Compression syndromes in reflex sympathetic dystrophy

Over an 8-year period we treated 93 cases of reflex sympathetic dystrophy. The initial treatment consisted of long-acting intramuscular corticosteroids and active exercises. Twenty-two patients who did not respond significantly to this treatment had carpal tunnel syndrome. In addition, five had cubital tunnel syndrome, one had ulnar tunnel syndrome, and one had a herniated disk of the cervical spine. All nerves were decompressed with significant improvement in the patient's condition. Pain was relieved in all except three who had mild pain. Motion of the proximal interphalangeal joint improved from an average of 35 degrees before operation to 76 degrees after operation. Grip strength improved from an average of 4 pounds to 27 pounds.     

The sequelae of reflex sympathetic dystrophy

This paper presents the results of a retrospective analysis of 94 patients who were assessed at a mean of 11 months after successful treatment of reflex sympathetic dystrophy (RSD) of the hand. Fifty-four percent still complained of pain related to the weather, and many complained of cold intolerance (44%), slight pain after use (34%), nail and hair growth changes (34%), sensory disturbances (34%) and stiffness of fingers in the morning (28%). There were also complaints of reduced finger extension, pain and loss of movement in the shoulder joint and hand swelling after use, and 78% of patients had significantly reduced grip strength. These results suggest that, in spite of resolution of the acute RSD problem, significant long term sequelae of RSD continue to impair function of the hand in a proportion of patients.     

Intravenous guanethidine in patients with reflex sympathetic dystrophy

Background : Intravenous regional guanethidine Bier block (IVRGBB) has been used predominantly in Europe for treating reflex sympathetic dystrophy (RSD). Our experience in the United States, where its use has been limited, is reported. Methods: Fifty-five patients received IVRGBB for RSD. Upper extremities received 20 mg (10 mg/ml) of guanethidine in 30–50 ml of 0.5% lidocaine; lower extremities received 40 mg in 40–75 ml of lidocaine (volume adjusted for size, weight, or prior adverse effect). Pain severity (mild, moderate, severe, excruciating) was obtained pretreatment. Pain severity and a global clinical assessment (GCA) (resolved, improved, no change, worse) were obtained following each treatment. The final GCA was analyzed vs: pretreatment score; age; sex; pain duration; number of treatments; and precipitating event. Adverse effects were documented. Results : Of 55 enrolled patients, 2 were lost to follow-up, and 2 returned 1 and 4 years later for repeat treatment. Therefore, 53 patients were evaluated for 55 treatments. Age: 38.2 ? 14.8 (SD) (range 10–77) years. Sex: 11 males, 44 females. Average pain duration: 2.0 ? 1.7 years (3 days - 7 years). Final assessment occurred at 3.88 ? 5.21 months (6 days - 2 2/3 years). Effect on pain: resolution-9.1%; improved-14.5%; no change-61.8%; worsening-14.5%. No significant relationship was found between GCA and the factors evaluated. There was a significant positive linear association between pretreatment pain and post treatment GCA (P = 0.032). Fifty-six adverse effects occurred in 19 (34.5%) patients (nausea, vomiting, orthostatic hypotension, dizziness, diarrhea, weakness). Conclusions : IVRGBB does not provide long-term pain relief and is associated with adverse effects in over 1 / 3 of patients.     

Vertebral crush fracture syndrome and reflex sympathetic dystrophy

The association of reflex sympathetic dystrophy in one or more extremities with vertebral crush fracture syndrome is reported in six cases. In two of them the reflex sympathetic dystrophy preceded the vertebral crush fractures. The 99mTc-methylene diphosphonate scintigraphy results of the skeletons of 42 consecutive patients suffering from vertebral collapse and of 30 matched controls without osteoporosis have been evaluated by three independent observers for abnormal uptakes in the extremities. An abnormal radioactive bone tracer uptake in the extremities has been observed in 15 osteoporotics (36%) and 8 controls (29%). In most cases, osteoporotics and controls, the abnormal uptake was of the zonal type in a localized area, probably reflecting bone remodeling due to localized degenerative changes. An abnormal uptake of the segmental type involving multiple joints and even multiple extremities, as seen in reflex sympathetic dystrophy, was observed in 7 patients of the osteoporotic group (17%) and in none of the control group (P less than 0.05). The patients with an abnormal segmental uptake were younger and had a significantly higher mean 24 h calcium:creatinine ratio as well as a higher urinary hydroxyproline excretion. These observations and results suggest that in some cases of idiopathic osteoporosis there might be a relation between reflex sympathetic dystrophy and vertebral crush fracture syndrome, the vertebral crush fracture syndrome being the axial type of reflex sympathetic dystrophy.     

