Erroneoneousness, Amputation, and the Hole In My Arm

It's my usual promise of creativity in the pipeline, Dear Readers.  And in the excitement of the mean time, I bring you fresh research to consider about my main demon, CRPS / RSD.  That's what most of you come here for, if search terms are any indication of intent.  The rest of you?  You fall into the wonderful realm of the Unknown, and we loves the Unknown, we does.

I will share a bit of my excitement with you while I remain able to move my arms.

Having deduced, inferred, and otherwise concluded that certain chores will never be done unless I do them myself, grumblegrumblegrumble, no matter how freaking difficult that may be from an effing wheelchair while in a world of twitchin' pain and with one non-functional shoulder.  Oh, yeah, and while essentially blind! {peeking::through::my::fingertips::to::see::if::you::are::still::there}

Right.  Whatever.  Meh.

Having figured that tough one out, I spent five hours delousing the Private Palatial Porch -- the only luxe-level miniature submarine port in our hemisphere -- scrubbing it, hosing it down, and just generally pulling it back from the brink of bacterial disaster.  No offense to the Upper Crust with whom Fred and I share this emblem of Hoit-and-Toity, but maintenance, regular maintenance, is the magic word.  I wore out three brooms but rediscovered a still viable sense of generosity, squelched the embers of considerable resentment, and have a quiet, beautiful spot for tomorrow morning's coffee.

I was almost too tired to clean up after myself but the Marlinspike Hall Domestic Staff (genetically indentured and engineered for generations of livelihood!) recently published several lists of grievances in full page four-color ads in the Business Section of the Tête de Hergé Tribune --  and I am pretty sure those are lists I'd like to stay off of.  So I tidied up, put dirty rags in the washer, cleaned the cleaning tools, and headed off to the showers.

Damn, my shoulder hurts, I said to myself for the millionty-umpteenth time, as I pulled off the protective layers of sweatshirts and tees.  

For about two weeks I've been watching a small red spot on the underside of my upper left arm.  It kinda resembled a bruise but wasn't a bruise.  There was a bit of a lump in the tissue beneath it but nothing too odd or alarming.  It never changed colors, never changed at all, just sat there, all red, until the last few days when some of the skin began to peel off.  Also in a minor, shy, inconsequential kind of way.

So I was surprised to see a neat, perfect hole in the middle of the red mark, and drainage on my favorite (and only) Patagonia organic cotton orange tee shirt.  [Patagonia stuff drives me nuts.  I wants it.  I wants it bad.  But the prices?  An insult!]

Anyway, yeah -- a tunnel, a sinus, a fistula, an everlovin' hole in my arm!  Are you thinking what I am thinking?  Well, are you?  Okay, if this is the first (last?) post you've ever read here, maybe not.  But if you are a veteran of the Shoulder Wars, if you support your local orthopedic surgeon with unbridled fervor, as I do, then yes, you are probably thinking:  Culture that Mother Fucker!  That has gotta connect with the infection in the bone, don'tcha know!  This could be the answer to the whole mystery -- this could be the annoying pathogen that refuses to grow in the labs or to die from the antibiotics!

So my fingers are fairly on fire with the urge to call a doctor and share that I've produced a draining hole in my arm, in the same arm from which we are preparing to yank the shoulder prosthesis because of unrelenting infection... but, of course, I don't scratch that itch.  

I slapped a band aid on the tiny hole and its tunnel, and will patiently await the arrival of Monday morning office hours, when I will politely telephone my MDVIP Go-To-Guy so as to get a culture of that Mother Fucker!

I knew you'd want to share in my excitement.

Ahem.  

Here are the two articles of CRPS interest that landed in my mailbox today:

J Bone Joint Surg Am. 2011 Oct 5;93(19):1799-805.

Therapy-resistant complex regional pain syndrome type I: to amputate or not?

Bodde MI, Dijkstra PU, den Dunnen WF, Geertzen JH.

Source

Center for Rehabilitation, Department of Rehabilitation Medicine (M.I.B., P.U.D., and J.H.B.G.), and Department of Pathology and Medical Biology (W.F.A.d.D, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands. E-mail address for M.I. Bodde: m.i.bodde@rev.umcg.nl. E-mail address for P.U. Dijkstra: p.u.dijkstra@rev.umcg.nl. E-mail address for W.F.A. den Dunnen: w.f.a.den.dunnen@path.umcg.nl. E-mail address for J.H.B. Geertzen: j.h.b.geertzen@rev.umcg.nl.

