Reflex Sympathetic Dystrophy Surgery 

Reflex sympathetic dystrophy (RSD) is a condition that is often described under various synonyms that point to its incompletely understood etiology. In 1864, Weir Mitchell coined the term causalgia to designate severe pain following nerve injury. In 1900, Sudeck described regional demineralization accompanying posttraumatic pain. In 1923, Leriche described vasomotor disequilibrium.^[1] In 1947, Evans introduced the term reflex sympathetic dystrophy. In 1993, the International Association for the Study of Pain renamed algodystrophy complex regional pain syndrome (also known as chronic regional pain syndrome or CRPS).

Reflex sympathetic dystrophy, or RSD, is type 1 CRPS. RSD can be considered an excessive sympathetic reaction of joints and periarticular soft tissues to any insult, traumatic or unknown.^[2] This is quite different from causalgia (type 2 CRPS), in which the etiology is a partial nerve injury. RSD is characterized by pain, regional edema, joint stiffness, muscular atrophy, vasomotor disturbances (including temperature changes), trophic skin changes, (see image below) and regional skeletal demineralization seen on radiographs. These changes are aggravated by activity and extend over a larger area than the primary injury or surgery, including the area distal to this focus.^{[3, 4, 5, 6]}

Because pathognomonic criteria are lacking for RSD, a taxonomic system based on clear definitions and objective quantification is desirable. Therefore, the current terminology of CRPS is increasingly being used as an umbrella to replace the myriad empirical descriptions used previously. No apparent relationship exists between the degree of initial trauma and severity of RSD, but RSD generally is more frequent following minor trauma or operations.

Reflex sympathetic dystrophy (RSD, algodystrophy, complex regional pain syndrome [CRPS]) usually follows minor trauma or surgery. It also has been associated with various clinical conditions (eg, diabetes, parkinsonism). RSD begins with spontaneous pain associated with vasomotor and sudomotor disturbances.

Bonica described the progress of severe cases in 3 stages.^[7] The acute stage of RSD is marked by pain, swelling, and warmth. Neurologic changes, such as hyperesthesia (glove and stocking distribution), incoordination, tremor, muscle spasms, and paresis, may be seen. The second dystrophic stage is characterized by cold skin with trophic changes. The final atrophic stage is manifested by muscle wasting and joint contractures. Symptoms usually are disproportionate to the cause and reflect disturbance of autonomic, sensory, and motor function.

Frequency

United States

According to various researchers, incidence of reflex sympathetic dystrophy (RSD) may be 2-17% following minor trauma or surgery. If causalgia is included in the broad definition, incidence can be as high as 32-35%. In the past, many subtle forms of RSD were missed, but with increased awareness of the condition, actual incidence may be much higher than initially thought.

International

There are no regions or population groups that have a predilection for reflex sympathetic dystrophy.

Mortality/Morbidity

Mortality associated with reflex sympathetic dystrophy (RSD) is negligible, though morbidity is extremely high. Despite good results following intravenous sympathetic blockade and intensive mobilization techniques, weakness of the extremity resulting from RSD is seen in almost 50-65% of patients, even 18-24 months following initial diagnosis. Full range of movement accompanying the above aggressive therapies is seen in 60-74% of patients. Prolonged morbidity is observed in about 50% of patients with psychiatric diathesis, workers' compensation claims, and lawsuits.^[8]

Race

No particular race has a predilection for reflex sympathetic dystrophy.

Sex

Reflex sympathetic dystrophy is more common in women than in men; the male-to-female ratio is approximately 3:7. The ratio of upper extremity to lower extremity involvement is approximately 2:1. Even in children, girls are affected more frequently than boys, but peculiarly, the lower extremity is involved more frequently than the upper extremity.^[9]

Age

Most patients with reflex sympathetic dystrophy (RSD) are aged 30-55 years, and the mean age is 45 years. With increasing awareness, RSD is being diagnosed in children more often; however, no studies exist pointing to a particular age distribution.