. Despite conservative therapy, her symptoms progressed to severe allodynia, swelling, and trophic changes. Diagnosis was confirmed by clinical findings, nerve conduction study, and infrared thermography. Conclusion: This case highlights the importance of early recognition and multimodal management of CRPS in elderly diabetic patients, particularly in low-resource settings where delayed diagnosis can lead to irreversible disability. Carpal tunnel syndrome Complex regional pain syndrome CRPS type I Diabetes mellitus Neuropathic pain Trigger finger Figures Figure 1 Figure 2 Introduction Complex Regional Pain Syndrome (CRPS) is a chronic neuropathic pain disorder characterized by severe, disproportionate pain, sensory abnormalities, autonomic dysfunction, and trophic changes.( 1 , 2 ) CPRS is a chronic pain condition characterized by hyperalgesia and allodynia, commonly involving the limbs.( 3 ) It commonly develops after minor trauma, fractures, or nerve injury and is divided into Type I (without definable nerve lesion) and Type II (with identifiable nerve injury).( 4 ) Elderly patients with comorbid diabetes and prior neuropathic conditions are particularly vulnerable due to microvascular and neuronal sensitization.( 5 ) This case report presents a unique instance of CRPS Type I in an elderly diabetic woman from rural Nepal, developing after trigger finger and early carpal tunnel syndrome- illustrating the diagnostic complexity and therapeutic challenges in low-resource settings. Case Presentation A 74-year-old right-handed female from Kailali, Nepal, presented with chronic pain and stiffness of the left wrist and middle finger for three months. She described difficulty in making a fist and mild swelling over the dorsal aspect of her hand. She was diagnosed clinically with Trigger Finger (left middle finger) and prescribed Indomethacin 75 mg OD for 10 days and Serratiopeptidase 10 mg TDS for 5 days. Despite medication, pain persisted and intensified over the next two weeks. She developed with burning pain, numbness, and paresthesia of the left hand. She reported burning, t ingling pain (NRS 8–9/10), worsened by light touch or movement, with no identifiable relieving factor On examination, diffuse swelling with allodynia and hyperalgesia of the left hand with reddish mottled discoloration was noticed in palmar and dorsum of left hands with nail bed dystrophy and hair loss. (Fig. 1 ) She exhibited tenderness over the carpal tunnel region, decreased grip strength of left hand, and nocturnal exacerbation of pain. Range of motion in wrist, metacarpophalyngeal, proximal inter phalyngeal and distal inter phalyngeal joints were restricted. Diagnosis: Based on the Budapest clinical criteria, findings were consistent with Complex Regional Pain Syndrome Type I (CRPS I) affecting the left upper limb, secondary to minor trauma and early carpal tunnel syndrome. ( 6 ) Laboratory results revealed Fasting blood glucose: 140 mg/dl, post-prandial blood glucose: 266 mg/dl, ESR: 17 mm/hr, CRP: <5 mg/L, Rheumatoid factor: <8.6 IU/mL (negative), Serum uric acid: 5.7 mg/dL (Normal). X-ray of the left hand (AP and oblique views) showed mild-to-moderate osteopenia and severe joint deformities and subluxations, particularly at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint. Marked joint-space narrowing and periarticular osteopenia. Marginal erosions and irregularity of articular surfaces. Ulnar deviation of the fingers at the MCP joints. (Fig. 2 ) Nerve conduction study demonstrated delayed distal latency and reduced conduction velocity in the left median nerve, consistent with early carpal tunnel syndrome. She was treated with Pregabalin 75 mg BD and referred to our center for interventional evaluation. Infrared thermography demonstrated temperature asymmetry confirming CRPS Type I of the left hand. Management She was managed with a multidisciplinary approach with pharmacotherapy, psychological counselling and with physiotherapy. She was prescribed Pregablin 75mg for neuropathic pain, Amitriptyline for central pain modulation and sleep, Calcium supplemented for bone health support and Alendronate 70mg once weekly for Osteopenia. Given persistent sympathetic pain features, a diagnostic Stellate Ganglion Block (SGB) was performed on the left side under ultrasound guidance. Informed consent was obtained. Under supine position, the anterolateral part of the left neck was scanned using linear high frequency ultrasound probe and Chassaignac tubercle was identified.( 7 ) Under all aseptic precautions, 2ml of 1% lignocaine was infiltrated in the skin following which 3ml of 2% lignocaine and 7ml of 5% dextrose was given around the right stellate ganglion. Warmth and flushing in the left hand within minutes, confirming successful sympathetic blockade. The patient was observed for 30 minutes. On reassessment in 30 minutes, the patient's pain during which left wrist movement - a key diagnostic maneuver - has significantly improved, with the Numeric Rating Scale (NRS) score decreasing by over 80% to 2/10. On follow up, swelling, skin discoloration, and allodynia subsided over subsequent weeks. The patient reported improved sleep and mobility of fingers. Repeat sessions were not required due to sustained improvement. At 4-week follow-up, she demonstrated pain NRS of 2/10 and was able to make a fist and hold light objects, improved in wrist and interphalangeal joints, normal skin and nail texture. Discussion The origins of Complex Regional Pain Syndrome (CRPS) trace back over 140 years to Silas Weir Mitchell's seminal work on Civil War nerve injuries. Initially, the condition was identified by two key features: "causalgia," referring to the intense burning pain, and "reflex sympathetic dystrophy," which described the frequent involvement of an overactive sympathetic nervous system.