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Año 2022 / Volumen 29 / Número 1

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Revisión

Actualizaciones en el abordaje terapéutico en el síndrome de dolor regional complejo
Complex regional pain syndrome, rehabilitation, pharmacotherapy, psychology.

Rev. Soc. Esp. Dolor. 2022; 29(1): 34-50 / DOI: 10.20986/resed.2022.3978/2022

María Teresa Bovaira, Carles García, Ana Amparo Calvo, Javier Desé, Guillem Tortosa, Victor Bayarri, Olga Alcaina, Alejandro Ortega, David Abejón

RESUMEN

Introducción: El síndrome de dolor regional complejo abarca una sintomatología que puede ser autolimitada o terriblemente limitante. Pese al enorme interés que despierta en la comunidad científica, no tenemos claro qué determina su evolución. Actualmente, parece claro que hay que ajustar el tratamiento en base a los mecanismos fisiopatológicos predominantes en cada paciente en función de su estadio evolutivo.
Fisiopatología: Se produce a causa de una compleja combinación de diferentes factores que se inician en el momento del traumatismo y que consisten en sensibilización del sistema nervioso, disfunción del sistema autónomo y cambios inflamatorios. Hay, además, un indudable componente inmunológico, con presencia de autoinmunización, una implicación genética y la constatación de que determinados estados psicológicos parecen influir en la progresión de la enfermedad.
Prevención: Se recomienda la administración de la vitamina C tras traumatismos o cirugías sobre miembros, sobre todo cuando existen factores de riesgo (fracturas distales de radio). Asimismo, hay que incentivar la movilización precoz y tratar los altos niveles de ansiedad para prevenir su desarrollo.
Tratamiento: El tratamiento debe ser precoz, multimodal y coordinado, con el objetivo fundamental no solo de aliviar el dolor, sino de recuperar funcionalmente el miembro afecto. La pieza angular del tratamiento es la rehabilitación. Se debe acompañar de farmacoterapia y autoinmunide tratamiento psicológico. Dentro de la farmacoterapia, tienen especial relevancia los corticoides (en las fases más agudas), los bifosfonatos y los “free-radical scavengers”. En fases avanzadas de la enfermedad, la ketamina intravenosa se plantea como una opción terapéutica. Los tratamientos intervencionistas deben considerarse cuando la evolución del síndrome no es óptima, sobre todo los bloqueos simpáticos, en caso de predominio de disfunción simpática, o la neuromodulación, que es la modalidad de tratamiento que mayor evidencia científica presenta.
Conclusiones: En el abordaje de esta compleja patología en la que intervienen múltiples mecanismos que debemos tratar simultáneamente, es necesaria la coordinación entre servicios para su mayor rendimiento, fundamentalmente rehabilitación, unidad del dolor y psicología.

ABSTRACT

Introduction: Complex Regional Pain Syndrome encompasses a symptomatology that can be self-limiting or terribly limiting. Despite the enormous interest it arouses in the scientific community, it is not clear what determines its evolution. Currently, it seems clear that treatment must be adjusted based on the predominant pathophysiological mechanisms in each patient according to its evolutionary stage.
Physiopathology: It is caused by a complex combination of different factors that start at the time of the trauma and consist of sensitization of the nervous system, dysfunction of the autonomic system and inflammatory changes. There is also an undoubted immunological component, with the presence of autoimmunization, genetic involvement and the finding that certain psychological states seem to influence the progression of the disease.
Prevention: The administration of vitamin C is recommended after trauma or surgery on limbs, especially when there are risk factors (distal radius fractures). Also, early mobilization should be encouraged and high levels of anxiety should be treated to prevent its development.
Treatment: Treatment should be early, multimodal and coordinated, with the fundamental objective not only of relieving pain, but also of functionally recovering the affected limb. The cornerstone of treatment is rehabilitation. It should be accompanied by pharmacotherapy and psychological treatment. Within the pharmacotherapy, corticoids (in the most acute phases), bisphosphonates and free-radical scavengers are of special relevance. In advanced stages of the disease, intravenous ketamine is considered as a therapeutic option. Interventional treatments should be considered when the evolution of the syndrome is not optimal, especially sympathetic blocks, in case of predominant sympathetic dysfunction, or neuromodulation, which is the treatment modality with the most scientific evidence.
Conclusions: In the approach to this complex pathology in which multiple mechanisms are involved that we must treat simultaneously, coordination between services is necessary for its greater performance, fundamentally rehabilitation, pain unity and psychology.

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Bovaira M, García C, Calvo A, Desé J, Tortosa G, Bayarri V, et all. Actualizaciones en el abordaje terapéutico en el síndrome de dolor regional complejo. Rev Soc Esp Dolor 2022; 29(1): 34-50 / DOI: 1020986/resed20223978/2022

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Recibido: 04/03/2022

Aceptado: 28/05/2022

Prepublicado: 09/06/2022

Publicado: 05/08/2022

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