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.     

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.     

Treatment of acute reflex sympathetic dystrophy with DMSO 50% in a fatty cream

Acute Reflex Sympathetic Dystrophy (acute RSD) was defined using a reproducible classification. Elevated temperature of the affected extremity ("calor"), measured by the dorsal side of the observer's hand and mentioned by the patient, pain ("dolor") measured by the Visual Analogue Scale (VAS), redness ("rubor"), edema ("tumor") and limited active range of motion ("functio laesa"), all contributed to the classification system. Patients scoring 4 or 5 positive symptoms were considered to have acute RSD.
A prospective, randomized and double blind study was performed in 32 patients, all suffering from acute RSD. In all of these patients the primary injury was the result of a previous accident. One patient was taken out of the study because of his surgery. The study involved treatment with a fatty cream with 50% dimethyl sulfoxide (DMSO, group A), or without DMSO (placebo, group B), both for 2 months. All patients received physiotherapy applied within pain limits.
Application of the creams resulted in both groups in an improvement of RSD-scores and VAS-scores after 2 months. However, the improvement of the RSD score in patients of group A (DMSO-group) was significantly (P<0.01) better compared to group B. The results suggest a certain activity of DMSO 50% cream in patients suffering from RSD and is, therefore, recommendable.     

Treatment of upper extremity reflex sympathetic dystrophy with joint stiffness using sympatholytic Bier blocks and manipulation

Twenty patients with reflex sympathetic dystrophy involving the upper extremity with associated joint stiffness were treated by manipulation under Bier blocks composed of lidocaine, methylprednisolone, and reserpine or guanethidine. Depending on the patients' response, repeat blocks were performed at 48- to 72-hour intervals. Range of motion in the affected joints (primarily the hand and wrist) improved from a pre-block mean of 46% to 81% of normal following the blocks. Patients also reported an 80% mean improvement in their pain. The treatment of advanced reflex sympathetic dystrophy using joint manipulation under sympatholytic Bier blocks appears to be a safe and effective method of treatment.     

Sympathectomy for reflex sympathetic dystrophy: Factors affecting outcome

This study includes our 12-year experience with chemical sympathetic blocks and surgical sympathectomies for causalgic pain of reflex sympathetic dystrophy (RSD) with emphasis on factors affecting clinical outcome. Medical records of patients undergoing sympathectomies for causalgic pain were analyzed. The patients were classified according to Drucker et al. as stage I, II, or III. Results of chemical and surgical sympathectomies were analyzed using both univariate and multivariate methods. Twenty-one patients had lumbar and seven had cervicodorsal sympathectomies for RSD. The mean duration between initial injury and chemical sympathetic block was 10 months with a mean of 11.4 months to surgical sympathectomy. Ten patients (36%) had overt extremity trauma as the precipitating event. Ten patients (36%) had a lumbar laminectomy, three of whom developed the syndrome bilaterally. There was no operative mortality; however, 25% had transient postoperative sympathetic neuralgia. The early and late (>6 months) satisfactory outcomes after surgical sympathectomy were 82% and 71%, respectively. Patients with stage II presentations were significantly more likely to have satisfactory early (92%) and late (79%) outcomes than stage III patients, 0% and 0% ( p =0.019). Patients with an excellent response to chemical sympathetic block were more likely to have satisfactory early and late surgical outcomes. The time between injury and chemical block and surgical sympathectomy was significantly shorter in patients who had satisfactory early and late surgical outcomes ( p <0.0001). Multivariate analyses demonstrated that the most important independent factor in determining early and late satisfactory outcomes of sympathectomy was the time between injury and sympathectomy ( p =0.001). Surgical sympathectomy should be confined to patients with stage II disease who have had an excellent response to chemical sympathetic block and when relief from repeated sympathetic block becomes less effective and the response is dramatic but of shorter duration.Presented at the Joint Annual Meeting of the SVS/ISCVS, Chicago, Ill., June 8–10, 1992.     

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.     

Reflex sympathetic dystrophy in children

This report presents the case of an 8-year-old boy who underwent a second clubfoot operation following early-stage reflex sympathetic dystrophy (RSD). After other conditions had been ruled out, the patient was submitted to physiotherapy supported by antiphlogistic and analgesic drugs as well as a partial immobilisation of the affected extremity. He remained asymptomatic during the following 4 weeks. RSD in children is not a well-recognised entity. This case of early-stage RSD illustrates the need to be aware of this possible complications after operation in the differential diagnosis of local pain and swelling of a limb. Received: 13 January 1998     

Reflex sympathetic dystrophy in children

Reflex sympathetic dystrophy (RSD) is an uncommonly reported entity in children. This paper reports five cases of RSD in children and summarizes 80 cases of pediatric RSD reported in the literature. The diagnosis is based on the clinical findings of pain, dysesthesia, and autonomic instability. Tache cérébrale, not previously described in the diagnosis of RSD, is a helpful sign of vasomotor dysfunction. RSD in childhood frequently affects the lower extremities, in contrast to the adult localization around the shoulders and hands. Noninvasive, nonpharmacologic management is generally successful. A simple outpatient program of massage and mobilization was beneficial in four of the five patients treated in this study.     

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.