( 8 ) In 1993, the term Complex Regional Pain Syndrome (CRPS) was standardized to describe this condition. It is categorized into two types: CRPS I, which follows tissue trauma like a fracture without a confirmed nerve injury, and CRPS II, which occurs after a distinct nerve injury. Furthermore, both types can be classified based on their response to nerve blocks as either Sympathetically Maintained Pain (SMP) or Sympathetically Independent Pain (SIP).( 9 ) The 1993 criteria was highly sensitive but lacked specificity, leading to potential over-diagnosis. This led to further work and the development of the more specific Budapest criteria, which are the currently accepted standard, formally adopted by the IASP in 2012.( 6 ) Our patient's condition was consistent with a diagnosis of Complex Regional Pain Syndrome Type I, based on the Budapest criteria. This diabetic patient presented with burning pain, numbness, and paresthesia of the left hand with decreased strength of grip, and nocturnal exacerbation of pain with features of early carpal tunnel syndrome with past history of herpes zoster infection of C6 dermatome and fracture of the left 5th metacarpal bone. However, A recent study of 1,043 CRPS patients identified fractures, blunt trauma, surgery, and carpal tunnel syndrome as the most frequent causes; however, the overall likelihood of developing CRPS from any of these inciting events remains low.( 10 ) This case underscores the complex interplay between peripheral neuropathy, sympathetic dysfunction, and chronic pain sensitization in elderly diabetic individuals. CRPS includes a variable clinical presentation and disease progression. Initially presented as a trigger finger, the patient developed median nerve compression neuropathy and subsequently CRPS I, likely triggered by a combination of minor trauma, metabolic dysfunction, and prior herpes zoster affecting the same dermatomal distribution. The exact cause of CRPS remains unknown, but it is characterized by an abnormal response to injury, involving peripheral and central nervous system sensitization, inflammation, and autonomic dysregulation.( 11 ) Genetic and psychological contributions are also believed to play a role in the progression of CRPS.( 12 ) CRPS is underdiagnosed in low-resource settings, where access to advanced diagnostics like thermography or nerve conduction studies is limited. In such patients, early recognition of allodynia, skin trophic changes, and disproportionate pain should raise suspicion for CRPS.( 13 ) It is essential to recognize that the clinical features of CRPS are variable; only persistent, disproportionate pain is a mandatory component, as no single characteristic is pathognomonic. Consequently, clinicians must first exclude other potential diagnoses. The New IASP Diagnostic Criteria for CRPS (Budapest Criteria) are then applied. These criteria evaluate symptoms and signs across four domains: sensory, vasomotor, sudomotor/edema, and motor/trophic.( 13 ) Quick recognition and timely care can make the difference between long-term disability and restored function. To overcome this, the International Research Consortium for CRPS (IRC) established in 2015 has been working toward a unified International Core Data Set and Clinical Research Registry (COMPACT). Such a global registry would allow clinicians and researchers to collect standardized data on CRPS presentation, progression, and treatment outcomes from diverse populations. This would help identify risk factors, potential subtypes, and predictors of response, ultimately improving patient care worldwide.( 14 ) Nerve conduction studies (NCS) are generally normal in Complex Regional Pain Syndrome Type I (CRPS-I), but are useful for ruling out other conditions that can cause similar symptoms, and for confirming a specific nerve injury in CRPS Type II (CRPS-II).( 15 ) In our study, Nerve conduction study demonstrated delayed distal latency and reduced conduction velocity in the left median nerve, consistent with early carpal tunnel syndrome. Thermography serves as a valuable tool for quantifying thermal changes in the affected CRPS limb. Limb skin temperature, an indicator of autonomic nervous system function, was assessed using serial infrared thermal imaging. The cold stress test evaluates the skin's vasomotor response, which is controlled by sympathetic nerves that regulate blood vessel constriction and dilation. In early-stage CRPS patients, the limb temperature typically rebounds quickly after the test. In contrast, patients with advanced CRPS often show a delayed temperature recovery due to abnormally prolonged vasoconstriction. Beyond its diagnostic applications, thermography can also be used to monitor treatment efficacy over time.( 16 ) The most effective treatment for CRPS is a comprehensive, interdisciplinary program focused on restoring function. While medications like antidepressants, anticonvulsants, and opiates are commonly used to manage pain and support rehabilitation, most lack strong evidence from CRPS-specific clinical trials. Instead, their use is justified by their proven efficacy in similar neuropathic pain conditions. The only medications with consistent support from multiple controlled CRPS trials are bisphosphonates.( 17 ) Bisphosphonates like alendronate have demonstrated benefit in improving pain and bone metabolism in CRPS. Bisphosphonates (eg, pamidronate, clodronate, alendronate) inhibit bone resorption. In two placebo-controlled trials of bisphosphonates for the treatment of CRPS, either alendronate (7.5 mg intravenously daily for 3 days) or clodronate (300 mg intravenously daily for 10 days) demonstrated improvement in pain, compared with placebo.