CRPS Treatment in Chennai — Complex Regional Pain Syndrome Specialist Care

You probably already know more about CRPS than most of the doctors you have seen.

You know that the pain is out of proportion to the original injury — and that this is the defining characteristic of the condition, not evidence that you are exaggerating. You know that the skin changes, the temperature differences, the swelling, the hypersensitivity to touch — these are real, measurable, physiological phenomena. Not psychological. Not imagined.

And yet.

You may have been told that the injury has healed, so the pain should be gone. You may have been given medication after medication that provided partial relief at best. You may have had doctors who looked at your imaging, found nothing acutely wrong, and sent you home with a prescription and uncertainty.

This is one of the great failures of how CRPS is managed in India — and across the world.

CRPS is real. It is one of the most painful conditions documented in medical literature, ranking above amputation and childbirth on validated pain scales in severe cases. It has a known pathophysiology. It has established treatments. And crucially — the earlier it is treated with the right interventional approach, the better the outcomes.

At Dr. RRB Pain Care, we start from a position of belief. What you are experiencing is real. And there is a meaningful treatment pathway.

CRPS is a chronic pain condition that develops — usually after an injury, surgery, fracture, or nerve trauma — in which the nervous system generates pain that is dramatically disproportionate to the original injury and persists far beyond the expected healing time.

The pain is not coming from ongoing tissue damage at the injury site. It is coming from a malfunctioning nervous system — one that has locked into an abnormal, self-perpetuating pain cycle that it cannot exit on its own.

CRPS most commonly affects a single limb — an arm, hand, leg, or foot — though it can spread. The affected limb looks and feels different from the normal side: it may be swollen, discoloured, hypersensitive to the lightest touch, and different in temperature. These are not subjective impressions. They are objective, measurable signs of sympathetic nervous system dysregulation.

CRPS Type I — previously known as Reflex Sympathetic Dystrophy (RSD) — occurs after an injury or trauma without evidence of a specific nerve injury. The triggering event can be surprisingly minor: a wrist sprain, a Colles fracture, a seemingly routine surgery. The disproportionate pain response that follows is the hallmark of the condition.

The vast majority of CRPS cases are Type I.

CRPS Type II — previously called Causalgia — occurs following a documented injury to a specific peripheral nerve. The clinical presentation is similar to Type I but the pathophysiology includes direct nerve damage as the initiating event.

Understanding why CRPS happens is important — not only for the patient, but for validating why standard treatments fail and why targeted interventional approaches are necessary.

CRPS involves three overlapping pathophysiological mechanisms, all of which must be understood for effective treatment:

The sympathetic nervous system — the part of the autonomic nervous system that controls blood flow, sweat glands, and the body's acute stress response — becomes dysregulated in CRPS. Rather than returning to its resting state after the initial injury, it remains in a state of chronic overactivation in the affected limb.

This abnormal sympathetic activity drives many of the visible features of CRPS: the temperature differences between limbs, the skin colour changes, the abnormal sweating, and — critically — the sustained sensitisation of peripheral pain receptors that perpetuates the pain cycle.

This is why sympathetic nerve blocks are so central to CRPS treatment. By temporarily interrupting the overactive sympathetic pathway, the pain cycle can be broken — and the nervous system can begin to reset.

Following the initial injury, an abnormal inflammatory response occurs in the affected limb — one that does not self-resolve in the way normal post-injury inflammation does. Inflammatory mediators sensitise peripheral nerve endings, lowering the pain threshold dramatically and causing allodynia (pain from stimuli that should not be painful, such as gentle touch or a slight breeze) and hyperalgesia (dramatically amplified pain response to stimuli that would normally be mildly painful).

In established CRPS, the pain is no longer purely peripheral — it involves changes in the spinal cord and brain itself. The central pain-processing system becomes sensitised, amplifying incoming signals from the affected limb. The brain's representation of the affected limb can be distorted — contributing to the movement difficulties, neglect-like phenomena, and profound disability seen in advanced CRPS.

