Reflex Sympathetic Dystrophy Surgery Workup

  • Author: Satishchandra Kale; Chief Editor: Mary Ann E Keenan, MD   more...
 
Updated: May 22, 2012
 

Laboratory Studies

  • Reflex sympathetic dystrophy remains largely a clinical diagnosis, and laboratory studies are not helpful.
Next

Imaging Studies

  • Radiography
    • Soft-tissue swelling and regional osteopenia may be present in patients with reflex sympathetic dystrophy. Regional osteopenia is evident on plain films in 80% of extremities (see image below). Radiograph of affected extremity, depicting regionRadiograph of affected extremity, depicting regional osteopenia contrasted with normal radiographic appearance of the opposite extremity.
    • Five radiographic patterns have been described by Genant et al.[15]
      • Irregular resorption of trabecular bone giving patchy appearance
      • Subperiosteal bony resorption
      • Intracortical bone resorption
      • Endosteal bone resorption
      • Surface erosions in subchondral and juxtacortical bone
  • Bone scanning
    • Three-phase technetium-99m is commonly used.
    • Scan findings are considered positive if flow is asymmetric in phases 1, 2, and/or 3.
    • Bone scans do not correlate with symptoms or provide prognostic information.
Previous
Next

Other Tests

  • Diagnostic sympathetic blockade - Pain relief following sympatholytic intervention (eg, IV phentolamine administration) is indicative of reflex sympathetic dystrophy.
  • Thermography - Sweating is analyzed using the following:
    • Resting sweat output (RSO)
    • Quantitative sudomotor axon reflex test (QSART)
  • Experimental investigations include the following:
    • Total digital blood flow using digital temperature measurements and laser Doppler flowmetry
    • Vital capillaroscopy - A technique using Doppler flowmetry to gauge anatomic vascular mapping and capillary blood flow in the affected extremity. (In such an extremity, enlarged, dilated, distorted, and irregularly spaced capillary loops are depicted. In addition, nail-fold capillaries may be absent in patients with underlying connective-tissue disease.)
  • Questionnaires used for subjective complaints of pain include the following:
    • Visual analogue score (VAS)
    • McGill pain questionnaire
Previous
Next

Procedures

  • A phentolamine block suggests sympathetically mediated pain (SMP) syndrome. A positive result to a phentolamine block test usually indicates a good prognosis with significant relief following administration of IV sympatholytic drugs.
Previous
Next

Histologic Findings

Because reflex sympathetic disease is a condition that seldom is treated surgically, histopathologic descriptions are rare.

Pathologic findings from osteonecrotic femoral head specimens have been studied extensively based on intramedullary pressures (IMP) and intraosseous phlebography.

The gross appearance is as follows:

  • Spongy bone
  • Easily collapsible trabeculae
  • Medullary necrosis
  • Trabecular necrosis

The microscopic appearance is as follows:

  • Areas of vascular stasis and fibrosis
  • Lipoblastomatosis
  • Thickened arteriolar walls
  • Preserved articular cartilage and synovium
  • Thickening and retraction of the joint capsule limiting movements of the joints
  • No tendon involvement
Previous
Next

Staging

  • The triphasic course of vasomotor instability has been used to stage reflex sympathetic dystrophy.
    • Phase 1: The limb is swollen, hot, pink, and dry.
    • Phase 2: The limb is swollen, cool, blue, and damp with sweat.
    • Phase 3: The edema and vasomotor irritability have settled, resulting in a largely contracted extremity.
Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Satishchandra Kale  MD, FRCS(UK), FRCS (Tr.& Orth.), M.Ch (Orth.), Diploma in Sports and Exercise Medicine(UK), MS(Orthopaedics), D.Ortho, MBA (International Business)

Satishchandra Kale is a member of the following medical societies: Bombay Orthopedic Society, British Orthopaedic Association, and Royal College of Surgeons of Edinburgh

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

Disclosure: Medscape Salary Employment

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, 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

  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. 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. 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. Jan 2012;116(1):113-21. [Medline].

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

  24. 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].

 
Previous
Next
 
Reflex sympathetic dystrophy following surgery for Dupuytren contracture.
Radiograph of affected extremity, depicting regional osteopenia contrasted with normal radiographic appearance of the opposite extremity.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.