( 18 , 19 ) Pharmacologic management targeting neuropathic pain, along with sympathetic blocks and rehabilitation, remains the cornerstone of treatment. Despite limited evidence specifically for CRPS, tricyclic antidepressants (TCAs) are commonly used for its management. Their pain-relieving effects are likely due to the enhancement of descending inhibitory pathways and sodium-channel blockade- mechanisms distinct from their antidepressant action.( 20 ) Gabapentin is thought to work by modulating calcium channels at a specific alpha2delta subunit.( 21 ) The drug has been studied extensively in painful diabetic neuropathy and postherpetic neuralgia, with demonstrated efficacy. In one randomized, blinded trial in 58 patients with CRPS, gabapentin had a mild effect on pain.( 22 ) opioids are being used in the management of CPRS. While strong evidence shows that opioids can reduce neuropathic pain and improve quality of life in the short term, well-controlled studies confirming their long-term efficacy are lacking.( 23 ) Other molecules tried are anti inflammatory, anti epileptics, alpha adrenergic agonist, sodium channel blockers, NMDA receptor antagonism like ketamine, amantadine, memantine, dextromethorphan, and methadone with variable effects.( 24 – 27 ) Other modalities of diagnostic as well as therapeutic option for CRPS is stellate ganglion block. A stellate ganglion block will block these nerves to reduce pain. It includes image guided infiltration of local anesthetics agents into the stellate ganglion in the neck. Various studies has shown decreased VAS and increased ROM of wrist joints in patients with CRPS type I.( 28 ) ( 29 , 30 ) Our patient underwent a comprehensive diagnostic and treatment plan, greatly improving her quality of life. This case shows how early diagnosis and a well-planned, multimodal treatment- including a stellate ganglion block- can bring remarkable recovery even in elderly diabetic patients with Complex Regional Pain Syndrome (CRPS) Type I. Conclusion CRPS is a complex and multifactorial condition which lacks definitive cure. The implementation of objectively quantifiable functional measures may be extremely helpful for early diagnosis and treatment of CRPS. A high index of suspicion, thorough clinical evaluation, and prompt multidisciplinary management can significantly improve outcomes, even in resource-limited environments like rural Nepal. Declarations Authors’ contribution statements: All authors contributed equally to this work. Funding: No funding was received for conducting this study. Data availability: No datasets were generated or analyzed during the current study. Ethics approval: Our institution does not require ethical approval for case studies. Patient Consent Statement: The patient’s consent was obtained before submission of the article. Consent for publication: The patient’s written consent was obtained for publication. Conflicts of interest/Competing interests The authors have no conflicts of interest to declare that are relevant to the content of this article. References Stanton-Hicks M d‘A. CRPS: what’s in a name? Taxonomy, epidemiology, neurologic, immune and autoimmune considerations. Reg Anesth Pain Med. 2019 Mar;44(3):376–87. Smart KM, Wand BM, O’Connell NE. Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Pain, Palliative and Supportive Care Group, editor. Cochrane Database Syst Rev [Internet]. 2016 Feb 24 [cited 2025 Nov 6];2016(3). Available from: http://doi.wiley.com/10.1002/14651858.CD010853.pub2 Taylor SS, Noor N, Urits I, Paladini A, Sadhu MS, Gibb C, et al. Complex Regional Pain Syndrome: A Comprehensive Review. Pain Ther. 2021 Dec;10(2):875–92. Rewhorn MJ, Leung AH, Gillespie A, Moir JS, Miller R. Incidence of Complex Regional Pain Syndrome after Foot and Ankle Surgery. J Foot Ankle Surg. 2014 May;53(3):256–8. Devarajan J, Mena S, Cheng J. Mechanisms of complex regional pain syndrome. Front Pain Res. 2024 May 17;5:1385889. Harden NR, Bruehl S, Perez RSGM, Birklein F, Marinus J, Maihofner C, et al. Validation of proposed diagnostic criteria (the “Budapest Criteria”) for Complex Regional Pain Syndrome. Pain. 2010 Aug;150(2):268–74. Sukhupayo R, Das G, Yadav A, Shakya E, Sangroula R. Dextrose Injection in Stellate Ganglion Block: A Case Report. Nepal Med J. 2024 July 5;7(1):12–6. Wilson J, Serpell M. Complex regional pain syndrome. Contin Educ Anaesth Crit Care Pain. 2007 Apr;7(2):51–4. Wesselmann U, Raja SN. REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIA. Anesthesiol Clin N Am. 1997 June;15(2):407–27. Ott S, Maihöfner C. Signs and Symptoms in 1,043 Patients with Complex Regional Pain Syndrome. J Pain. 2018 June;19(6):599–611. Misidou C, Papagoras C. Complex Regional Pain Syndrome: An update. Mediterr J Rheumatol. 2019 Mar 1;30(1):16–25. Shim H, Rose J, Halle S, Shekane P. Complex regional pain syndrome: a narrative review for the practising clinician. Br J Anaesth. 2019 Aug;123(2):e424–33. Harnik MA, Kesselring P, Ott A, Urman RD, Luedi MM. Complex Regional Pain Syndrome (CRPS) and the Value of Early Detection. Curr Pain Headache Rep. 2023 Sept;27(9):417–27. Harden RN, McCabe CS, Goebel A, Massey M, Suvar T, Grieve S, et al. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition. Pain Med. 2022 June 10;23(Supplement_1):S1–53. Jesudason EP, Fullilove S, Henderson J, Gwyn R, Solari F. Twenty questions on complex regional pain syndrome. Orthop Trauma. 2023 Apr;37(2):84–91. Pérez-Concha T, Tijero B, Acera M, Fernández T, Gabilondo I, Gómez-Esteban JC. Usefulness of thermography in the diagnosis and classification of complex regional pain syndrome. Neurología. 2023 June;38(5):342–9. Mackey S, Feinberg S. Pharmacologic therapies for complex regional pain syndrome. Curr Pain Headache Rep. 2007 Mar;11(1):38–43. Varenna M, Zucchi F, Ghiringhelli D, Binelli L, Bevilacqua M, Bettica P, et al. Intravenous clodronate in the treatment of reflex sympathetic dystrophy syndrome. A randomized, double blind, placebo controlled study. J Rheumatol. 