Rotator Cuffs and Intrathecal Baclofen

After posting such a spaz attack as today's earlier contribution, I thought I'd offer up something cut, dry, and relatively boring.  Er... a few infinitely fascinating new studies referencing CRPS/RSD.

The first involves rotator cuff tears and CRPS, and that just makes me chortle. Er... chuckle. Smile. A little.

After my left shoulder "collapsed" from AVN secondary to lupus in 2002, I had it replaced. That hospitalization -- giggle::giggle -- did not go well and the prosthesis never did quite meet my Stringent Standards for Shoulder Membership. Fast forward to 2008 and the Search for the Guilty Pathogen Infecting My Shoulder Hardware... Over the next two years, that left prosthesis was removed, a spacer put in. That spacer was removed... but there was still infection, so a second spacer was put in that had a specially made antibiotic-laced cement ball. All surgeries were followed by at least 6 weeks of intravenous antibiotic via PICC line. Unfortunately, the handcrafted spacer proved highly irritating to the joint, was removed, and I was gifted with a new prosthesis... because no one knew what else to do. I was to live with the pain until I couldn't, then we'd see what limited options remained. I reached that point last Fall, underwent my fifth unsuccessful aspiration under fluoroscopy, and then cried "uncle" in October and went in to see the orthopedic wizard. He snapped some x-rays. His verdict? My rotator cuff was gone!

Have you ever had a day like that? You lose your rotator cuff, can't remember where you last put it?

Anyway... the pain picture is complicated because those muscles and tendons got the hell out of Dodge. Dr. ShoulderMan has since opined that a reverse replacement will be my fate... but has asked me to resume living with it until I can't. It's crazy-making.

I have my suspicions, based on some recent sneaky behavior by the right prosthesis (that underwent more surgeries than it's lefterly brother, even), that the rotator cuff on that side has fled to Mexico.

Now, we do not EVER badmouth, or allow anyone else to badmouth, Dr. ShoulderMan, Wizard Surgeon and Kindly Person. Why? Well, complicate my shoulder picture, if you will, with the addition of CRPS/RSD. See? See?!? The fact that my arms are still usable and not completely at the mercy of this neurological disorder is a testament to his abilities.

The disease has spread from one arm to another, just as it has from leg to leg. As it spread, he was busy performing major shoulder operations on both sides approximately every 9 to 12 weeks. Can you imagine what terrible shape I would be in if I hadn't lucked out by finding the best ShoulderMan in all of Tête de Herge?

So I kinda shiver and laugh when I see this in today's MedWord offering:

Shoulder surface temperature and bone scintigraphy findings in patients with rotator cuff tears.Koike Y, Sano H, Kinjyo T, Imamura I, Masahiro O, Goto M, Ooyama M, Kita A, Itoi E.
Upsala Journal of Medical Sciences, 2011 Feb 16
Department of Orthopaedic Surgery, Japanese Red Cross Sendai Hospital, 2-43-3, Yagiyama Honcyo, Taihaku-Ku, Sendai, Miyagi, Japan, 982-8501.


ABSTRACT
Abstract Background. Complex regional pain syndrome (CRPS) is one of the serious complications after surgical treatment of a rotator cuff tear. Both a measurement of body surface temperature and bone scintigraphy have been used as diagnostic tools for the early phase of CRPS.Unfortunately, few studies have been carried out that applied these methods to the patients after rotator cuff repair.
Purposes. To clarify both shoulder surface temperature and bone scintigraphy findings in patients with rotator cuff tears. Subjects and methods. Subjects comprised patients with unilateral rotator cuff tears (five men and five women, mean age 61 years). For measurements of shoulder surface temperature, a Thermochron was attached to both shoulders. As for bone scintigraphy, intravenous injection of technetium-labelled hydroxymethylenebisphosphonic acid (99mTc-HMDP)was performed, and then images were taken with a gamma camera.
Results. During the measurements, the changes in body surface temperature for the affected and healthy shoulders remained within the standard deviation of the reference group. The intensity of radioisotope (RI) uptake for the affected shoulder joint was significantly increased compared to that for the healthy shoulder joint (P < 0.05).
Conclusion. RI uptake is increased in shoulders with rotator cuff tears, whereas shoulder surface temperature shows no differences on the affected and unaffected sides.

When you've sufficiently recovered from that bit of hilarity, check out the second item caught by my little CRPS bot, as published in the 18 February issue of Pain Medicine.  Watch out, though, because it's exciting.  You might be up all night.  I'm just sayin':

The Lack of Efficacy of Different Infusion Rates of Intrathecal Baclofen in Complex Regional Pain Syndrome: A Randomized, Double-Blind, Crossover Study

Anton Adriaan van der Plas MD,  Johan Marinus PhD,  Sam Eldabe MD,  Eric Buchser MD,  Jacobus Johannes van Hilten MD, PhD

ABSTRACT
Objective.  Intrathecal baclofen (ITB) is effective in the treatment of dystonia related to complex regional pain syndrome (CRPS). In a previous study, we noted that the responsiveness to ITB declined in 30% of patients once drug delivery was switched from an external to an implanted device associated with a reduction of the infusion rate (IR).


Design.  In a double-blind study, we investigated the effect of varying the IR at a fixed daily dose on the efficacy and safety of ITB in patients with CRPS-related dystonia. Patients were randomized to either slower infusion rate delivery (SIRD) or four-times faster infusion rate delivery (FIRD) for 2 weeks and were crossed over after a 1-week washout period.


Patients.  Patients were eligible if they experienced no beneficial response to ITB on dystonia despite a minimum dose of 600 µg/day, or because side effects limited dose escalation.


Outcome Measures.  Primary outcome measures were changes in global dystonia and pain severity.


Results.  There were no significant differences between the FIRD and the SIRD groups for the median change of numeric rating scale dystonia (–0.3 [interquartile range {IQR} −1.1–0.5]), pain (0.1 [IQR –0.8–1.3]), and secondary outcomes, except for the frequency of adverse events, which was significantly higher during FIRD (12 vs 2). FIRD was preferred only by patients who were included because side effects to ITB prevented dose escalation.


Conclusions.  Increasing the IR at a fixed daily dose is not associated with improvement of dystonia or pain but warrants further investigation in patients in whom side effects prevent further dose escalation.

  I tried to share the preceding fascination with Bianca and Fred, but I developed a terrible lisp talking about the FIRD and SIRD groups... 

Back when I was shooting for implantation of a SCS, I also had interest in pursuing intrathecal baclofen.  Some prognosticator mentioned something, blahblahblah, about the potential for infection, and ruled me ineligible for both.  And the band played on...

I'm outta here.