Reflex Sympathetic Dystrophy_ [Print] - eMedicine Radiology

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Reflex Sympathetic Dystrophy_ [Print] - eMedicine Radiology

  1. 1. 21/08/10 1:33 PMReflex Sympathetic Dystrophy: [Print] - eMedicine Radiology Page 1 of 12http://emedicine.medscape.com/article/394928-print emedicine.medscape.com eMedicine Specialties > Radiology > Musculoskeletal Reflex Sympathetic Dystrophy Lawrence E Holder, MD, Clinical Professor, Department of Radiology, University of Florida, Shands Jacksonville Medical Center Updated: Oct 20, 2009 Introduction Background Reflex sympathetic dystrophy (RSD), also known as complex regional pain syndrome (CRPS), is an incompletely understood response of the body to an external stimulus, resulting in pain that usually is nonanatomic and disproportionate to the inciting event or expected healing response. As early as the 1930s and 1940s, a short circuit in the reflex arc between somatic afferent sensory fibers and autonomic sympathetic efferents was postulated to explain overall increased sympathetic stimulation. Currently, no specific pathologic, histologic, or biochemical markers of this condition exist.[1,2,3 ] Reflex sympathetic dystrophy of the hand. Delayed image palmar view reveals increased tracer diffusely involving the entire right wrist, metacarpals, and phalanges, with juxta-articular accentuation. Relatively less increased uptake is observed distally, but all areas are involved. The dot of increased activity distal to the third ray is a hot marker indicating the right side.
  2. 2. 21/08/10 1:33 PMReflex Sympathetic Dystrophy: [Print] - eMedicine Radiology Page 2 of 12http://emedicine.medscape.com/article/394928-print Reflex sympathetic dystrophy of the foot. Delayed image plantar view reveals increased tracer uptake diffusely involving the lowermost right leg, ankle, tarsals, metatarsals, and phalanges. Uptake is less distally than proximally, but all areas are involved. The dot of increased activity distal to fifth toe is a hot marker indicating the right side. Although controversy continues regarding the term, definition, and process of diagnosis, the presence of sympathetically maintained pain is accepted as an etiology for, or at least as a significant component of, many regional pain problems.[4,5 ] Recent studies According to Andresen et al, outpatient CT-assisted temporary thoracic sympathetic nerve blockade is an effective adjunct therapy, with a low complication rate, for complex regional pain syndrome (CRPS). In their study, in addition to physiotherapy and pharmacotherapy with analgesics and calcitonin, sympathetic nerve blockade was performed 3 times, at 2-day intervals. The CT-assisted puncture was performed in the prone position at the level of the intervertebral space of the second and third thoracic vertebrae. All patients reported immediate pain relief. Color-coded duplex ultrasonography of the arteries of the affected limb was performed before and after puncture and showed increased peripheral blood flow.[6 ] Sharma et al collected epidemiologic and other data regarding CRPS, via the Reflex Sympathetic Dystrophy Syndrome Association of America, to help elucidate the epidemiology, symptoms, progression, therapy, and psychosocial factors related to the disease.[7 ] Their findings included the following: It most often affects white women 25-55 years of age. It is often precipitated by trauma (surgical or nonsurgical) and commonly involves the lower extremities (approximately 56%) and upper extremities (approximately 38%). Pain is usually accompanied by edema, vasomotor, sudomotor, motor, and trophic changes. It commonly spreads to other areas of the body. Multiple pharmacologic and nonpharmacologic interventions usually fail. It frequently interferes with work (approximately 62% disability rate), sleep (approximately 96%), mobility (approximately 86%), and self-care (approximately 57%).