2000 June;27(6):1477–83. Adami S, Fossaluzza V, Gatti D, Fracassi E, Braga V. Bisphosphonate therapy of reflex sympathetic dystrophy syndrome. Ann Rheum Dis. 1997 Mar;56(3):201–4. Sudoh Y, Cahoon EE, Gerner P, Wang GK. Tricyclic antidepressants as long-acting local anesthetics. Pain. 2003 May;103(1–2):49–55. Fink K, Dooley DJ, Meder WP, Suman-Chauhan N, Duffy S, Clusmann H, et al. Inhibition of neuronal Ca(2+) influx by gabapentin and pregabalin in the human neocortex. Neuropharmacology. 2002 Feb;42(2):229–36. van de Vusse AC, Stomp-van den Berg SGM, Kessels AHF, Weber WEJ. Randomised controlled trial of gabapentin in Complex Regional Pain Syndrome type 1 [ISRCTN84121379]. BMC Neurol. 2004 Sept 29;4:13. Watson CPN, Moulin D, Watt-Watson J, Gordon A, Eisenhoffer J. Controlled-release oxycodone relieves neuropathic pain: a randomized controlled trial in painful diabetic neuropathy. Pain. 2003 Sept;105(1–2):71–8. Zhao Z, Chen SR, Eisenach JC, Busija DW, Pan HL. Spinal cyclooxygenase-2 is involved in development of allodynia after nerve injury in rats. Neuroscience. 2000;97(4):743–8. Te AE. A modern rationale for the use of phenoxybenzamine in urinary tract disorders and other conditions. Clin Ther. 2002 June;24(6):851–61; discussion 837. Galer BS, Miller KV, Rowbotham MC. Response to intravenous lidocaine infusion differs based on clinical diagnosis and site of nervous system injury. Neurology. 1993 June;43(6):1233–5. Correll GE, Maleki J, Gracely EJ, Muir JJ, Harbut RE. Subanesthetic ketamine infusion therapy: a retrospective analysis of a novel therapeutic approach to complex regional pain syndrome. Pain Med Malden Mass. 2004 Sept;5(3):263–75. Yucel I, Demiraran Y, Ozturan K, Degirmenci E. Complex regional pain syndrome type I: efficacy of stellate ganglion blockade. J Orthop Traumatol. 2009 Dec;10(4):179–83. Cepeda MS, Lau J, Carr DB. Defining the Therapeutic Role of Local Anesthetic Sympathetic Blockade in Complex Regional Pain Syndrome: A Narrative and Systematic Review: Clin J Pain. 2002 July;18(4):216–33. Price DD, Long S, Wilsey B, Rafii A. Analysis of Peak Magnitude and Duration of Analgesia Produced by Local Anesthetics Injected into Sympathetic Ganglia of Complex Regional Pain Syndrome Patients: Clin J Pain. 1998 Sept;14(3):216–26. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8123027","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":607652909,"identity":"fe88dae7-a52d-4dd1-b2b3-fa682cb2c9b8","order_by":0,"name":"Sahaj 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15:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8123027/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8123027/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104998624,"identity":"3e5d522c-76ab-4586-9f6a-bc18a8350bd3","added_by":"auto","created_at":"2026-03-19 16:30:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":709319,"visible":true,"origin":"","legend":"\u003cp\u003eOn inspection of palmer and dorsum of both hands showed diffuse swelling with reddish mottled discoloration in left hand with nail bed dystrophy and hair loss.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8123027/v1/7097b28501e515cb936beae7.png"},{"id":104998622,"identity":"e6511f50-4488-44db-b66a-0c4080f897d9","added_by":"auto","created_at":"2026-03-19 16:30:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":780166,"visible":true,"origin":"","legend":"\u003cp\u003eRadiographs (AP and oblique views) of the left hand showing severe joint space narrowing, periarticular osteopenia, marginal erosions, and ulnar deviation of fingers.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8123027/v1/d4352315eac09e453e328e01.png"},{"id":107035861,"identity":"4b22b657-2285-4e65-abd3-d9c6a1216db6","added_by":"auto","created_at":"2026-04-16 04:26:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2564381,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8123027/v1/55031ed5-3bf9-480b-aa94-6f3358e8e96a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Post-Traumatic Complex Regional Pain Syndrome Type I in an Elderly Diabetic Female Following Early Carpal Tunnel Syndrome and Trigger Finger: A Case Report from Rural Nepal","fulltext":[{"header":"Introduction","content":"\u003cp\u003eComplex Regional Pain Syndrome (CRPS) is a chronic neuropathic pain disorder characterized by severe, disproportionate pain, sensory abnormalities, autonomic dysfunction, and trophic changes.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) CPRS is a chronic pain condition characterized by hyperalgesia and allodynia, commonly involving the limbs.(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) It commonly develops after minor trauma, fractures, or nerve injury and is divided into Type I (without definable nerve lesion) and Type II (with identifiable nerve injury).(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) Elderly patients with comorbid diabetes and prior neuropathic conditions are particularly vulnerable due to microvascular and neuronal sensitization.(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) This case report presents a unique instance of CRPS Type I in an elderly diabetic woman from rural Nepal, developing after trigger finger and early carpal tunnel syndrome- illustrating the diagnostic complexity and therapeutic challenges in low-resource settings.