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...
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
- Intravenous regional infusions
Other therapies
- Newer interventions include the following:
- Biofeedback
- Acupressure
- Acupuncture
Surgical Care
- Surgical/ablative therapies include the following[22] :
- Chemical sympathectomy
- Surgical sympathectomy
- Implantable electrical stimulators
- Bilateral anterior cingulotomy
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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