Central Nervous System Measures of Pain Responses Pre- and Post-Anesthetic Ketamine in a Patient with Complex Regional Pain Syndrome – Source: Pain Medicine, Feb 25, 2009

[Note: Complex regional pain syndrome is a rare disorder that involves intense pain in one limb, often followed by swelling, stiffness and muscle atrophy/contraction. It appears to be triggered by some illness, trauma, or injury that results in a disruption of central nervous system pain signalling relating to one part of the body.]

Background: Previous reports have indicated that ketamine anesthesia may produce significant improvement if not complete recovery of patients with complex regional pain syndrome (CRPS).

Aims: Here we report on a patient who had CRPS affecting mainly the right side of her body who underwent functional magnetic resonance imaging (fMRI) scans prior to and in the months following apparent successful treatment with anesthetic doses of ketamine.

Materials and Methods: The patient underwent two imaging sessions: one during her pain state (CRPS +) and 1 month after her ketamine treatment in her pain-free state (CRPS -).

Both spontaneous and evoked (brush, cold, and heat) pain scores decreased:
• From 7-9/10 on a visual analog scale prior to the treatment
• To 0-1 immediately following and for months after the treatment.

For each imaging session, the identical mechanical (brush) and thermal (cold and heat) stimuli were applied to the same location (the skin of the dorsum of the right hand).

Comparison of CRPS + vs CRPS – for the three stimuli showed significant changes:
• Throughout the cerebral cortex (frontal, parietal, temporal, cingulate, and hippocampus),
• In subcortical regions such as caudate nucleus,
• And in the cerebellum.

In addition:
• Resting state network analysis showed a reversal of brain network state,
• And the recovered state paralleled specific default networks in healthy volunteers.

Discussion: The observed changes in brain response to evoked stimuli provide a readout for the subjective response.

Conclusion: Future studies of brain function in these patients may provide novel insight into brain plasticity in response to this treatment for chronic pain.

Source: Pain Medicine, Feb 25, 2009. Becerra L, Schwartzman RJ, Kiefer RT, Rohr P, Moulton EA, Wallin D, Dendse G, Morris S, Borsook D. Pain/Analgesia Imaging Neuroscience (PAIN) Group, Brain Imaging Center, McLean Hospital, Harvard Medical School, Belmont, Massachusetts; Drexel University College of Medicine, Department of Neurology, Philadelphia, Pennsylvania, USA; Department of Anesthesiology and Intensive Care Medicine, Eberhard-Karls University, Tuebingen, Germany. [E-mail: David Borsook, MD, PhD, dborsook@partners.org]

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