  3. 3. 21/08/10 1:33 PMReflex Sympathetic Dystrophy: [Print] - eMedicine Radiology Page 3 of 12http://emedicine.medscape.com/article/394928-print Both remission and relapse are common. Clinical guidelines The following are the clinical diagnostic criteria for CRPS[8 ] : (1) Continuing pain, which is disproportionate to any inciting event (2) Must report at least one symptom in 3 of the 4 following categories: Sensory: Reports of hyperesthesia and/or allodynia Vasomotor: Reports of temperature asymmetry and/or skin color changes and/or skin color asymmetry Sudomotor/Edema: Reports of edema and/or sweating changes and/or sweating asymmetry Motor/Trophic: Reports of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin) (3) Must display at least 1 sign at time of evaluation in 2 or more of the following categories: Sensory: Evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement) Vasomotor: Evidence of temperature asymmetry and/or skin color changes and/or asymmetry Sudomotor/Edema: Evidence of edema and/or sweating changes and/or sweating asymmetry Motor/Trophic: Evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin) (4) There is no other diagnosis that better explains the signs and symptoms Presentation Demographics Patients younger than 50 years predominate. In the upper extremity, orthopedic surgeons see children only rarely. Rheumatologists, who generally use less strict criteria for diagnosis, report a slightly higher frequency of involvement in children. Similarly, pediatricians report a moderate frequency of lower extremity neurovascular or neuroregulatory disease in children that has been termed reflex sympathetic dystrophy (RSD). In these children, a bone scan pattern often reveals marked decreased tracer uptake on delayed images compared to increased uptake in adults; therefore, this may represent a different condition, such as pseudodystrophy. In the upper extremity, the author's experience demonstrates a clear female preponderance, especially in patients presenting to the orthopedic surgeon.
  4. 4. 21/08/10 1:33 PMReflex Sympathetic Dystrophy: [Print] - eMedicine Radiology Page 4 of 12http://emedicine.medscape.com/article/394928-print The incidence of reflex sympathetic dystrophy (RSD) following trauma is difficult to estimate, since the literature is replete with studies in which clinical criteria for the diagnosis of RSD vary dramatically, with many often equating unexplained pain to RSD.[9 ] For example, upper extremity RSD, as understood and treated by hand surgeons, is described differently than lower extremity RSD diagnosed by rheumatologists or hip RSD described by obstetricians. Some authors suggest that 8-10% of patients with fracture develop RSD, but in this author's experience, the frequency is much lower. Most reflex sympathetic dystrophy patients recover completely over time.[10 ]Uncommonly, the syndrome progresses to the point of incapacitation and a "claw hand" is observed. Presentation and natural history Reflex sympathetic dystrophy (RSD) involving the hand, wrist, shoulder, ankle, and foot has been established, with diffuse involvement of adjacent carpals or tarsals, metacarpals or metatarsals, phalanges, and, frequently, the distal forearm or leg.[7,11 ] Rarely, segmental involvement of 1, 2, or 3 rays of the hand is observed. Involvement of the knee, although described, is less well documented and, along with focal pain conditions in the hip (often interchangeably termed reflex sympathetic dystrophy or transient osteoporosis), may be a different process.[12,13 ] Radiologists and orthopedic surgeons usually agree to define reflex sympathetic dystrophy (RSD) (as stated by Schutzer[14 ]) as an "excessive or exaggerated response to an injury of an extremity, manifested by four somewhat constant characteristics: (1) intense or unduly prolonged pain, (2) vasomotor disturbances, (3) delayed functional recovery, and (4) various associated trophic changes." The key feature is pain, which often is the initial presenting symptom. Various clinical schemas have been proposed that relate stages of disease to signs and symptoms and the time elapsed since the inciting event.