Reflex Sympathetic Dystrophy Surgery Treatment & Management

  • Author: Satishchandra Kale, MD, FRCS(UK), Dip Sports Medicine(UK), MS(Orthopaedics), DOrtho; Chief Editor: Mary Ann E Keenan, MD   more...
 
Updated: May 14, 2010
 

Medical Care

The goals of treatment of reflex sympathetic dystrophy are reduction of edema, reduction of reflex muscular contractures, reduction of articular stiffening, and pain blockage with mobilization under sympathetic blockade.[16, 17, 18]

Prophylaxis

There is evidence that vitamin C (oral administration) may reduce the incidence of complex regional pain syndrome after wrist fractures. A daily dose of 500 mg for 50 days is recommended.[19]

Physical therapies

  • The following physical therapies may be useful:[20]
    • Active and passive range-of-motion exercises
    • Transcutaneous electrical nerve stimulation (TENS)
    • Desensitization techniques
    • Sensory reeducation of the extremity

Pharmacologic therapy

  • Pharmacologic agents used are classified as follows:
    • Analgesics: Drugs with a long half-life are preferred (eg, codeine)
    • Antidepressants: These drugs modulate sympathetic activity and provide analgesia (eg, amitriptyline)
    • Anticonvulsants (eg, phenytoin)
    • Membrane-stabilizing agents (eg, lidocaine, tocainide)
    • Adrenergic compounds
      • Phentolamine - Relief with IV phentolamine is pathognomic of sympathetically maintained pain (SMP). Patients with a positive response to IV phentolamine are likely to respond to other forms of sympatholytic interventions.
      • Phenoxybenzamine - Nonselective adrenergic agent[21]
      • Clonidine - Alpha 2 -adrenergic agonists
    • Calcium channel blockers - Reduce sympathetic tone by blocking calcium release following stimulation of adrenergic receptors (eg, nifedipine, amlodipine)
    • Corticosteroids - Membrane-stabilizing action (prednisolone 60 mg rapidly tapered over 5-10 d is commonly used)
  • Various routes of administration for pharmacologic interventions include the following:
    • Intravenous regional infusions
      • Guanethidine sulfate
      • Phentolamine
      • Bretylium tosylate
      • Reserpine
      • Cortisone sulfate
    • Epidural injections (eg, clonidine) may provide relief in selected patients
    • Intra-articular injections of steroid preparations (eg, triamcinolone)
    • Intra-arterial injections (eg, reserpine, guanethidine)
    • Continuous autonomic blockade using local anesthetic agents for scalene/axillary/brachial/stellate ganglion blocks

Other therapies

  • Newer interventions include the following:
    • Biofeedback
    • Acupressure
    • Acupuncture
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Surgical Care

  • Surgical/ablative therapies include the following[22] :
    • Chemical sympathectomy
    • Surgical sympathectomy
    • Implantable electrical stimulators
    • Bilateral anterior cingulotomy
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Activity

  • Intensive physical therapy following a successful sympathetic blockade is key to faster rehabilitation in patients with reflex sympathetic blockade (RSD).
  • IV blocks with rigorous mobilization techniques must be implemented early in the treatment process for RSD.
  • Active and passive mobilization and heat and cold modalities all have been used with good effect in RSD, acting via the gate theory. The gate theory suggests that a finite amount of information can be received at the spinal cord or at the cortical level. The gate is the dorsal horn of the spinal cord. Therefore, painful stimuli, if displaced or modified by less noxious stimuli, cannot be processed through the gate.
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Contributor Information and Disclosures
Author

Satishchandra Kale, MD, FRCS(UK), Dip Sports Medicine(UK), MS(Orthopaedics), DOrtho  Consultant Trauma and Orthopedic Surgeon, East and North Hertfordshire NHS Trust, UK

Satishchandra Kale, MD, FRCS(UK), Dip Sports Medicine(UK), MS(Orthopaedics), DOrtho is a member of the following medical societies: British Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

James F Kellam, MD  Vice-Chair, Department of Orthopedic Surgery, Director of Orthopedic Trauma and Education, Carolinas Medical Center

James F Kellam, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Orthopaedic Trauma Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Samuel Agnew, MD, FACS  Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, and Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS  Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD  Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania

Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association

Disclosure: Nothing to disclose.

References

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  2. Naleschinski D, Baron R. Complex Regional Pain Syndrome Type I: Neuropathic or Not?. Curr Pain Headache Rep. May 12 2010;[Medline].

