Concomitant Glomus Tumor with CRPS in the Hand
A 41-year-old male patient received conservative treatment on his left wrist and hand for 3 months due to pain developed by a motor vehicular accident 6 months prior to his visit. Since he did not see any improvement from the conservative treatment, he had a wrist arthroscopy performed at a private clinic. The pain persisted even after surgery, so alternative wrist arthroscopy was performed at the orthopedics department of Severance Hospital. Afterwards, he was referred to a pain clinic with a possible diagnosis of CRPS.\nAt the time of admission to the hospital, the patient had spontaneous pain in his left hand, wrist and forearm with a numerical rating scale (NRS) of 9 and also paroxysmal pain, intermittent heat sensation, sweating and shiny skin with a numerical rating scale of 10. From the clinical assessment, the skin color change (redness) on the left hand, edema, allodynia, hyperalgesia, and hyperhidrosis were observed. Additionally, motion was limited in the left wrist and there was muscle atrophy in the left hand and forearm. There was no particularly abnormal finding from the blood test and digital infrared thermal imaging. However, the dynamic blood flow images and blood pool images in the 3-phase bone scan found an increase in radio-uptake in the left upper extremity. There was an increase in bone uptake in the left wrist and hand joint on the delayed phase images ().\nPatient's symptoms and signs were matched to CRPS diagnostic criteria (Budapest diagnostic criteria) [], and treatment was initiated for CRPS. After stellate ganglion block (SGB) with 10 ml of 1% lidocaine, the pain was reduced temporarily from a NRS of 9 to 5 and after intravenous regional sympathetic block (IVRSB) with 10 µg of alprostadil and 30 ml of 0.2% lidocaine, the NRS was reduced from 9 to 7 for a couple of days. On top of the SGB and IVRSB, 75 mg of pregabalin and 1 combination tablet of tramadol/acetaminophen (ultracet®) was administered twice a day. After treatment for 3 months, the spontaneous pain in the left forearm and wrist was reduced from a NRS of 9 to a NRS of 5, but there was no improvement in the paroxysmal pain with a NRS of 10 in the little finger region. Severe tenderness of the left 5th fingernail was observed on the physical examination, and a positive result was reported for a cold sensitivity test. Magnetic resonance imaging (MRI) was conducted with the possibility of a glomus tumor and a 3 mm sized enhanced ovoid shaped mass was observed at the radial side of the subungual region in his left 5th finger ().\nSurgical excision was carried out and glomus tumor was confirmed through the pathology result. Twenty µg/ml of fentanyl was administered intravenously at a rate of 2 ml/hour for 2 days after the surgery, while Ultracet® and immediate release oxycodone were administered until patient discharge after the surgery. In addition, daily SGB was conducted on the day before the surgery until the discharge date. The paroxysmal excruciating pain with a NRS of 10 in the left 5th finger disappeared after surgery. However, throbbing pain with a NRS of 5 on the left 4th and 5th finger continued even after the surgery and CRPS symptoms such as the left wrist, forearm, elbow, shoulder pain (NRS of 5-6) and skin color change are still present.