This question was submitted by Deepa Kattail and Anjana Kundu. If you would like to submit a future question, please send it to Franklin Chiao at [email protected].

A previously healthy 16 year old, 60 kg female with a diagnosis of CRPS type I after a right ankle sprain while skiing 6 months ago presents to your pain clinic. Although the edema, purplish discoloration and cold foot and ankle seen 1-2 weeks after the injury have subsided, allodynia and intense pain of the entire right lower extremity persist. She is unable to bear weight on that leg and has been wheelchair bound at this point. All imaging studies were normal after the initial injury. Despite regular physical therapy and compliance with her oral medication regimen (gabapentin, amitriptyline, acetaminophen, ibuprofen and hydromorphone as needed) she continues to have severe excruciating pain interfering with school attendance, sleep, ambulation and is limiting progress with PT. An assessment by the pediatric pain psychologist did not reveal any major mental health concerns except some reactive depression. A lumbar sympathetic block performed during earlier phase, failed to provide any analgesia despite obvious signs of sympathetic blockade. She and her family are desperate to get some pain relief, want help with being able to participate in PT more aggressively and seek other options for pain control.

Which option, supported by current guidelines, would be most appropriate at this time?