区域麻酔と理学療法の併用が奏効した難治性複合性局所疼痛症候群の1例

A Case of Intractable Complex Regional Pain Syndrome Successfully Treated with a Combination of Regional Anesthesia and Physical Therapy

はじめに

　複合性局所疼痛症候群（complex regional pain syndrome：CRPS）とは組織損傷後に創傷が治癒した後にも痛みが遷延する病態である．症状は痛覚過敏，発汗異常，浮腫，関節可動域制限，骨萎縮，筋萎縮など多彩であり，発症要因として受傷様式，創傷の状態，心理的状態など複数の因子の関与が指摘されているが，CRPSの原因，発生機序，病態は明らかになっていない^{1, 2)}．本邦ではCRPSの疾患概念の確立と治療方針の共通化を目的に，厚生労働省研究班によるCRPSの判定指標が2008年に報告されている^{1, 3)}．CRPS治療が成功するには理学療法，薬物療法，神経ブロック法，硬膜外脊髄電気刺激療法などさまざまな治療を含めた学際的アプローチが必要であると報告されており⁴⁾，それぞれの病態を推測して治療法を決定することが望ましい²⁾．今回われわれはCRPSに対して区域麻酔と理学療法を併用し，疼痛が改善した症例を経験したので報告する．なお，論文掲載に関して本人より書面にて同意を得ている．

Abstract　We report a case of intractable complex regional pain syndrome (CRPS). The pain improved with regional anesthesia and physical therapy.

A 24-year-old man with hemophilia A, developed throbbing pain from his left foot to the ankle, with no identifiable cause. No organic abnormalities were observed. He diagnosed with CRPS at the pain clinic and admitted to the hospital 10 months after symptom onset for physical therapy with regional anesthesia under clotting factor replacement therapy. Spinal anesthesia was administered on the first and second day of hospitalization, and plantar load stimulation and ankle stretching were performed in the operating room. Subsequently, sciatic nerve blocks and continuous epidural blocks were given, and plantar contact training, ankle joint ROM training, and parallel bar walking training were conducted with cognitive behavioral therapy. Sciatic nerve blocks were continued after discharge. Ninety-five days after onset, the patient was re-admitted for physical therapy, and ROM exercises, partial weight bearing, and gait training together with sciatic nerve blocks and cognitive-behavioral therapy. On discharge following re-admission, the pain improved. The patient walked using one crutch. One year later, the pain further improved, and the patient walked independently.

The combination of regional anesthesia, physical therapy, and cognitive behavioral therapy created a virtuous cycle of pain relief, improved physical functions, and prevented withdrawal from catastrophizing, ultimately leading to overall improvement.