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 74-year-old right-handed female from Kailali, Nepal, presented with chronic pain and stiffness of the left wrist and middle finger for three months. She described difficulty in making a fist and mild swelling over the dorsal aspect of her hand. She was diagnosed clinically with Trigger Finger (left middle finger) and prescribed Indomethacin 75 mg OD for 10 days and Serratiopeptidase 10 mg TDS for 5 days. Despite medication, pain persisted and intensified over the next two weeks. She developed with burning pain, numbness, and paresthesia of the left hand. She reported burning, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003et\u003c/span\u003eingling pain (NRS 8\u0026ndash;9/10), worsened by light touch or movement, with no identifiable relieving factor On examination, diffuse swelling with allodynia and hyperalgesia of the left hand with reddish mottled discoloration was noticed in palmar and dorsum of left hands with nail bed dystrophy and hair loss. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) She exhibited tenderness over the carpal tunnel region, decreased grip strength of left hand, and nocturnal exacerbation of pain. Range of motion in wrist, metacarpophalyngeal, proximal inter phalyngeal and distal inter phalyngeal joints were restricted.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDiagnosis:\u003c/h2\u003e \u003cp\u003eBased on the Budapest clinical criteria, findings were consistent with Complex Regional Pain Syndrome Type I (CRPS I) affecting the left upper limb, secondary to minor trauma and early carpal tunnel syndrome. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Laboratory results revealed Fasting blood glucose: 140 mg/dl, post-prandial blood glucose: 266 mg/dl, ESR: 17 mm/hr, CRP: \u0026lt;5 mg/L, Rheumatoid factor: \u0026lt;8.6 IU/mL (negative), Serum uric acid: 5.7 mg/dL (Normal). X-ray of the left hand (AP and oblique views) showed mild-to-moderate osteopenia and severe joint deformities and subluxations, particularly at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint. Marked joint-space narrowing and periarticular osteopenia. Marginal erosions and irregularity of articular surfaces. Ulnar deviation of the fingers at the MCP joints. (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) Nerve conduction study demonstrated delayed distal latency and reduced conduction velocity in the left median nerve, consistent with early carpal tunnel syndrome. She was treated with Pregabalin 75 mg BD and referred to our center for interventional evaluation. Infrared thermography demonstrated temperature asymmetry confirming CRPS Type I of the left hand.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eManagement\u003c/h3\u003e\n\u003cp\u003eShe was managed with a multidisciplinary approach with pharmacotherapy, psychological counselling and with physiotherapy. She was prescribed Pregablin 75mg for neuropathic pain, Amitriptyline for central pain modulation and sleep, Calcium supplemented for bone health support and Alendronate 70mg once weekly for Osteopenia. Given persistent sympathetic pain features, a diagnostic Stellate Ganglion Block (SGB) was performed on the left side under ultrasound guidance. Informed consent was obtained. Under supine position, the anterolateral part of the left neck was scanned using linear high frequency ultrasound probe and Chassaignac tubercle was identified.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) Under all aseptic precautions, 2ml of 1% lignocaine was infiltrated in the skin following which 3ml of 2% lignocaine and 7ml of 5% dextrose was given around the right stellate ganglion. Warmth and flushing in the left hand within minutes, confirming successful sympathetic blockade. The patient was observed for 30 minutes. On reassessment in 30 minutes, the patient's pain during which left wrist movement - a key diagnostic maneuver - has significantly improved, with the Numeric Rating Scale (NRS) score decreasing by over 80% to 2/10. On follow up, swelling, skin discoloration, and allodynia subsided over subsequent weeks. The patient reported improved sleep and mobility of fingers. Repeat sessions were not required due to sustained improvement. At 4-week follow-up, she demonstrated pain NRS of 2/10 and was able to make a fist and hold light objects, improved in wrist and interphalangeal joints, normal skin and nail texture.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe origins of Complex Regional Pain Syndrome (CRPS) trace back over 140 years to Silas Weir Mitchell's seminal work on Civil War nerve injuries. Initially, the condition was identified by two key features: \"causalgia,\" referring to the intense burning pain, and \"reflex sympathetic dystrophy,\" which described the frequent involvement of an overactive sympathetic nervous system.(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) In 1993, the term Complex Regional Pain Syndrome (CRPS) was standardized to describe this condition. It is categorized into two types: CRPS I, which follows tissue trauma like a fracture without a confirmed nerve injury, and CRPS II, which occurs after a distinct nerve injury. Furthermore, both types can be classified based on their response to nerve blocks as either Sympathetically Maintained Pain (SMP) or Sympathetically Independent Pain (SIP).(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) The 1993 criteria was highly sensitive but lacked specificity, leading to potential over-diagnosis. This led to further work and the development of the more specific Budapest criteria, which are the currently accepted standard, formally adopted by the IASP in 2012.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Our patient's condition was consistent with a diagnosis of Complex Regional Pain Syndrome Type I, based on the Budapest criteria. This diabetic patient presented with burning pain, numbness, and paresthesia of the left hand with decreased strength of grip, and nocturnal exacerbation of pain with features of early carpal tunnel syndrome with past history of herpes zoster infection of \u003cb\u003eC6 dermatome\u003c/b\u003e and fracture of the left 5th metacarpal bone. However, A recent study of 1,043 CRPS patients identified fractures, blunt trauma, surgery, and carpal tunnel syndrome as the most frequent causes; however, the overall likelihood of developing CRPS from any of these inciting events remains low.