Abstract

BACKGROUND:

Amputation for the treatment of long-standing, therapy-resistant complex regional pain syndrome type I (CRPS-I) is controversial. An evidence-based decision regarding whether or not to amputate is not possible on the basis of current guidelines. The aim of the current study was to systematically review the literature and summarize the beneficial and adverse effects of an amputation for the treatment of long-standing, therapy-resistant CRPS-I.

METHODS:

A literature search, using MeSH terms and free text words, was performed with use of PubMed and EMBASE. Original studies published prior to January 2010 describing CRPS-I as a reason for amputation were included. The reference lists of the identified studies were also searched for additional relevant studies. Studies were assessed with regard to the criteria used to diagnose CRPS-I, level of amputation, amputation technique, rationale for the level of amputation, reason for amputation, recurrence of CRPS-I after the amputation, phantom pain, prosthesis fitting and use, and patient functional ability, satisfaction, and quality of life.

RESULTS:

One hundred and sixty articles were identified, and twenty-six studies with Level-IV evidence (involving 111 amputations in 107 patients) were included. Four studies applied CRPS-I diagnostic criteria proposed by the International Association for the Study of Pain, Bruehl et al., or Veldman et al. Thirteen studies described symptoms without noting whether the patient met diagnostic criteria for CRPS-I, and nine studies stated the diagnosis only. The primary reasons cited for amputation were pain (80%) and a dysfunctional limb (72%). Recurrence of CRPS-I in the stump occurred in thirty-one of sixty-five patients, and phantom pain occurred in fifteen patients. Thirty-six of forty-nine patients were fitted with a prosthesis, and fourteen of these patients used the prosthesis. Thirteen of forty-three patients had paid employment after the amputation. Patient satisfaction was reported in eight studies, but the nature of the satisfaction was often not clearly indicated. Changes in patient quality of life were reported in three studies (fifteen patients); quality of life improved in five patients and the joy of life improved in another six patients.

CONCLUSIONS:

The previously published studies regarding CRPS-I as a reason for amputation all represent Level-IV evidence, and they do not clearly delineate the beneficial and adverse affects of an amputation performed for this diagnosis. Whether to amputate or not in order to treat long-standing, therapy-resistant CRPS-I remains an unanswered question.

LEVEL OF EVIDENCE:

Therapeutic Level IV. See instructions to Authors for a complete description of levels of evidence.

A pertinent read might be this Wikipedia entry on Evidence-Based Medicine.

infer what you like from
 my haphazard choice
of illustration... hmm, a stethoscope and money,
 medical research and money, hmm,
orphaned diseases and money,
invested ignorance, hmm...

The second item is an article of my least favorite type: the overview (and this one with a big freaking error in the first sentence of its abstract, too!).  Don't shoot the messenger and don't believe everything you read in Rheumatology.  Unfortunately, it's also been published through Medscape, so a lot of medicos will be influenced by its erroneoneousness.

That's right.  I said it.  I dared.  Erroneoneousness.

From Rheumatology

Complex Regional Pain Syndrome in Adults

Andreas Goebel

Authors and Disclosures

Posted: 10/20/2011; Rheumatology. 2011;50(10):1739-1750. © 2011 Oxford University Press

Abstract and Introduction

Abstract

Complex regional pain syndrome (CRPS) is a highly painful, limb-confined condition, which arises usually after trauma. It is associated with a particularly poor quality of life, and large health-care and societal costs. The causes of CRPS remain unknown. The condition's distinct combination of abnormalities includes limb-confined inflammation and tissue hypoxia, sympathetic dysregulation, small fibre damage, serum autoantibodies, central sensitization and cortical reorganization. These features place CRPS at a crossroads of interests of several disciplines including rheumatology, pain medicine and neurology. Significant scientific and clinical advances over the past 10 years hold promise both for an improved understanding of the causes of CRPS, and for more effective treatments. This review summarizes current concepts of our understanding of CRPS in adults. Based on the results from systematic reviews, treatment approaches are discussed within the context of these concepts. The treatment of CRPS is multidisciplinary and aims to educate about the condition, sustain or restore limb function, reduce pain and provide psychological intervention. Results from recent randomized controlled trials suggest that it is possible that some patients whose condition was considered refractory in the past can now be effectively treated, but confirmatory trials are required. The review concludes with a discussion of the need for additional research.

Read the entire article in all of its shameless erroneoneousness  HERE.  


And I think I have shown remarkable restraint not to completely deep six this purportedly science-based piece of work for including references to, and citations of, that unmitigated turd, Jose Ochoa.  


Hmm?  What?  Oh, puh-leeze. The truth shall set me free and all that jazz.