[15 ]One example of staging by Rosenthal and Wortmann[16 ]is as follows: Stage 1 has a duration of weeks to months. The limb has nonfocal pain, swelling with associated joint stiffness and decreased range of motion, and increased skin temperature. Stage 2 has a duration of 3-6 months. Pain continues but decreases over time. Swelling evolves into thickening of the dermis and fascia. Early signs of atrophy and osteoporosis become evident, and the extremity becomes cooler. Stage 3 is the atrophic stage. Pain continues and atrophy is exacerbated by continued decreased range of motion and increased joint stiffness. The extremity is cooler with decreased vascularity. Symptomatically, reflex sympathetic dystrophy (RSD) is a condition of the extremities. Reflex sympathetic dystrophy is known and accepted best when it affects the upper extremity, predominantly in a regional distribution involving the distal forearm, wrist, hand, and, occasionally, the arm and shoulder. No pathophysiologic mechanism has been established. Efferent sympathetic nervous system overactivity and/or abnormal activity involving spinal internuncial neurons, peripheral nociceptors, and/or mechanoreceptors have been postulated.[17,18 ] Many biomechanical factors have been considered, beginning with tissue injury as an initial inciting event, with substance P, histamine, and prostaglandins all possibly involved. Other possible etiologies include vasodilatation, shunting, and regional hypoxia associated with nociceptor stimulation,[19 ]as well as the role of alpha-adrenergic receptors in maintaining and controlling thermoregulatory modulation. Segmental involvement of 1, 2, or 3 rays in the hand has been reported infrequently, according to Kline and Holder,[20 ] and bilateral involvement is rare to nonexistent. In the lower extremity (most often foot and ankle), a less well-defined clinical pattern also is associated with a similar spectrum of pathophysiologic speculations.[21 ] In the knee, potentially sympathetically related postoperative and posttraumatic signs and symptoms have been ascribed to RSD or other neuroregulatory processes but with less accepted clinical or diagnostic standards of reference. More recently, the term complex regional pain syndrome (CRPS)
  5. 5. 21/08/10 1:33 PMReflex Sympathetic Dystrophy: [Print] - eMedicine Radiology Page 5 of 12http://emedicine.medscape.com/article/394928-print has been introduced to encompass a variety of chronic pain syndromes, with RSD labeled as type I.[22,23,24,25 ] All sympathetically maintained pain syndromes (SMPS) may not be RSD. Preferred Examination Radiologic examination Radionuclide bone imaging (RNBI) is the only generally accepted imaging technique to provide objective and relatively specific evidence of reflex sympathetic dystrophy (RSD) in the upper and lower extremities, predominantly the hands and feet.[26 ]Delayed bone imaging has been reported to be up to 100% sensitive for the variant of sympathetically maintained pain termed RSD by hand and foot surgeons. Plain radiography is only 60% sensitive and not specific; when positive, radiographs often show only osteoporosis, occasionally in combination with soft tissue swelling or diffuse soft tissue atrophy. No consistent findings have been found in the occasional study done with other imaging modalities, and none are suggested for diagnosis. Nonimaging diagnostic testing Pain in response to mild cooling stimuli: A drop of acetone or ethyl chloride spray provoking severe pain suggests SMPS rather than a sympathetically independent pain syndrome (SIPS). Phentolamine test: The blocking of alpha-adrenergic receptors by intravenous phentolamine compared to a placebo helps classify patients as SMPS versus SIPS. Limitations of Techniques Patients are observed who present with acute or subacute pain and vasomotor or neuroregulatory signs or symptoms and who do not demonstrate the classic diffuse increased uptake on delayed RNBI. The relationship of these patients to those with abnormal RNBI remains unexplained. Differential Diagnoses [Reiter Syndrome, Musculoskeletal] Abdominal Aortic Aneurysm, Diagnosis Osteoarthritis, Primary Osteomyelitis, Acute Pyogenic Osteomyelitis, Chronic Rheumatoid Arthritis, Hands Other Problems to Be Considered Algodynia Algodystrophy Diffuse cellulitis Diffuse local trauma Neuroregulatory abnormalities Pseudodystrophy Phlebitis Regional migratory osteoporosis Scleroderma of the hands Sudeck atrophy Transient bone marrow edema[27 ] Transient osteoporosis