This is why early intervention is critical. Once central sensitisation is established, treatment becomes significantly more complex and outcomes are less predictable.

The three mechanisms of CRPS — sympathetic dysregulation, neuroinflammation, and central sensitisation — require a multi-modal treatment approach. No single drug or single procedure treats all three. This is why CRPS management must be specialist-led, coordinated, and systematically progressive.

CRPS has no single diagnostic test. No blood test. No scan. No imaging finding that confirms it. This is one reason it is so frequently missed or dismissed.

The internationally recognised standard for diagnosing CRPS is the Budapest Criteria — validated diagnostic criteria developed to ensure consistent, accurate diagnosis across clinical settings.

1. Continuing pain disproportionate to the inciting event

Sensory: Reports of hyperaesthesia (increased sensitivity) or allodynia (pain from non-painful stimuli)

Vasomotor: Reports of temperature asymmetry, skin colour changes or asymmetry

Sudomotor/Oedema: Reports of oedema (swelling), sweating changes or sweating asymmetry

Motor/Trophic: Reports of decreased range of motion, motor dysfunction, or trophic changes (skin, hair, nail changes)

3. At least one sign in two or more of the same categories at time of evaluation

4. No other diagnosis that better explains the signs and symptoms

At Dr. RRB Pain Care, the diagnosis of CRPS is approached systematically using the Budapest Criteria alongside clinical examination, thermographic assessment where indicated, and a thorough review of imaging and prior investigation history. Many patients arrive already diagnosed — and the consultation focuses on staging, treatment planning, and initiation of the interventional pathway.

The most treatable stage. Characterised by severe, burning pain, rapid onset of swelling, skin warmth and redness, and hypersensitivity. The affected limb is typically warm because blood flow is increased. Sympathetic nerve blocks at this stage can interrupt the cycle before central sensitisation has consolidated.

This is the window. The earlier a patient reaches a pain specialist in Stage 1, the better every outcome measure.

The limb begins to change. Swelling becomes more persistent. The skin may thin. Hair growth in the affected area may become abnormal. The limb shifts from warm to cooler — blood flow becomes reduced rather than increased. Pain is now more constant and less fluctuating. Central sensitisation is developing. Treatment is still highly effective but requires more intensive intervention.

Muscle wasting, significant joint contractures, irreversible skin and tissue changes. Pain can be severe and constant. Central sensitisation is established. This stage requires the most complex treatment approach — often including advanced neuromodulation alongside sympathetic procedures. Meaningful improvement is still achievable but requires greater effort and time.

CRPS does not always follow these stages in a linear sequence — and some patients improve spontaneously in Stage 1. However, the majority of patients who reach Dr. RRB Pain Care without prior specialist care have been in Stage 2 or Stage 3 for months or years. Earlier referral changes outcomes dramatically.

CRPS produces a cluster of symptoms across multiple systems — sensory, autonomic, motor, and trophic — that together create the distinctive and debilitating presentation of the condition.

Intense, constant burning or aching pain in the affected limb

Allodynia — pain triggered by stimuli that should not cause pain: the weight of a bedsheet, the movement of air, gentle touch

Hyperalgesia — dramatically amplified pain response to stimuli that would normally be mildly painful

Pain that extends beyond the original injury site — spreading proximally up the limb over time

Temperature asymmetry — the affected limb is measurably warmer or cooler than the contralateral limb

Skin colour changes — the limb may appear red and mottled in early stages, progressing to bluish or pale discolouration

Oedema (swelling) — especially in the hand or foot in upper and lower limb CRPS respectively

Abnormal sweating — either increased or decreased sweating in the affected area compared to the unaffected side