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) This case underscores the complex interplay between peripheral neuropathy, sympathetic dysfunction, and chronic pain sensitization in elderly diabetic individuals. CRPS includes a variable clinical presentation and disease progression. Initially presented as a trigger finger, the patient developed median nerve compression neuropathy and subsequently CRPS I, likely triggered by a combination of minor trauma, metabolic dysfunction, and prior herpes zoster affecting the same dermatomal distribution. The exact cause of CRPS remains unknown, but it is characterized by an abnormal response to injury, involving peripheral and central nervous system sensitization, inflammation, and autonomic dysregulation.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Genetic and psychological contributions are also believed to play a role in the progression of CRPS.(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eCRPS is underdiagnosed in low-resource settings, where access to advanced diagnostics like thermography or nerve conduction studies is limited. In such patients, early recognition of allodynia, skin trophic changes, and disproportionate pain should raise suspicion for CRPS.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) It is essential to recognize that the clinical features of CRPS are variable; only persistent, disproportionate pain is a mandatory component, as no single characteristic is pathognomonic. Consequently, clinicians must first exclude other potential diagnoses. The New IASP Diagnostic Criteria for CRPS (Budapest Criteria) are then applied. These criteria evaluate symptoms and signs across four domains: sensory, vasomotor, sudomotor/edema, and motor/trophic.(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eQuick recognition and timely care can make the difference between long-term disability and restored function. To overcome this, the International Research Consortium for CRPS (IRC) established in 2015 has been working toward a unified International Core Data Set and Clinical Research Registry (COMPACT). Such a global registry would allow clinicians and researchers to collect standardized data on CRPS presentation, progression, and treatment outcomes from diverse populations. This would help identify risk factors, potential subtypes, and predictors of response, ultimately improving patient care worldwide.(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eNerve conduction studies (NCS) are generally normal in Complex Regional Pain Syndrome Type I (CRPS-I), but are useful for ruling out other conditions that can cause similar symptoms, and for confirming a specific nerve injury in CRPS Type II (CRPS-II).(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) In our study, Nerve conduction study demonstrated delayed distal latency and reduced conduction velocity in the left median nerve, consistent with early carpal tunnel syndrome.\u003c/p\u003e \u003cp\u003eThermography serves as a valuable tool for quantifying thermal changes in the affected CRPS limb. Limb skin temperature, an indicator of autonomic nervous system function, was assessed using serial infrared thermal imaging. The cold stress test evaluates the skin's vasomotor response, which is controlled by sympathetic nerves that regulate blood vessel constriction and dilation. In early-stage CRPS patients, the limb temperature typically rebounds quickly after the test. In contrast, patients with advanced CRPS often show a delayed temperature recovery due to abnormally prolonged vasoconstriction. Beyond its diagnostic applications, thermography can also be used to monitor treatment efficacy over time.(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe most effective treatment for CRPS is a comprehensive, interdisciplinary program focused on restoring function. While medications like antidepressants, anticonvulsants, and opiates are commonly used to manage pain and support rehabilitation, most lack strong evidence from CRPS-specific clinical trials. Instead, their use is justified by their proven efficacy in similar neuropathic pain conditions. The only medications with consistent support from multiple controlled CRPS trials are bisphosphonates.(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) Bisphosphonates like alendronate have demonstrated benefit in improving pain and bone metabolism in CRPS. Bisphosphonates (eg, pamidronate, clodronate, alendronate) inhibit bone resorption. In two placebo-controlled trials of bisphosphonates for the treatment of CRPS, either alendronate (7.5 mg intravenously daily for 3 days) or clodronate (300 mg intravenously daily for 10 days) demonstrated improvement in pain, compared with placebo.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Pharmacologic management targeting neuropathic pain, along with sympathetic blocks and rehabilitation, remains the cornerstone of treatment. Despite limited evidence specifically for CRPS, tricyclic antidepressants (TCAs) are commonly used for its management. Their pain-relieving effects are likely due to the enhancement of descending inhibitory pathways and sodium-channel blockade- mechanisms distinct from their antidepressant action.(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) Gabapentin is thought to work by modulating calcium channels at a specific alpha2delta subunit.(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) The drug has been studied extensively in painful diabetic neuropathy and postherpetic neuralgia, with demonstrated efficacy. In one randomized, blinded trial in 58 patients with CRPS, gabapentin had a mild effect on pain.