So, I'm going to talk about doing these decompressions in people with complex regional pain syndrome. And so, I think maybe others have heard this when they were training, that if you operate on pain, you get pain and you should probably run for the hills and not do it. And I'd like to put out there that maybe when you operate on pain, you actually get happiness. And that surgery actually is sometimes a really important part of the treatment for complex regional pain syndrome. Sometimes it's sort of different than what we were taught when we were in training. Because sometimes, and I think probably all of the times, but maybe sometimes we can't figure it out, but a nerve injury is the cause, it is the reason, it is why these people continue to have pain. And if you can fix that, you can help them. So, when that patient runs into your house, or comes to your clinic, and they have that hand that is big and swollen, and they're standing like this, do not be afraid. You might be able to help them, so take a moment. So we've talked a lot about the diagnosis, Dr. Haggart showed you the physical exam. You can do nerve diagnostic studies. But a lot of times when that patient comes into your clinic and they won't let you even touch their hand, you know, really the exam is somewhat limited. So additional things that you could potentially do for that complex regional pain syndrome is you can do diagnostic blocks. I find these so, so helpful. If you have someone who has an ultrasound machine and can put some numbing on that nerve and they say, my goodness, you know, I had a 70% relief of pain for that hour or two, that gives you a clue. Okay, that's the nerve. Maybe if we can help fix that nerve and make it less unhappy, we can do something. The other thing is you can do MRIs. A lot of these patients will tolerate it. And you know, if you look at this MR neurogram here, you can see the fascicles actually of the ulnar nerve. And so occasionally, MR neurogram can be helpful, especially for some more of the proximal nerves. The nerve will be bright and you can see the fascicles and help you, guide you. But it's really diagnostic blocks that are going to help you. All right, so you've done a wonderful exam. You haven't been afraid. And you are actually going to operate on someone with complex regional pain syndrome. And so I've operated on a whole bunch of these people. And so this is sort of what I've come up with and it seems to work pretty well. There's good data that if you give gabapentin two hours prior to incision, that actually helps with postoperative pain. You have to give at least 900 when they've done the dose responses. At 600, it's not as effective. So 900 or 1200 is what you want to do. You want to have the arm numb prior to doing your intervention. So a preoperative block. Given that these people are so painful, I actually try to always use also a pain catheter to get them for that first few days after the surgery and there's just the manipulation of the tissue. There's also pretty good data that if ketamine effusion while you're doing your operation will help with the pain postoperatively. So this is, you just have to whisper in your anesthesiologist's ear and say very nicely because they don't like it when you boss them around, and you say, you know, maybe would you consider giving this person some ketamine since they're a chronic pain patient? And in general, the anesthesiologist, unless there's some other contraindication, may do that for you and it will help. And you're already thinking about what you're going to do afterwards as far as a multimodal postoperative pain, and you're not going to immobilize them. You're not going to put in a splint because there's really good information that splinting is bad. So now you're going to do the surgical treatment, and there's many different ways that you might want to attack the nerve injury that's causing the complex regional pain. Truthfully, I've not had good results with scar revision, though it's out there. And what you're going to do is release the nerve, just like we've been seeing here. You're going to do a neuralysis of the nerve that is entrapped that is continuing to cause the pain. But the trick is you want to make sure that you're releasing it from all of the areas of entrapment. And so you want to do a nice exam, but keep in mind that there may be two. Their arms are so swollen, they may have both a pronator and a cubital tunnel, or they may have, you know, the lacertus and the carpal tunnel. So you want to do all the releases of the nerves that are entrapped that you think are causing the trouble. You are not going to put a cast on them. I think I said that before, but there really is some good evidence to suggest that something about immobilization sort of upregulates the pathways that are associated with complex regional pain. So for these patients, I put a soft dressing on upper limb, lower limb, and I have them actually moving their hands in just a few days. So afterwards, you're going to give them a multimodal pain approach. And this is what I use. Each of these medicines actually work in a slightly different way. So NSAID or ibuprofen around the clock for the first two weeks, acetaminophen around the clock for two weeks, vitamin C, gabapentin, Lyrica, whatever their antineuropathic that they're on. And then they just take the narcotic as needed. And it's pretty interesting with the block and some of these, actually sometimes they don't even need the narcotics. At two weeks, you're going to start them on some therapy to start with edema control, gentle joint immobilization, and some desensitization. This is where you can actually get in trouble. You want to have a therapist who you have a good relationship with and who's not going to be like, whoa, we need to get your strength back, and we need to get your finger and arm moving, and they start cranking on them. The theme is really early and very gentle to start bringing these people through. So this is just sort of what might run into your office. I had a guy, he was CRPS after a cabbage and sort of felt like a cubital tunnel. He was seen by several surgeons. They all ran away. He was given a bunch of like methadone. He had sort of diffuse pain. You know, it hurts everywhere. But when you sort of kind of drilled down, you were feeling cubital tunnel. We did an MR neurogram, which really showed a bright ulnar nerve at the cubital tunnel. And we did our protocol, we did the cubital tunnel release, and he was fixed. And I don't have great pictures. I do a lot of lower limb. I think hand surgeons are actually the best ones to do nerves, and so, you know, perineal nerves and things like that. But what can happen, which is sort of extraordinary, so this is just a lower limb. So this is a lady who couldn't walk. And you can see her hobbit fat foot that she has beforehand, before the surgery. We did a perineal release at the superficial perineal, and then at the common perineal. And she, not only was her pain better, but her swelling in her foot also went away. So you know, I've done, I don't know, a whole bunch of these pain patients, and I've only made one person worse. I mean, probably 200. I don't make everybody better, but I probably 60% of people I get better. Not perfect. And 20% of people, it's really miraculous. So do not be afraid. Okay. Can I have the rest of the panelists come on up? Thank you.

surgery

complex regional pain syndrome

nerve injury

diagnostic blocks

multimodal pain approach