Reduced range of movement — stiffness and difficulty moving the affected limb

Tremor or involuntary movements

Weakness — difficulty lifting objects, gripping, or weight-bearing

Dystonia — abnormal posturing of the limb in advanced cases

Changes in skin texture — thinning, glossy appearance

Abnormal nail growth — brittle, ridged, or abnormally fast-growing nails

Changes in hair growth in the affected area

Bone thinning (osteoporosis) visible on X-ray

Appropriate pharmacological management forms the foundation of CRPS treatment — not as a standalone solution, but as the support layer that allows interventional procedures and rehabilitation to work:

Neuropathic agents: Pregabalin or gabapentin for the burning, electric quality of CRPS pain

SNRI antidepressants: Duloxetine for both neuropathic pain modulation and the mood impact of chronic pain

Low-dose naltrexone (LDN): Emerging evidence for neuroinflammation modulation in CRPS

Bisphosphonates: For inflammatory subtype CRPS — shown to reduce bone pain and inflammation

Topical agents: Lidocaine patches or ketamine cream for localised allodynia management

Vitamin C: Evidence supports prophylactic use post-fracture to reduce CRPS incidence — discussed where relevant

Sympathetic nerve blocks are the cornerstone of interventional CRPS management — particularly in Stages 1 and 2. By temporarily interrupting the overactive sympathetic nerve pathway driving the pain cycle, these blocks achieve three critical objectives simultaneously: pain relief, improved blood flow, and a therapeutic window during which physiotherapy can occur without pain exacerbation.

Stellate Ganglion Block — For Upper Limb CRPS

The stellate ganglion is a cluster of sympathetic nerve cells in the lower neck, at the C6-C7 level. It is the primary sympathetic relay for the upper limb, head, and neck.

In upper limb CRPS — affecting the arm, elbow, forearm, wrist, or hand — a Stellate Ganglion Block interrupts the abnormal sympathetic signals driving the pain and vascular changes in the affected arm.

The procedure is performed under real-time ultrasound guidance, with the patient lying on their back. Local anaesthetic is delivered precisely to the stellate ganglion — with the surrounding carotid artery, jugular vein, and trachea all clearly visualised throughout. A successful block is confirmed by Horner's syndrome (drooping eyelid, constricted pupil, anhidrosis on the treated side) — a temporary, expected, and harmless phenomenon that confirms the sympathetic pathway has been interrupted.

Warmth spreading into the affected arm within minutes of the block

Reduction in burning pain during the block period — hours to days

Improved colour and temperature of the affected limb

Ability to participate in physiotherapy that was previously impossible due to pain

A series of blocks — typically 3 to 6 — is more effective than a single block, as each session builds on the neurological reset initiated by the previous one.

Lumbar Sympathetic Block — For Lower Limb CRPS

For CRPS affecting the leg, knee, ankle, or foot, the Lumbar Sympathetic Block targets the sympathetic chain at the lumbar vertebral level (L2-L4) — interrupting the sympathetic drive to the lower limb.

Performed under fluoroscopic guidance with the patient prone, the needle is positioned anterior to the lumbar vertebral body — the anatomical location of the lumbar sympathetic chain. Contrast dye confirms correct placement before local anaesthetic is injected.

The result mirrors the stellate ganglion block: warmth spreading into the affected leg, reduction in burning pain, improved limb colour, and a therapeutic window for rehabilitation.

When sympathetic nerve blocks provide significant but temporary relief — confirming that the sympathetic pathway is the primary driver of the patient's pain — Radiofrequency Ablation (RFA) of the sympathetic ganglia offers a more sustained solution.

RFA uses thermal energy to selectively disrupt the sympathetic nerve fibres at the target ganglion — producing relief that lasts significantly longer than local anaesthetic blocks, typically 6–18 months.

Stellate Ganglion RFA — for upper limb CRPS where stellate blocks have been effective but short-lived

Lumbar Sympathetic Chain RFA — for lower limb CRPS with confirmed sympathetic-mediated pain

The progression from diagnostic/therapeutic blocks to RFA is a deliberate, staged approach — ensuring the procedure is offered only to patients in whom the sympathetic pathway has been confirmed as a primary driver.