The results of the treatment of post-traumatic reflex sympathetic dystrophy within upper extremity]

Results of a retrospective study of the treatment of 146 patients with post-traumatic reflex sympathetic dystrophy within upper extremity in various stages were presented. Treatment included the following methods: regional intravenous steroid blocks, mannitol, mannitol combined with dexamethasone, physical therapy, calcitonin and surgery. Uniform, clearly defined criteria of diagnosis of the condition and criteria of assessment of the results were used in the study. Final assessment was carried out 6-15 months after ending of the treatment (mean 11 months). Good result (no pain and full finger flexion) was obtained in 94 patients (64%), moderate (pain only after load or loss of flexion less than 3 cm) in 31 (21%) and poor (pain at rest or reduction of flexion more than 3 cm) in 21 (15%). There was found that method of treatment had not significant effect on the result, except surgical treatment after which the worst results were obtained. Significant effect of duration of the disease on the results of the treatment was noted: the earlier treatment the better results. In spite of satisfactory withdrawal of other signs and symptoms, considerable reduction of grip strength after treatment persisted (mean grip strength ratio 28% of the other side) suggesting functional impairment of the hand. The critical approach to evaluation of the results of the treatment of early reflex sympathetic dystrophy was suggested with regard to spontaneous recovery of the condition in many cases.     

The diagnosis of reflex sympathetic dystrophy using an algometer

Thirty-three patients with reflex sympathetic dystrophy were studied prospectively to ascertain the pressure-pain threshold of affected and unaffected limbs. The affected side had a lower threshold which was found to be statistically significant. In all 18 patients with upper limb involvement, the pain threshold was reduced on the affected side, but this applied to only 11 of the 15 with leg involvement. This difference may be because patients with lower limb symptoms had been referred later in the course of the syndrome. We showed by repeated tests that after an average of 49 days there was a slow return to normality. The estimation of pressure-pain thresholds may help in the earlier diagnosis of reflex sympathetic dystrophy.     

Thermal self-regulation for pain control in reflex sympathetic dystrophy syndrome

Reflex sympathetic dystrophy syndrome is comprised of a variety of changes in vasomotor and trophic responsivity, as well as, stiffness, edema and severe pain. This study examined 20 patients with reflex sympathetic dystrophy syndrome who had failed to respond to a variety of techniques commonly used to treat this disorder. These patients had documented histories of reflex sympathetic dystrophy syndrome ranging from 18 to 60 months. All had been referred for psychological evaluation and provision of pain management. A combination of thermal biofeedback, relaxation training, and supportive psychotherapy were used to reduce subjective pain. The results indicate that patients were able to significantly increase their initial (p less than 0.0001) and postrelaxation (p less than 0.0001) hand temperatures, as well as to significantly reduce their subjective pain ratings (p less than 0.0001). This reduction in pain was maintained at 1-year telephone follow-up, with 14 of the 20 patients returning to work by that time. This intervention was effective as a pain reduction strategy for our patients with reflex sympathetic dystrophy syndrome who had failed to benefit from other treatments.     

Epidural spinal cord stimulation in the management of reflex sympathetic dystrophy

Eighteen subjects with intractable pain due to reflex sympathetic dystrophy (RSD) underwent treatment by epidural spinal cord stimulation (SCS). All the patients had previously undergone multiple sympathetic blocks and/or surgical sympathectomy with either no results or only temporary therapeutic effects. Four subjects did not experience any beneficial effects during a 1-week trial and the electrode was removed, and 14 patients had the system internalized surgically. In 4 cases two separate systems (electrode + pulse generator) were implanted, in order to cover distant areas of the body involved by the disease (neck, shoulders, upper extremities, trunk and lower extremities). Follow-up varies from 4 to 14 months. In the implanted group, pain relief was absent in 3 patients, minimal in 1, moderate in 5 and good in 6. Pain relief was strictly limited to the body parts covered by the parasthesiae induced by SCS. In 3 patients, SCS produced visible changes in the swelling of the painful extremities. None of the patients was made neurologically worse. In 7 patients there were technical problems related to electrode breakage or migration, change in the pattern of paresthesiae and poor connection due to body fluid infiltration. All the problems were corrected surgically under local anesthesia. SCS has some value in the management of refractory RSD pain in selected cases. Because of the limited series and follow-up, its value in the comprehensive management of RSD requires further investigation.