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

Updated: May 08, 2018
  • Author: Satishchandra Kale, MD, MBBS, MBA, MCh(Orth), FRCS(Edin), FRCS(Tr&Orth); Chief Editor: Vinod K Panchbhavi, MD, FACS  more...
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Treatment

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 [14, 15, 16, 12] :

  • Reduction of edema
  • Reduction of reflex muscular contractures
  • Reduction of articular stiffening
  • Pain blockage with mobilization under sympathetic blockade [17]

Management approaches include the following:

  • Prophylactic vitamin supplementation
  • Pharmacologic therapy [18]
  • Physical therapy [19]
  • 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. [20]

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 [21] ); 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. [22]

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Physical and Other Therapies

The following physical therapies may be useful [23, 19] :

  • 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 [24]

Newer interventions include the following:

  • Biofeedback
  • Acupressure
  • Acupuncture
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Surgical Therapy

Surgical/ablative therapies include the following [17] :

  • 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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