Post on 01-Jun-2015
Reflex Sympathetic Dystrophy
HISTORYAmbroise Pare 17th century: “burning pain after nerve
injury”Weir Mitchell 1872: “Causalgia” a. burning pain b. Allodynia c. Autonomic ChangesSudeck 1900: Regional demineralisation with post
traumatic painEvans 1946: “RSD”International Association For Study of Pain: “CRPS 1” = RSD “ CRPS 2” = Causalgia
CRPS RSD
Algodystrophy
Sudeck’s Atrophy
Shoulder Hand Syndrome
Causalgia
CRPS 1
1. Without nerve lesion
2. Burns, blunt trauma, sprain, stroke, shingles
3. A/w: Anxiety disorder Dependency, insecurity Personality disorders, Sense of Dissatisfaction
CRPS 2
1. With nerve lesion
2. Crush injury, laceration
IASP CRITERA “Initiating Noxious Event:-External/Internal Hyperalgesia, continuing pain, allodynia out
of proportion to the inciting event e/o oedema, changes in skin blood flow or
abnormal sudomotor activity in region of pain Absence of any alternative explanation for
the symptoms +FOR CRPS II: Known nerve injury
PATHOLOGY Poorly understood Theories: CRPS 1:-
1. Ongoing nociceptor input that maintains a central state of hyper excitability for prolonged periods
2. Inflammatory cause: resembles it and relieved by steroids
Sympathetically
maintained pain
Nociceptor input
maintained by ineracn
btw Primary afferents
and sympathetic
efferents through
alpha adrenergic
mechanism
Sympathetically
independent pain
Maintaining nociceptor
input comes from other
causes such as
peripheral nerve
stimulation
Eg: Neuroma
INJURY
REACTIVE VASOMOTOR SPASM
LOSS OF VASCULAR TONE
VASODILATION
BONE RESORBTION
DECREASED MOBILITY
DECREASED CIRCULATON
FIBROSIS/SHORTENING OF INVOLVED LIGAMENTS
SIGNS & SYMPTOMS Pain
Vasomotor changes
Trophic changes
Within 3 weeks – 6 months of original injury
AUTONOMIC1. B/L temp. difference (Dynamic)2. Skin Discoloration3. Subcutaneous Thickening4. Peripheral Oedema
RADIOLOGIC: Osteopenia
SENSORY1. Sensitivity
2. Muscle belly tenderness
3. Hyperalgesia over bony prominences, hyperpathia
MOTOR1. Muscle atrophy/
weakness
2. Joint stiffness
3. Muscle contractures
4. Mechanical allodynia
3 Patterns of spreading Symptoms
1. Continuous type
2. Mirror Image type
3. Independent type
STAGESBased on severity and chronology
STAGE I. MILD
Days/wks after injury
Pain/swelling/dysfunction - localized
Exaggerated symptoms
Limb relatively immobile and sensitive
May last up to 3 months
STAGE II :Increased chronicity
Increased symptom severity
Limb increasingly cold
Oedema +
Skin mottled
Lasts 3-12 months
Immobilization – Joint stiffness
STAGE III: ATROPHIC
Most severe
Symptoms near intolerance
Occurs > 1 year on
Dystrophic changes in skin, muscle and bone
UNRESPONSIVE TO Rx - PERMANENT
3 PREREQOISITES FOR DIAGNOSIS
Persistent lesion or injury
Predisposing constitution
Abnormal sympathetic arc
DIAGNOSTIC CRITERIA BY KOZEN
Persistent and Diffuse pain
in the hand
Loss of function of the hand
Autonomic Dysfunction
Relief by interruption of Sympathetic reflex
RADIOGRAPHY
1/3rd pts. Normal X ray picture
Osteopenia in affected limb
(after 2-4 weeks of symptoms)
Increased Power Doppler Flow in RSD of Lower Extrimity
BONE SCAN / SCINTIGRAPHY
Preferred Diagnostic test
INCREASED UPTAKE—CRPS INDUCED OSTEOPENIA
MacKinnon & Holder- strictest criteria for diagnosis of RSD in hand
REQUIRED DIFFUSE INCREASE IN DELAYED PERIARTICULAR UPTAKE IN ALL JOINTS OF
AFFECTED HAND
BEST DIAGNOSTIC & PROGNOSTIC TEST
LA block of appropriate sympathetic ganglia
Novocain (5% Procaine hydrochloride) used as a pharmacologic neural blocker
STELLATE GANGLION – ULLUMBAR PARAVERTEBRAL GANGLIA – LL
Guanethadine: Initially symptoms increase then decrease
Phentolamine test: Alpha adrenoceptors blocked
TREATMENT Educate regarding therapeutic goals
Minimize pain
Physiotherapy
Determine contribution of SNS to the pain
Physiotherapy
Elevation, massage, contrast baths, stockings
AIM: improve jt. ROM & muscle strength
Acupuncture
TENS- 1. Non invasive 2. No side effects
Psychiatric treatment Alternative treatments
a. Qi emission b. Qi instruction
Thermal biofeedback, Relaxation training, supportive psychotherapy
PHARMACOLOGY1. Corticosteroids :- Prednisolone 30mg /day x 12 weeks DECREASES: pain, edema, inflamn, ectopic
electrical activity after nerve injury
2. Bisphosphonates :-7.5 mg/250 ml of saline daily x 3 days INCREASES ROM
3. Mannitol 10%, 1000ml/24 hrs x 1 week4. Dimethyl sulfoxide cream 50% on the skin5. N-acetyl cysteine 600mg tid
CONSTANT PAIN+ INFLAMMATION N.S.A.I.D.S CONSTANT PAIN – INFLAMMATION Tramadol CONSTANT PAIN – SLEEP DISTURBED Anti-depressants, Oral lidocaine, Mexiletine SPONTANEOUS PAROXYSMAL JABS Anticonvulsants SYMPATHETICALLY MEDIATED PAIN Clonidine patch MUSCLE CRAMPS/ DYSTONIA Baclofen
SYMPATHETIC BLOCKS 3-6 tries Diagnostic, therapeutic, prognostic Continuous sympathetic block preferred
over serial blocks
Stellate ganglion block
Axillary Sympathectomy
Lower limb Sympathectomy
Effective Sympathetic Denervation Horner’s syndrome
Skin temp 34 deg.
50% increase in skin blood flow
Abolition of skin resistance response
Post sympathectomy pain
1. Proximal to original pain
2. Resolves on its own
OR
After sympathetic blocks
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