(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) opioids are being used in the management of CPRS. While strong evidence shows that opioids can reduce neuropathic pain and improve quality of life in the short term, well-controlled studies confirming their long-term efficacy are lacking.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) Other molecules tried are anti inflammatory, anti epileptics, alpha adrenergic agonist, sodium channel blockers, NMDA receptor antagonism like ketamine, amantadine, memantine, dextromethorphan, and methadone with variable effects.(\u003cspan additionalcitationids=\"CR25 CR26\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOther modalities of diagnostic as well as therapeutic option for CRPS is stellate ganglion block. A stellate ganglion block will block these nerves to reduce pain. It includes image guided infiltration of local anesthetics agents into the stellate ganglion in the neck. Various studies has shown decreased VAS and increased ROM of wrist joints in patients with CRPS type I.(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eOur patient underwent a comprehensive diagnostic and treatment plan, greatly improving her quality of life. This case shows how early diagnosis and a well-planned, multimodal treatment- including a stellate ganglion block- can bring remarkable recovery even in elderly diabetic patients with Complex Regional Pain Syndrome (CRPS) Type I.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCRPS is a complex and multifactorial condition which lacks definitive cure. The implementation of objectively quantifiable functional measures may be extremely helpful for early diagnosis and treatment of CRPS. A high index of suspicion, thorough clinical evaluation, and prompt multidisciplinary management can significantly improve outcomes, even in resource-limited environments like rural Nepal.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors’ contribution statements:\u003c/strong\u003e All authors contributed equally to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funding was received for conducting this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u003c/strong\u003e No datasets were generated or analyzed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003e Our institution does not require ethical approval for case studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Consent Statement:\u003c/strong\u003e The patient’s consent was obtained before submission of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e The patient’s written consent was obtained for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare that are relevant to the content of this article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStanton-Hicks M d\u0026lsquo;A. CRPS: what\u0026rsquo;s in a name? Taxonomy, epidemiology, neurologic, immune and autoimmune considerations. Reg Anesth Pain Med. 2019 Mar;44(3):376\u0026ndash;87. \u003c/li\u003e\n\u003cli\u003eSmart KM, Wand BM, O\u0026rsquo;Connell NE. Physiotherapy for pain and disability in adults with complex regional pain syndrome (CRPS) types I and II. Cochrane Pain, Palliative and Supportive Care Group, editor. Cochrane Database Syst Rev [Internet]. 2016 Feb 24 [cited 2025 Nov 6];2016(3). Available from: http://doi.wiley.com/10.1002/14651858.CD010853.pub2 \u003c/li\u003e\n\u003cli\u003eTaylor SS, Noor N, Urits I, Paladini A, Sadhu MS, Gibb C, et al. Complex Regional Pain Syndrome: A Comprehensive Review. Pain Ther. 2021 Dec;10(2):875\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eRewhorn MJ, Leung AH, Gillespie A, Moir JS, Miller R. Incidence of Complex Regional Pain Syndrome after Foot and Ankle Surgery. J Foot Ankle Surg. 2014 May;53(3):256\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eDevarajan J, Mena S, Cheng J. Mechanisms of complex regional pain syndrome. Front Pain Res. 2024 May 17;5:1385889. \u003c/li\u003e\n\u003cli\u003eHarden NR, Bruehl S, Perez RSGM, Birklein F, Marinus J, Maihofner C, et al. Validation of proposed diagnostic criteria (the \u0026ldquo;Budapest Criteria\u0026rdquo;) for Complex Regional Pain Syndrome. Pain. 2010 Aug;150(2):268\u0026ndash;74. \u003c/li\u003e\n\u003cli\u003eSukhupayo R, Das G, Yadav A, Shakya E, Sangroula R. Dextrose Injection in Stellate Ganglion Block: A Case Report. Nepal Med J. 2024 July 5;7(1):12\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eWilson J, Serpell M. Complex regional pain syndrome. Contin Educ Anaesth Crit Care Pain. 2007 Apr;7(2):51\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eWesselmann U, Raja SN. REFLEX SYMPATHETIC DYSTROPHY AND CAUSALGIA. Anesthesiol Clin N Am. 1997 June;15(2):407\u0026ndash;27. \u003c/li\u003e\n\u003cli\u003eOtt S, Maih\u0026ouml;fner C. Signs and Symptoms in 1,043 Patients with Complex Regional Pain Syndrome. J Pain. 2018 June;19(6):599\u0026ndash;611. \u003c/li\u003e\n\u003cli\u003eMisidou C, Papagoras C. Complex Regional Pain Syndrome: An update. Mediterr J Rheumatol. 2019 Mar 1;30(1):16\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003eShim H, Rose J, Halle S, Shekane P. Complex regional pain syndrome: a narrative review for the practising clinician. Br J Anaesth. 2019 Aug;123(2):e424\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003eHarnik MA, Kesselring P, Ott A, Urman RD, Luedi MM. Complex Regional Pain Syndrome (CRPS) and the Value of Early Detection. Curr Pain Headache Rep. 2023 Sept;27(9):417\u0026ndash;27. \u003c/li\u003e\n\u003cli\u003eHarden RN, McCabe CS, Goebel A, Massey M, Suvar T, Grieve S, et al. Complex Regional Pain Syndrome: Practical Diagnostic and Treatment Guidelines, 5th Edition. Pain Med. 2022 June 10;23(Supplement_1):S1\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eJesudason EP, Fullilove S, Henderson J, Gwyn R, Solari F. Twenty questions on complex regional pain syndrome. Orthop Trauma. 