Mannitol as Salvage Treatment for CRPS? Not so much...

By definition, salvage treatment/therapy is

1. A final treatment for people who are nonresponsive to or cannot tolerate other available therapies for a particular condition and whose prognosis is often poor....
Salvage therapy is given in the hope of a cure or at least of some more quality time or a better quality existence.

The Wikipedia entry notes that "it is used both to mean a second attempt and a final attempt."

"Salvage treatment/therapy" is not a new concept to me, but it's also not one that I spend an inordinate amount of time investigating. I think that when I first started reading reports and studies, the SCS was considered out there, a regular Hail Mary of a treatment, plus oddities like Hyperbaric Oxygen Therapy... Now, I suppose the ketamine coma falls under the rubrique, as well as intrathecal catheters and intraspinal administration of narcotics, and drugs such as baclofen.

[Most articles note that the term is usually used in reference to the treatment of HIV/AIDS and certain cancers, diseases in which "final attempts" are certainly of a more dire nature.]

The advocation of mannitol as a treatment drug in CRPS is certainly not widespread --indeed, one of its most steadfast promoters is the infamous Dr. Hooshmand, who proposes its use to deter "toxic metabolic water retention in the nerve cells" and "neuro-inflammation."


INJURY: International Journal of the Care of the Injured
Volume 41, Issue 7, Pages 773-777 (July 2010)
Edward C.T.H. Tan, Marijn C.T. Tacken, Johannes M.M. Groenewoud, Harry van Goor, Jan Paul M. Frölke

Department of Surgery, Radboud University Nijmegen Medical Centre, The Netherlands

Department of Medical Technology Assessment, Radboud University Nijmegen Medical Centre, The Netherlands

Edward C.T.H. Tan is corresponding author, and may be reached at: Department of General Surgery - Traumatology, Radboud University Nijmegen Medical Centre, 690 Internal Postal Code, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. Tel.: +31 24 361 38 71; fax: +31 24 354 05 01.

ABSTRACT : Mannitol as salvage treatment for Complex Regional Pain Syndrome Type I

Introduction
Complex Regional Pain Syndrome Type I (CRPS I) is a continuation of symptoms and signs due to a pathological exaggerated reaction in an extremity of the human body after an injury or operation. Although the clinical picture of CRPS I in the majority of patients is well known, the underlying pathophysiology remains unclear. In the Netherlands, intravenous mannitol administration used as hydroxyl radical scavenger for patients who do not respond to conservative treatment of CRPS I is advocated but little evidence supports this salvage strategy. In this study the effect of mannitol as salvage medication was evaluated in a well-defined multimodal step-up treatment protocol.

Patients and methods
A consecutive group of 68 adult patients with persistent CRPS I was analysed, who underwent a total of 100 mannitol infusions. The effect of treatment was considered per sign and per symptom according to the Veldman et al. criteria for CRPS I.

Results
Overall improvement of CRPS I after mannitol treatment was successful in 24% after 1 week, and in 30% after 1 month. Mannitol treatment had some effect in patients with initially warm CRPS I in contrast to patients with cold CRPS I (OR=6.30 with CI [2.37–16.75]). Also patients with CRPS I at the upper extremity had more benefit than patients with CRPS I at the lower extremity (OR=3.26 with CI [1.34–7.93]). Poor results of mannitol treatment were associated with cold CRPS I (p<0.001), p="0.04)" p="0.04)."

Conclusion
Mannitol did not significantly contribute to the overall success of treatment in patients with CRPS I. Patients, presenting with acute, warm CRPS I in the upper extremity may have some benefit.