  6. 6. 21/08/10 1:33 PMReflex Sympathetic Dystrophy: [Print] - eMedicine Radiology Page 6 of 12http://emedicine.medscape.com/article/394928-print Transient osteoporosis of the hip Transient regional osteoporosis Vascular injuries Radiography Findings Osteoporosis, although found in as many as 60% of patients with upper extremity reflex sympathetic dystrophy (RSD), is not specific, often representing changes of disuse secondary to the pain associated with RSD. Occasionally, soft tissue swelling or diffuse soft tissue atrophy may be seen; these are nonspecific findings. Magnetic Resonance Imaging Findings MRI changes in established reflex sympathetic dystrophy (RSD) rarely have been evaluated, and as with studies using other modalities, the definition of RSD has varied considerably. In one study by Schweitzer et al[28 ]involving the lower extremity (n=35), soft tissue thickening with and without contrast enhancement (n=31) was demonstrated without any marrow changes, while in another study of the upper extremity (n = 17) by Koch et al,[29 ] no marrow changes and only inconsistent soft tissue or muscle signal changes were seen. In the hand, Sintzoff et al[30 ]used MRI to detect what was believed to be bone marrow edema and then equated bone marrow edema to RSD. MRI thus is not an established technique in the imaging evaluation of RSD. Ultrasonography Findings A single-power Doppler study by Nazarian et al[31 ] involving the lower extremities suggested increased flow without side-to-side asymmetry in patients with reflex sympathetic dystrophy (RSD). Ultrasound thus is not an established technique in the imaging evaluation of RSD. Nuclear Imaging Findings Three-phase radionuclide bone imaging (RNBI) is performed primarily because the differential diagnosis often includes infection or other lesions for which information about the perfusion to the extremity (phase I) or relative vascularity of the extremity (phase II) is helpful. For regional reflex sympathetic dystrophy (RSD) of the hand or foot, the hallmark on the radionuclide angiogram (RNA; phase I) is diffuse increased perfusion to the entire extremity, including the distal forearm or leg and, occasionally, reaching the shoulder or hip, even when the inciting lesion is distal. Similar diffuse increased vascularity, manifested by diffuse increased tracer accumulation on blood pool or tissue-phase images (phase II) is seen. On these images, juxta-articular accentuation may be seen. RNA findings are abnormal in approximately 40% of patients and blood pool findings in approximately 50%, most often in clinical stage I or II of the disease. Delayed images demonstrate diffuse increased tracer throughout the hand or foot, including the wrist or ankle, with juxta-articular accentuation and, often, proximal uptake involving the forearm or leg and, occasionally, the shoulder and arm or hip and femur. Activity in the hands or feet usually is more prominent proximally than distally, but the amount of abnormal tracer uptake has not been correlated with clinical severity. Quantification occasionally has been helpful but is not used routinely.
  7. 7. 21/08/10 1:33 PMReflex Sympathetic Dystrophy: [Print] - eMedicine Radiology Page 7 of 12http://emedicine.medscape.com/article/394928-print Degree of Confidence When radionuclide bone imaging (RNBI), especially in the upper extremity, demonstrates classic diffuse findings, reflex sympathetic dystrophy (RSD) is certain (specificity). When RNBI does not demonstrate that pattern, the most common variant of sympathetically maintained pain syndrome (SMPS) or complex regional pain syndrome (CRPS) type 1 is excluded (sensitivity). In the lower extremity, patients with severe infection, especially if underlying diabetes mellitus is present, may demonstrate diffuse increased delayed image tracer uptake on RNBI performed to diagnose osteomyelitis. This is not usually a diagnostic issue clinically. Multimedia Media file 1: Reflex sympathetic dystrophy of the hand. Delayed image palmar view reveals increased tracer diffusely involving the entire right wrist, metacarpals, and phalanges, with juxta-articular accentuation. Relatively less increased uptake is observed distally, but all areas are involved. The dot of increased activity distal to the third ray is a hot marker indicating the right side.
