Working Diagnosis:
Complex Regional Pain Syndrome

Treatment:
Rest and oral medications provided no relief. Multiple spinal sympathetic blocks provided patient with minimal relief. Finally, 5 perineural prolotherapy injections were performed every 2 months over a span of 10 months. Each time 0.5cc of a solution of 8.5mL D5W, 0.5mL 8.4% sodium bicarb, and 1mL 1% lidocaine was injected subcutaneously approximately every centimeter along the distribution of pain over the foot. Case Photo #2

Outcome:
Patient reported 50% relief of pain at 4 week follow-up with 75% improvement after 4 months. With each set of injections the area and intensity of pain/sensitivity decreased. After the final set she reported about 95% improvement overall. The patient is currently ambulating and running as previous to the injury without any difficulty and has returned to full military duties.

Author's Comments:
The underlying factor in this case is initial trauma to the left foot then causing allodynia over entire dorsum of the foot. Limited evidence suggests perineural dextrose prolotherapy may stimulate the body to repair injured or painful area of the body. This technique was introduced by John Lyftogt, M.D. and is often referred to as Lyftogt technique. There have been reports of perineural prolotherapy being effective for CRPS. Further clinical trials are needed to demonstrate the efficacy of perineural dextrose prolotherapy in conditions like CRPS.

Editor's Comments:
CRPS or chronic regional pain syndrome affects the extremities after a trauma or nerve injury. The diagnosis can be difficult, as there is no one definitive diagnostic test. The associated pain can lead to additional psychologic co-morbidities.

Below I also listed papers currently in pubmed that Dr Lyftogt has participated in if you would like more information regarding prolotherapy. It appears that the prolotherapy agents differ depending on the study.

References:
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-e433. doi: 10.1016/j.bja.2019.03.030. Epub 2019 May 2. PMID: 31056241; PMCID: PMC6676230.

1. Maniquis-Smigel L, Reeves KD, Rosen HJ, Lyftogt J, Graham-Coleman C, Cheng AL, Rabago D. Analgesic Effect and Potential Cumulative Benefit from Caudal Epidural D5W in Consecutive Participants with Chronic Low-Back and Buttock/Leg Pain. J Altern Complement Med. 2018 Dec;24(12):1189-1196. doi: 10.1089/acm.2018.0085. Epub 2018 Jun 8. PMID: 29883193; PMCID: PMC6308281.
2. Maniquis-Smigel L, Dean Reeves K, Jeffrey Rosen H, Lyftogt J, Graham-Coleman C, Cheng AL, Rabago D. Short Term Analgesic Effects of 5% Dextrose Epidural Injections for Chronic Low Back Pain: A Randomized Controlled Trial. Anesth Pain Med. 2016 Dec 6;7(1):e42550. doi: 10.5812/aapm.42550. PMID: 28920043; PMCID: PMC5554430.
3. Yelland MJ, Sweeting KR, Lyftogt JA, Ng SK, Scuffham PA, Evans KA. Prolotherapy injections and eccentric loading exercises for painful Achilles tendinosis: a randomised trial. Br J Sports Med. 2011 Apr;45(5):421-8. doi: 10.1136/bjsm.2009.057968. Epub 2009 Jun 22. PMID: 19549615.

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