Not All Complex Regional Pain Syndrome Is Sympathetically Mediated: Spinal Cord Stimulation in a Young Female after Patella Fracture—A Case Report

Abstract Complex regional pain syndrome (CRPS) is a rare, chronic, debilitating condition characterized by pain and sensory, vasomotor, sudomotor, motor, and trophic abnormalities that are disproportionate to the inciting event. Although sympathetic nervous system dysfunction is traditionally considered a hallmark of CRPS pathophysiology, emerging evidence suggests mechanistic heterogeneity in this disorder. An 18-year-old female developed CRPS Type I in her left lower limb 2 months after a patella fracture. She presented with severe burning pain, edema, allodynia, lustrous skin with erythema, trophic changes, and severe restriction of knee mobility. An interdisciplinary treatment approach was implemented, including physical therapy (mirror therapy, tactile desensitization, and transcutaneous electrical nerve stimulation), psychological support, polypharmacy, and sympathetic-targeted interventions (two sessions of lumbar sympathetic neurolysis with 70% alcohol, intravenous lignocaine desensitization, and 48 h epidural lignocaine infusion). Despite this comprehensive approach, pain relief remains minimal and unsustained. Due to financial constraints, spinal cord stimulation (SCS) was delayed for approximately 2 years. A successful SCS trial using Medtronic OctaLead placed at T8–T10 vertebral level achieved >60% pain reduction. Following permanent implantation, the patient maintained significant pain relief at 6-month follow-up, with improved knee flexion, independent ambulation to the bathroom, and improvement in Patient Health Questionnaire-9 score from 15 to 11. This case demonstrates that CRPS is not uniformly sympathetically mediated and highlights the critical role of early neuromodulation when conventional sympathetic-targeted therapies fail. Clinicians should maintain a low threshold for considering SCS in refractory CRPS, particularly in young patients at a high risk for long-term disability.