For patients with established CRPS that has not responded adequately to sympathetic procedures and rehabilitation, Spinal Cord Stimulation (SCS) represents the next tier of interventional management.

SCS involves the placement of fine electrodes in the epidural space adjacent to the spinal cord. A mild electrical current is delivered to the dorsal columns of the spinal cord — modulating the central pain-processing pathways that have become sensitised in CRPS.

Evidence for SCS in CRPS is strong — it is one of the most evidence-supported applications of neuromodulation in pain medicine. A trial period is conducted before any permanent implantation, allowing the patient to assess the benefit before committing to the definitive procedure.

Dr. RRB will discuss the SCS pathway with appropriate patients and coordinate referral to neuromodulation specialists where required.

For CRPS with dominant central sensitisation — where allodynia and hyperalgesia are the most disabling features — low-dose intravenous ketamine infusion can provide meaningful pain reduction by modulating NMDA receptor-mediated central sensitisation.

Ketamine infusions are administered in a controlled clinical setting over several hours. The effect can last weeks to months and is often used in combination with sympathetic procedures and rehabilitation to address both the peripheral and central components of CRPS simultaneously.

One of the most important and specifically targeted rehabilitation approaches for CRPS — and one that is underutilised in most physiotherapy programmes in India.

GMI works by progressively retraining the brain's representation of the affected limb through a three-stage programme:

Stage 1 — Left/Right Discrimination: The patient views images of limbs and distinguishes left from right. This reactivates the brain's motor cortex representation of the affected limb without triggering the pain response.

Stage 2 — Imagined Movements: The patient imagines moving the affected limb through a range of positions — again without actual movement that would provoke pain.

Stage 3 — Mirror Therapy: The affected limb is hidden behind a mirror while the patient moves the healthy limb. The mirror reflection creates the visual illusion of a normally moving, pain-free limb — tricking the brain into reducing the pain signal associated with the affected limb.

Clinical evidence supports GMI as a meaningful component of CRPS rehabilitation — particularly for patients with the motor and central components of the condition.

Gradual, controlled exposure of the hypersensitive limb to progressively less aversive stimuli — starting with items like a soft brush or different fabric textures, progressing to firmer contact and then functional activity. This systematic desensitisation resets the allodynia over time.

CRPS is a rare and technically demanding condition. Stellate ganglion blocks and lumbar sympathetic blocks require specialised training, imaging guidance, and clinical experience with the sympathetic nervous system — skills that are not widely available in Tamil Nadu. Dr. RRB Pain Care is among a very limited number of centres in South India providing the full spectrum of CRPS interventional treatment — from initial sympathetic blocks through to RFA and neuromodulation pathway coordination.

The stellate ganglion block carries a perception of risk — it is performed in the neck, adjacent to the carotid artery, jugular vein, and trachea. This perception is warranted if the procedure is performed without imaging. At Dr. RRB Pain Care, every stellate ganglion block is performed under real-time ultrasound guidance — the modern international standard — with continuous visualisation of all adjacent structures throughout the procedure. This makes the procedure both safe and precisely effective.

Dr. RajaRajan Balasubramanian holds the FIPP certification — awarded by the World Institute of Pain (USA) — confirming competency in advanced interventional pain procedures to the highest international standard. This includes sympathetic nerve procedures, which form the core of CRPS management.

CRPS demands a clinician who understands its complexity — who knows the Budapest Criteria, who understands the sympathetically-mediated and non-sympathetically-mediated subtypes, who can stage the condition and adapt the treatment plan accordingly. This is not a condition for general practitioners or physiotherapists alone. It requires a pain specialist who has dedicated study and clinical experience to this specific domain.

Many CRPS patients arrive with an existing team — an orthopaedic surgeon, a neurologist, a physiotherapist. Dr. RRB does not replace that team. He coordinates with it — ensuring that the pain management component is integrated with, not siloed from, the broader care plan.

