Reflex sympathetic dystrophy (1)

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Reflex sympathetic dystrophy (1)

  1. 1. Reflex SympatheticDystrophy
  2. 2. HISTORYAmbroise Pare 17thcentury: “burning pain after nerveinjury”Weir Mitchell 1872: “Causalgia”a. burning painb. Allodyniac. Autonomic ChangesSudeck 1900: Regional demineralisation with posttraumatic painEvans 1946: “RSD”International Association For Study of Pain:“CRPS 1” = RSD“ CRPS 2” = Causalgia
  3. 3. CRPS RSD Algodystrophy Sudeck’s Atrophy Shoulder Hand Syndrome Causalgia
  4. 4. CRPS 11. Without nerve lesion2. Burns, blunt trauma,sprain, stroke, shingles3. A/w: Anxiety disorderDependency,insecurityPersonality disorders,Sense ofDissatisfactionCRPS 21. With nerve lesion2. Crush injury, laceration
  5. 5. IASP CRITERA “Initiating Noxious Event:-External/Internal Hyperalgesia, continuing pain, allodynia outof proportion to the inciting event e/o oedema, changes in skin blood flow orabnormal sudomotor activity in region of pain Absence of any alternative explanation forthe symptoms +FOR CRPS II: Known nerve injury
  6. 6. PATHOLOGY Poorly understood Theories: CRPS 1:-1. Ongoing nociceptor input that maintains acentral state of hyper excitability forprolonged periods2. Inflammatory cause: resembles it andrelieved by steroids
  7. 7. Sympatheticallymaintained painNociceptor inputmaintained by ineracnbtw Primary afferentsand sympatheticefferents throughalpha adrenergicmechanismSympatheticallyindependent painMaintaining nociceptorinput comes from othercauses such asperipheral nervestimulationEg: Neuroma
  8. 8. INJURYREACTIVE VASOMOTOR SPASMLOSS OF VASCULAR TONEVASODILATIONBONE RESORBTIONDECREASED MOBILITYDECREASED CIRCULATONFIBROSIS/SHORTENING OF INVOLVED LIGAMENTS
  9. 9. SIGNS & SYMPTOMS Pain Vasomotor changes Trophic changesWithin3 weeks – 6 monthsof original injury
  10. 10.  AUTONOMIC1. B/L temp. difference (Dynamic)2. Skin Discoloration3. Subcutaneous Thickening4. Peripheral Oedema RADIOLOGIC: Osteopenia
  11. 11.  SENSORY1. Sensitivity2. Muscle bellytenderness3. Hyperalgesia overbony prominences,hyperpathia MOTOR1. Muscle atrophy/weakness2. Joint stiffness3. Muscle contractures4. Mechanical allodynia
  12. 12.  3 Patterns of spreading Symptoms1. Continuous type2. Mirror Image type3. Independent type
  13. 13. STAGESBased on severity and chronologySTAGE I. MILDDays/wks after injuryPain/swelling/dysfunction - localizedExaggerated symptomsLimb relatively immobile and sensitiveMay last up to 3 months
  14. 14. STAGE II :Increased chronicityIncreased symptom severityLimb increasingly coldOedema +Skin mottledLasts 3-12 monthsImmobilization – Joint stiffness
  15. 15. STAGE III: ATROPHICMost severeSymptoms near intoleranceOccurs > 1 year onDystrophic changes in skin, muscle and boneUNRESPONSIVE TO Rx - PERMANENT
  16. 16. 3 PREREQOISITES FORDIAGNOSIS Persistent lesion or injury Predisposing constitution Abnormal sympathetic arc
  17. 17. DIAGNOSTIC CRITERIA BYKOZEN Persistent andDiffuse painin the hand Loss offunction of thehand AutonomicDysfunctionRelief by interruptionof Sympathetic reflex
  18. 18.  RADIOGRAPHY1/3rdpts. Normal X ray pictureOsteopenia in affected limb(after 2-4 weeks of symptoms)Increased Power Doppler Flow in RSD ofLower Extrimity
  19. 19.  BONE SCAN / SCINTIGRAPHYPreferred Diagnostic testINCREASED UPTAKE—CRPS INDUCEDOSTEOPENIA MacKinnon & Holder- strictest criteria for diagnosis of RSD in handREQUIRED DIFFUSE INCREASE IN DELAYEDPERIARTICULAR UPTAKE IN ALL JOINTS OFAFFECTED HAND
  20. 20. BEST DIAGNOSTIC &PROGNOSTIC TESTLA block of appropriate sympathetic gangliaNovocain (5% Procaine hydrochloride) used as apharmacologic neural blockerSTELLATE GANGLION – ULLUMBAR PARAVERTEBRAL GANGLIA – LLGuanethadine: Initially symptoms increase thendecreasePhentolamine test: Alpha adrenoceptors blocked
  21. 21. TREATMENT Educate regarding therapeutic goals Minimize pain Physiotherapy Determine contribution of SNS to the pain
  22. 22.  PhysiotherapyElevation, massage, contrast baths, stockingsAIM: improve jt. ROM & muscle strength Acupuncture TENS- 1. Non invasive 2. No side effects
  23. 23.  Psychiatric treatment Alternative treatmentsa. Qi emission b. Qi instructionThermal biofeedback, Relaxation training,supportive psychotherapy
  24. 24. PHARMACOLOGY1. Corticosteroids :- Prednisolone 30mg /day x 12 weeksDECREASES: pain, edema, inflamn, ectopicelectrical activity after nerve injury2. Bisphosphonates :-7.5 mg/250 ml of saline daily x 3 daysINCREASES ROM3. Mannitol 10%, 1000ml/24 hrs x 1 week4. Dimethyl sulfoxide cream 50% on the skin5. N-acetyl cysteine 600mg tid
  25. 25.  CONSTANT PAIN+ INFLAMMATIONN.S.A.I.D.S CONSTANT PAIN – INFLAMMATIONTramadol CONSTANT PAIN – SLEEP DISTURBEDAnti-depressants, Oral lidocaine, Mexiletine SPONTANEOUS PAROXYSMAL JABSAnticonvulsants SYMPATHETICALLY MEDIATED PAINClonidine patch MUSCLE CRAMPS/ DYSTONIABaclofen
  26. 26. SYMPATHETIC BLOCKS 3-6 tries Diagnostic, therapeutic, prognostic Continuous sympathetic block preferredover serial blocks
  27. 27.  Stellate ganglion block Axillary Sympathectomy Lower limb Sympathectomy
  28. 28. Effective Sympathetic Denervation Horner’s syndrome Skin temp 34 deg. 50% increase in skin blood flow Abolition of skin resistance response
  29. 29.  Post sympathectomy pain1. Proximal to original pain2. Resolves on its ownORAfter sympathetic blocks
  30. 30. THANK YOU

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