2023 Apr;37(2):84\u0026ndash;91. \u003c/li\u003e\n\u003cli\u003eP\u0026eacute;rez-Concha T, Tijero B, Acera M, Fern\u0026aacute;ndez T, Gabilondo I, G\u0026oacute;mez-Esteban JC. Usefulness of thermography in the diagnosis and classification of complex regional pain syndrome. Neurolog\u0026iacute;a. 2023 June;38(5):342\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eMackey S, Feinberg S. Pharmacologic therapies for complex regional pain syndrome. Curr Pain Headache Rep. 2007 Mar;11(1):38\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eVarenna M, Zucchi F, Ghiringhelli D, Binelli L, Bevilacqua M, Bettica P, et al. Intravenous clodronate in the treatment of reflex sympathetic dystrophy syndrome. A randomized, double blind, placebo controlled study. J Rheumatol. 2000 June;27(6):1477\u0026ndash;83. \u003c/li\u003e\n\u003cli\u003eAdami S, Fossaluzza V, Gatti D, Fracassi E, Braga V. Bisphosphonate therapy of reflex sympathetic dystrophy syndrome. Ann Rheum Dis. 1997 Mar;56(3):201\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eSudoh Y, Cahoon EE, Gerner P, Wang GK. Tricyclic antidepressants as long-acting local anesthetics. Pain. 2003 May;103(1\u0026ndash;2):49\u0026ndash;55. \u003c/li\u003e\n\u003cli\u003eFink K, Dooley DJ, Meder WP, Suman-Chauhan N, Duffy S, Clusmann H, et al. Inhibition of neuronal Ca(2+) influx by gabapentin and pregabalin in the human neocortex. Neuropharmacology. 2002 Feb;42(2):229\u0026ndash;36. \u003c/li\u003e\n\u003cli\u003evan de Vusse AC, Stomp-van den Berg SGM, Kessels AHF, Weber WEJ. Randomised controlled trial of gabapentin in Complex Regional Pain Syndrome type 1 [ISRCTN84121379]. BMC Neurol. 2004 Sept 29;4:13. \u003c/li\u003e\n\u003cli\u003eWatson CPN, Moulin D, Watt-Watson J, Gordon A, Eisenhoffer J. Controlled-release oxycodone relieves neuropathic pain: a randomized controlled trial in painful diabetic neuropathy. Pain. 2003 Sept;105(1\u0026ndash;2):71\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eZhao Z, Chen SR, Eisenach JC, Busija DW, Pan HL. Spinal cyclooxygenase-2 is involved in development of allodynia after nerve injury in rats. Neuroscience. 2000;97(4):743\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eTe AE. A modern rationale for the use of phenoxybenzamine in urinary tract disorders and other conditions. Clin Ther. 2002 June;24(6):851\u0026ndash;61; discussion 837. \u003c/li\u003e\n\u003cli\u003eGaler BS, Miller KV, Rowbotham MC. Response to intravenous lidocaine infusion differs based on clinical diagnosis and site of nervous system injury. Neurology. 1993 June;43(6):1233\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eCorrell GE, Maleki J, Gracely EJ, Muir JJ, Harbut RE. Subanesthetic ketamine infusion therapy: a retrospective analysis of a novel therapeutic approach to complex regional pain syndrome. Pain Med Malden Mass. 2004 Sept;5(3):263\u0026ndash;75. \u003c/li\u003e\n\u003cli\u003eYucel I, Demiraran Y, Ozturan K, Degirmenci E. Complex regional pain syndrome type I: efficacy of stellate ganglion blockade. J Orthop Traumatol. 2009 Dec;10(4):179\u0026ndash;83. \u003c/li\u003e\n\u003cli\u003eCepeda MS, Lau J, Carr DB. Defining the Therapeutic Role of Local Anesthetic Sympathetic Blockade in Complex Regional Pain Syndrome: A Narrative and Systematic Review: Clin J Pain. 2002 July;18(4):216\u0026ndash;33. \u003c/li\u003e\n\u003cli\u003ePrice DD, Long S, Wilsey B, Rafii A. Analysis of Peak Magnitude and Duration of Analgesia Produced by Local Anesthetics Injected into Sympathetic Ganglia of Complex Regional Pain Syndrome Patients: Clin J Pain. 1998 Sept;14(3):216\u0026ndash;26. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Carpal tunnel syndrome, Complex regional pain syndrome, CRPS type I, Diabetes mellitus, Neuropathic pain, Trigger finger","lastPublishedDoi":"10.21203/rs.3.rs-8123027/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8123027/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Complex Regional Pain Syndrome (CRPS) is a challenging neuropathic pain disorder often following trauma or surgery, with disproportionate pain and autonomic changes. Early identification is essential, particularly in elderly diabetic patients, where overlapping neuropathies can obscure diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation\u003c/strong\u003e: We report a case of a 74-year-old woman from rural Nepal presenting with chronic left-hand pain initially diagnosed as trigger finger and early carpal tunnel syndrome, which evolved into CRPS Type I. Despite conservative therapy, her symptoms progressed to severe allodynia, swelling, and trophic changes. Diagnosis was confirmed by clinical findings, nerve conduction study, and infrared thermography.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThis case highlights the importance of early recognition and multimodal management of CRPS in elderly diabetic patients, particularly in low-resource settings where delayed diagnosis can lead to irreversible disability.\u003c/p\u003e","manuscriptTitle":"Post-Traumatic Complex Regional Pain Syndrome Type I in an Elderly Diabetic Female Following Early Carpal Tunnel Syndrome and Trigger Finger: A Case Report from Rural Nepal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-19 16:30:41","doi":"10.21203/rs.3.rs-8123027/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf51a2a0-87fa-41b6-8794-17f7c93cc14c","owner":[],"postedDate":"March 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-16T04:24:20+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-19 16:30:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8123027","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8123027","identity":"rs-8123027","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}