  8. 8. 21/08/10 1:33 PMReflex Sympathetic Dystrophy: [Print] - eMedicine Radiology Page 8 of 12http://emedicine.medscape.com/article/394928-print Media file 2: Reflex sympathetic dystrophy of the foot. Delayed image plantar view reveals increased tracer uptake diffusely involving the lowermost right leg, ankle, tarsals, metatarsals, and phalanges. Uptake is less distally than proximally, but all areas are involved. The dot of increased activity distal to fifth toe is a hot marker indicating the right side. References 1. Albazaz R, Wong YT, Homer-Vanniasinkam S. Complex regional pain syndrome: a review. Ann Vasc Surg. Mar 2008;22(2):297-306. [Medline]. 2. Broggi G. Pain and psycho-affective disorders. Neurosurgery. Jun 2008;62(6 Suppl 3):901-19; discussion 919- 20. [Medline]. 3. Gann C. Reflex sympathetic dystrophy/complex regional pain syndrome. AAOHN J. Feb 2008;56(2):88. [Medline]. 4. Nath RK, Mackinnon SE, Stelnicki E. Reflex sympathetic dystrophy. The controversy continues. Clin Plast Surg. Jul 1996;23(3):435-46. [Medline]. 5. Fournier RS, Holder LE. Reflex sympathetic dystrophy: diagnostic controversies. Semin Nucl Med. Jan 1998;28(1):116-23. [Medline]. 6. Andresen R, Radmer S, Nickel J, Fischer G, Brinckmann W. [Ambulatory CT-assisted thoracic sympathetic block as an additional approach to treatment of complex regional pain syndromes after sport injuries]. Sportverletz Sportschaden. Mar 2009;23(1):35-40. [Medline]. 7. Sharma A, Agarwal S, Broatch J, Raja SN. A web-based cross-sectional epidemiological survey of complex regional pain syndrome. Reg Anesth Pain Med. Mar-Apr 2009;34(2):110-5. [Medline]. 8. Harden RN. Complex Regional Pain Syndrome: Treatment Guidelines. Reflex Sympathetic Dystrophy Association. Available at http://www.rsds.org/3/clinical_guidelines/index.html. Accessed October 20, 2009. 9. Schinkel C, Scherens A, Köller M, Roellecke G, Muhr G, Maier C. Systemic inflammatory mediators in post- traumatic complex regional pain syndrome (CRPS I) - longitudinal investigations and differences to control groups. Eur J Med Res. Mar 17 2009;14(3):130-5. [Medline]. 10. Hsu ES. Practical management of complex regional pain syndrome. Am J Ther. Mar-Apr 2009;16(2):147- 54. [Medline].
  9. 9. 21/08/10 1:33 PMReflex Sympathetic Dystrophy: [Print] - eMedicine Radiology Page 9 of 12http://emedicine.medscape.com/article/394928-print 11. 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]. 12. Driessens M. Infrequent presentations of reflex sympathetic dystrophy and pseudodystrophy. Hand Clin. Aug 1997;13(3):413-22. [Medline]. 13. Small E. Reflex sympathetic dystrophy: reflections from a clinician. Adolesc Med State Art Rev. May 2007;18(1):221-5, xii. [Medline]. 14. Schutzer SF, Gossling HR. The treatment of reflex sympathetic dystrophy syndrome. J Bone Joint Surg Am. Apr 1984;66(4):625-9. [Medline]. 15. Wong GY, Wilson PR. Classification of complex regional pain syndromes. New concepts. Hand Clin. Aug 1997;13(3):319-25. [Medline]. 16. Rosenthal AK, Wortmann RL. Diagnosis, pathogenesis, and management of reflex sympathetic dystrophy syndrome. Compr Ther. Jun 1991;17(6):46-50. [Medline]. 17. Holder LE, Mackinnon SE. Reflex sympathetic dystrophy in the hands: clinical and scintigraphic criteria. Radiology. Aug 1984;152(2):517-22. [Medline]. 18. Lamé IE, Peters ML, Patijn J, Kessels AG, Geurts J, van Kleef M. Can the outcome of spinal cord stimulation in chronic complex regional pain syndrome type I patients be predicted by catastrophizing thoughts?. Anesth Analg. Aug 2009;109(2):592-9. [Medline]. 