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Surgery for Reflex Sympathetic Dystrophy (Complex Regional Pain Syndrome Type 1) Treatment & Management

  • Author: Satishchandra Kale, MD, MS, MBBS, MCh, MBA, FRCS(Edin); Chief Editor: Harris Gellman, MD  more...
 
Updated: Jul 07, 2016
 

Approach Considerations

The goals of treatment of reflex sympathetic dystrophy (RSD; also referred to as complex regional pain syndrome [CRPS] type 1) are as follows[16, 17, 18] :

  • Reduction of edema
  • Reduction of reflex muscular contractures
  • Reduction of articular stiffening
  • Pain blockage with mobilization under sympathetic blockade

Management approaches include the following:

  • Prophylactic vitamin supplementation
  • Pharmacologic therapy
  • Physical therapy
  • Surgery
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Pharmacologic Therapy

There is evidence that prophylactic oral administration of vitamin C may reduce the incidence of CRPS after wrist fractures. A daily dose of 500 mg for 50 days is recommended.[19]

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 intravenous [IV] phentolamine is pathognomic of sympathetically maintained pain [SMP], and patients with a positive response to IV phentolamine are likely to respond to other forms of sympatholytic interventions); phenoxybenzamine (nonselective adrenergic agent [20] ); clonidine (alpha 2-adrenergic agonist)
  • Calcium channel blockers - These 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 days is commonly used)

Various routes of administration for pharmacologic interventions include the following:

  • IV 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

In using sympathetic blockade, the presence of allodynia and hypoesthesia are negative predictors for success. The use of sympathetic blocks as treatment for RSD (CRPS 1) should be considered carefully between potential success and possible adverse effects. The procedure is as likely to cause a transient increase in pain as a decrease in pain. Patients should be warned about this symptomatology.[21]

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Physical and Other Therapies

The following physical therapies may be useful:[22]

  • Active and passive range-of-motion exercises
  • Transcutaneous electrical nerve stimulation (TENS)
  • Desensitization techniques
  • Sensory reeducation of the extremity
  • Mirror visual feedback in the treatment of complex regional pain syndrome [23]

Newer interventions include the following:

  • Biofeedback
  • Acupressure
  • Acupuncture
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Surgical Therapy

Surgical/ablative therapies include the following[24] :

  • 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 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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Prevention

Most cases of RSD in orthopedic practice can be prevented through early detection and early treatment. In most cases, a possible cause can be identified, such as overly tight bandages or plasters, a limb improperly splinted, or neglect of active movement of the part. The treating physician should be aware of and alert for compression syndromes of the underlying nerve or for swelling and pain resulting from a displaced bone fragment. The mainstay of treatment is mobilization of the affected part.

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Contributor Information and Disclosures
Author

Satishchandra Kale, MD, MS, MBBS, MCh, MBA, FRCS(Edin) FRCS(Tr & Orth), FRCS(Edin), MCh(Orth), Diploma in Sports and Exercise Medicine(UK), MS(Orthopaedics)

Satishchandra Kale, MD, MS, MBBS, MCh, MBA, FRCS(Edin) is a member of the following medical societies: British Orthopaedic Association, Royal College of Surgeons of Edinburgh, Bombay Orthopedic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; 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, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

James F Kellam, MD, FRCSC, FACS, FRCS(Ire) Professor, Department of Orthopedic Surgery, University of Texas Medical School at Houston

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

Disclosure: Nothing to disclose.

References
  1. Leriche R. The Surgery of Pain. London:. BailliereTindall & Cox. 1939.

  2. Naleschinski D, Baron R. Complex Regional Pain Syndrome Type I: Neuropathic or Not?. Curr Pain Headache Rep. 2010 May 12. [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. Ackerman WE 3rd, Ahmad M. Recurrent postoperative CRPS I in patients with abnormal preoperative sympathetic function. J Hand Surg [Am]. 2008 Feb. 33(2):217-22. [Medline].

  9. 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. 2010 Mar-Apr. 26(3):175-81. [Medline].

  10. 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. 2010 Jan. 110(1):211-5. [Medline].

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

  12. 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. 2008 May. 93(5):390-7. [Medline].

  13. 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. 1992 Jul. 74(6):910-9. [Medline].

  14. Allen G, Galer BS, Schwartz L. Epidemiology of complex regional pain syndrome: a retrospective chart review of 134 patients. Pain. 1999 Apr. 80(3):539-44. [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. 1975 Oct. 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. 2008 Mar. 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. Inchiosa MA Jr, Kizelshteyn G. Treatment of complex regional pain syndrome type I with oral phenoxybenzamine: rationale and case reports. Pain Pract. 2008 Mar-Apr. 8(2):125-32. [Medline].

  21. van Eijs F, Geurts J, van Kleef M, Faber CG, Perez RS, Kessels AG, et al. Predictors of pain relieving response to sympathetic blockade in complex regional pain syndrome type 1. Anesthesiology. 2012 Jan. 116(1):113-21. [Medline].

  22. 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. 2009 Dec. 23(12):1059-66. [Medline].

  23. McCabe CS, Haigh RC, Ring EF, Halligan PW, Wall PD, Blake DR. A controlled pilot study of the utility of mirror visual feedback in the treatment of complex regional pain syndrome (type 1). Rheumatology (Oxford). 2003 Jan. 42(1):97-101. [Medline].

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

  25. Tan AK, Duman I, Taskaynatan MA, Hazneci B, Kalyon TA. The effect of gabapentin in earlier stage of reflex sympathetic dystrophy. Clin Rheumatol. 2007 Apr. 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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