  3. Koman LA, Poehling GG, Smith TL. Complex regional pain syndromes: Reflex sympathetic dystrophy and causalgia. In: Green DP, Lampert R, eds. Greens Operative Hand Surgery. 4th ed. Churchill Livingstone;1998:636-62.

  4. Mitchell SW, Morehouse GR, Keen WW. Gunshot Wounds and Other Injuries of Nerves. Philadelphia:. JB Lipincott;1864.

  5. Mitchell SW. Injuries of Nerves and their Consequences. Philadelphia:. JB Lippincott;1972.

  6. Clinical Orthopaedics. Reflex sympathetic dystrophy. In: Bailliere's Clinical Orthopaedics. Vol 1. WB Saunders Co;1996.

  7. Bonica JJ, ed. The Management of Pain. 2nd ed. Philadelphia:. Lea & Febiger;1990:220-243.

  8. Allen G, Galer BS, Schwartz L. Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain. Apr 1999;80(3):539-44. [Medline].

  9. Wilder RT, Berde CB, Wolohan M, et al. Reflex sympathetic dystrophy in children. Clinical characteristics and follow-up of seventy patients. J Bone Joint Surg Am. Jul 1992;74(6):910-9. [Medline].

  10. Ackerman WE 3rd, Ahmad M. Recurrent postoperative CRPS I in patients with abnormal preoperative sympathetic function. J Hand Surg [Am]. Feb 2008;33(2):217-22. [Medline].

  11. Herlyn P, Müller-Hilke B, Wendt M, Hecker M, Mittlmeier T, Gradl G. Frequencies of polymorphisms in cytokines, neurotransmitters and adrenergic receptors in patients with complex regional pain syndrome type I after distal radial fracture. Clin J Pain. Mar-Apr 2010;26(3):175-81. [Medline].

  12. Bernateck M, Karst M, Gratz KF, Meyer GJ, Fischer MJ, Knapp WH, et al. The first scintigraphic detection of tumor necrosis factor-alpha in patients with complex regional pain syndrome type 1. Anesth Analg. Jan 2010;110(1):211-5. [Medline].

  13. Wesseldijk F, Fekkes D, Huygen FJ, Bogaerts-Taal E, Zijlstra FJ. Increased plasma serotonin in complex regional pain syndrome type 1. Anesth Analg. Jun 2008;106(6):1862-7. [Medline].

  14. Higashimoto T, Baldwin EE, Gold JI, Boles RG. Reflex sympathetic dystrophy: complex regional pain syndrome type I in children with mitochondrial disease and maternal inheritance. Arch Dis Child. May 2008;93(5):390-7. [Medline].

  15. Genant HK, Kozin F, Bekerman C, et al. The reflex sympathetic dystrophy syndrome. A comprehensive analysis using fine-detail radiography, photon absorptiometry, and bone and joint scintigraphy. Radiology. Oct 1975;117(1):21-32. [Medline].

  16. Gellman H. Reflex sympathetic dystrophy: alternative modalities for pain management. Instr Course Lect. 2000;49:549-57. [Medline].

  17. van Laere M, Claessens M. The treatment of reflex sympathetic dystrophy syndrome: current concepts. Acta Orthop Belg. 1992;58 Suppl 1:259-61. [Medline].

  18. Albazaz R, Wong YT, Homer-Vanniasinkam S. Complex regional pain syndrome: a review. Ann Vasc Surg. Mar 2008;22(2):297-306. [Medline].

  19. Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am. July 2007;89(7):1424-31. [Medline].

  20. Ek JW, van Gijn JC, Samwel H, van Egmond J, Klomp FP, van Dongen RT. Pain exposure physical therapy may be a safe and effective treatment for longstanding complex regional pain syndrome type 1: a case series. Clin Rehabil. Dec 2009;23(12):1059-66. [Medline].

  21. Inchiosa MA Jr, Kizelshteyn G. Treatment of complex regional pain syndrome type I with oral phenoxybenzamine: rationale and case reports. Pain Pract. Mar-Apr 2008;8(2):125-32. [Medline].

  22. Birch R. Pain. In: Surgical Disorders of the Peripheral Nerves. Churchill Livingstone;1994:385-93.

  23. Tan AK, Duman I, Taskaynatan MA, Hazneci B, Kalyon TA. The effect of gabapentin in earlier stage of reflex sympathetic dystrophy. Clin Rheumatol. Apr 2007;26(4):561-5. [Medline].

 
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Reflex sympathetic dystrophy following surgery for Dupuytren contracture.
Radiograph of affected extremity, depicting regional osteopenia contrasted with normal radiographic appearance of the opposite extremity.
 
 
 
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