19. Wesselmann U, Raja SN. Pain: nociceptive and neuropathic mechanisms. Reflex sympathetic dystrophy and causalgia. Anesthesiol Clin North America. 1997;15:407-27. 20. Kline SC, Holder LE. Segmental reflex sympathetic dystrophy: clinical and scintigraphic criteria. J Hand Surg [Am]. Sep 1993;18(5):853-9. [Medline]. 21. Holder LE, Cole LA, Myerson MS. Reflex sympathetic dystrophy in the foot: clinical and scintigraphic criteria. Radiology. Aug 1992;184(2):531-5. [Medline]. 22. Huge V, Lauchart M, Förderreuther S, Kaufhold W, Valet M, Azad SC, et al. Interaction of hyperalgesia and sensory loss in complex regional pain syndrome type I (CRPS I). PLoS ONE. Jul 23 2008;3(7):e2742. [Medline]. 23. Guttmann O, Wykes V. Images in clinical medicine. Complex regional pain syndrome type 1. N Engl J Med. Jul 31 2008;359(5):508. [Medline]. 24. 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]. 25. Eisenberg E, Shtahl S, Geller R, Reznick AZ, Sharf O, Ravbinovich M, et al. Serum and salivary oxidative analysis in Complex Regional Pain Syndrome. Pain. Aug 15 2008;138(1):226-32. [Medline]. 26. Mackinnon SE, Holder LE. The use of three-phase radionuclide bone scanning in the diagnosis of reflex sympathetic dystrophy. J Hand Surg [Am]. Jul 1984;9(4):556-63. [Medline]. 27. Korompilias AV, Karantanas AH, Lykissas MG, Beris AE. Bone marrow edema syndrome. Skeletal Radiol. Jul 16 2008;[Medline]. 28. Schweitzer ME, Mandel S, Schwartzman RJ, et al. Reflex sympathetic dystrophy revisited: MR imaging findings before and after infusion of contrast material. Radiology. Apr 1995;195(1):211-4. [Medline].
  10. 10. 21/08/10 1:33 PMReflex Sympathetic Dystrophy: [Print] - eMedicine Radiology Page 10 of 12http://emedicine.medscape.com/article/394928-print 29. Koch E, Hofer HO, Sialer G, et al. Failure of MR imaging to detect reflex sympathetic dystrophy of the extremities. AJR Am J Roentgenol. Jan 1991;156(1):113-5. [Medline]. 30. Sintzoff S, Sintzoff S, Stallenberg B, Matos C. Imaging in reflex sympathetic dystrophy. Hand Clin. Aug 1997;13(3):431-42. [Medline]. 31. Nazarian LN, Schweitzer ME, Mandel S, et al. Increased soft-tissue blood flow in patients with reflex sympathetic dystrophy of the lower extremity revealed by power Doppler sonography. AJR Am J Roentgenol. Nov 1998;171(5):1245-50. [Medline]. 32. Amadio PC, Mackinnon SE, Merritt WH, et al. Reflex sympathetic dystrophy syndrome: consensus report of an ad hoc committee of the American Association for Hand Surgery on the definition of reflex sympathetic dystrophy syndrome. Plast Reconstr Surg. Feb 1991;87(2):371-5. [Medline]. 33. Poncelet C, Perdu M, Levy-Weil F, et al. Reflex sympathetic dystrophy in pregnancy: nine cases and a review of the literature. Eur J Obstet Gynecol Reprod Biol. Sep 1999;86(1):55-63. [Medline]. 34. Schiepers C. Clinical value of dynamic bone and vascular scintigraphy in diagnosing reflex sympathetic dystrophy of the upper extremity. Hand Clin. Aug 1997;13(3):423-9. [Medline]. 35. Veldman PH, Reynen HM, Arntz IE, Goris RJ. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet. Oct 23 1993;342(8878):1012-6. [Medline]. Keywords reflex sympathetic dystrophy, complex regional pain syndrome type I, CRPS-I, sympathetically mediated pain syndrome, SMPS, causalgia, algodystrophy, algodynia, Sudek's atrophy, Sudek atrophy, shoulder-hand syndrome, RSD Contributor Information and Disclosures Author Lawrence E Holder, MD, Clinical Professor, Department of Radiology, University of Florida, Shands Jacksonville Medical Center Lawrence E Holder, MD is a member of the following medical societies: American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine Disclosure: Nothing to disclose. Medical Editor Leon Lenchik, MD, Director, Densitometry Minifellowship, Assistant Professor, Department of Radiology, Wake Forest University Medical Center Leon Lenchik, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America Disclosure: Nothing to disclose. Pharmacy Editor Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand Disclosure: Nothing to disclose. Managing Editor Wilfred CG Peh, MD, MBBS, FRCP(Glasg), FRCP(Edin), FRCR, Clinical Professor, Faculty of Medicine, National University of Singapore; Senior Consultant Radiologist, Alexandra Hospital, Singapore
  11. 11. 21/08/10 1:33 PMReflex Sympathetic Dystrophy: [Print] - eMedicine Radiology Page 11 of 12http://emedicine.medscape.com/article/394928-print Wilfred CG Peh, MD, MBBS, FRCP(Glasg), FRCP(Edin), FRCR is a member of the following medical societies: American Roentgen Ray Society, British Institute of Radiology, International Skeletal Society, Radiological Society of North America, Royal College of Physicians, and Royal College of Radiologists Disclosure: Nothing to disclose. CME Editor Robert M Krasny, MD, Resolution Imaging Medical Corporation Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America Disclosure: Nothing to disclose. Chief Editor Felix S Chew, MD, MBA, EdM, Professor, Department of Radiology, Vice Chairman for Radiology Informatics, Section Head of Musculoskeletal Radiology, University of Washington Felix S Chew, MD, MBA, EdM is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America Disclosure: Nothing to disclose. Further Reading Related eMedicine topics Reflex Sympathetic Dystrophy (Orthopedic Surgery) Reflex Sympathetic Dystrophy (Rheumatology) Reflex Sympathetic Dystrophy (Neurology) Complex Regional Pain Syndromes (Physical Medicine and Rehabilitation) Complex Regional Pain Syndrome (Emergency Medicine) Clinical guidelines Complex regional pain syndrome: treatment guidelines (third edition). Reflex Sympathetic Dystrophy Syndrome Association - Private Nonprofit Organization. 2002 Feb (revised 2006 Jun). 67 pages. NGC:005233 Complex Regional Pain Syndrome: Treatment Guidelines This new edition of the guidelines has been edited by R. Norman Harden, MD, Director, Center for Pain Studies, Addison Chair, Rehabilitation Institute of Chicago; Associate Professor, Physical Medicine & Rehabilitation, Northwestern University, Feinberg School of Medicine, Chicago, IL. Clinical trials Study of Proteins Associated With Complex Regional Pain Syndrome Safety and Efficacy Study of Ethosuximide for the Treatment of Complex Regional Pain Syndrome (CRPS) Autonomic Dysfunction and Spinal Cord Stimulation in Complex Regional Pain Syndrome (CRPS) A Study of the Effect of Lenalidamide on Complex Regional Pain Syndrome Type 1 Pregabalin Versus Placebo as an Add on for Complex Regional Pain Syndrome (CPRS) of the Upper Limb Managed by Stellate Ganglion Block (The PREGA Study) Association Between Focal Dystonia and Complex Regional Pain Syndrome Neurotropin to Treat Chronic Neuropathic Pain Evaluation and Diagnosis of People With Pain and Fatigue Syndromes Safety and Efficacy Study of Ethosuximide for the Treatment of Complex Regional Pain Syndrome (CRPS). © 1994-2010 by Medscape. All Rights Reserved
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