The most important answer: now. Sooner than you think. Earlier than feels necessary.

You have been diagnosed with CRPS and are not currently under the care of an interventional pain specialist

You have severe burning pain in a limb following a fracture, surgery, or injury that has persisted for more than 4 weeks without adequate explanation

You are experiencing allodynia — pain from touch, temperature, or air movement on the affected limb

You notice visible skin or temperature differences between your affected and normal limb

You have had sympathetic nerve blocks that helped but the relief has been short-lived — RFA may provide more sustained benefit

You have been managing CRPS with medication alone and are not improving

You have been told your injury has healed but the pain has not resolved — and you want a specialist opinion on whether CRPS may be responsible

You are in Stage 1 or Stage 2 — this is the most critical time to act

CRPS that is treated early, by a specialist who understands the condition, has a meaningfully different trajectory from CRPS that is left without specialist intervention. The research is clear on this. The window is real.

This is the question every CRPS patient asks — and it deserves a fully honest answer. There is no guaranteed cure for CRPS. However, a significant proportion of patients — particularly those diagnosed and treated early — achieve complete or near-complete remission of symptoms. In Stage 1 and early Stage 2, outcomes with specialist interventional treatment are considerably better than outcomes with medication management alone. Even in established CRPS, treatment can substantially reduce pain intensity, improve function, restore limb use, and give patients their life back — even if "cure" in the absolute sense is not achievable for every patient. Realistic goals — meaningful pain reduction, improved daily function, reduced medication burden — are achievable for most patients who access appropriate specialist care.

CRPS Type I (previously called Reflex Sympathetic Dystrophy or RSD) occurs after an injury or trauma without evidence of a specific identified nerve injury. It is the most common form — accounting for approximately 90% of CRPS cases. Type II (previously called Causalgia) occurs after a documented nerve injury. The clinical presentation of both types is similar — burning pain, skin changes, temperature asymmetry, allodynia. The distinction has implications for understanding the pathophysiology but does not substantially change the treatment approach at Dr. RRB Pain Care.

The standard approach involves a series of stellate ganglion blocks rather than a single procedure — typically 3 to 6 blocks, spaced 1–2 weeks apart. Each block builds on the neurological reset initiated by the previous one. The response to the first block guides the decision about proceeding with further blocks or transitioning to radiofrequency ablation of the stellate ganglion for longer-lasting effect. Some patients achieve sustained remission after a series of blocks combined with rehabilitation; others transition to RFA for more durable relief.

Yes — when performed by an experienced specialist using real-time ultrasound guidance. The stellate ganglion is located in the lower neck adjacent to the carotid artery, jugular vein, and trachea. Without imaging, this proximity creates risk. With ultrasound guidance — the standard at Dr. RRB Pain Care — all adjacent structures are continuously visualised throughout the procedure, making precise, safe needle placement consistently achievable. Temporary expected effects include Horner's syndrome (drooping eyelid and pupil constriction on the treated side) — confirming the block has worked and resolving fully as the anaesthetic wears off.

Yes. Given how few specialists in South India have dedicated CRPS expertise, Dr. RRB Pain Care sees patients from across Tamil Nadu, Andhra Pradesh, Kerala, and Karnataka for CRPS management. Travel is worthwhile for early-stage and mid-stage CRPS — because the window for best outcomes is time-limited and specialist care makes a documented difference. Patients from outside Chennai are accommodated with coordinated scheduling to minimise travel burden. The clinic is on the GST Road at Singaperumal Koil, approximately 45 minutes from Chennai Central station by road.

FINAL CTA SECTION

Every week without targeted treatment is a week in which the nervous system has the opportunity to consolidate the pain pathways further. Every month of untreated CRPS is a month closer to Stage 3 — where treatment becomes harder and outcomes less predictable.

You have already waited long enough.

One consultation. A specialist who understands exactly what is happening in your nervous system. A clear treatment plan — built around your stage, your symptoms, and your life.