Balloon atrial septostomy under two-dimensional echocardiographic control: a new outlook

The comorbidity of eating disorders and reflex sympathetic dystrophy syndrome in the same patients raises the possibility of a common pathway for both conditions. Reflex sympathetic dystrophy syndrome may be manifesting itself in those individuals who have sympathetic overdrive. Microtrauma, often induced by compulsive exercise, and depression may be contributory factors. It is recommended that: patients with eating disorders who develop pain in an extremity should be investigated for possible reflex sympathetic dystrophy syndrome; patients with reflex sympathetic dystrophy syndrome should be discouraged from dieting, and eating disorders should be suspected if they begin to lose weight or are already malnourished.     

Algodystrophy (reflex sympathetic dystrophy syndrome) and causalgia: novel concepts regarding the nosology, pathophysiology, and pathogenesis of complex regional pain syndromes. Is the sympathetic hyperactivity hypothesis wrong?

Concepts regarding the nosology, pathophysiology and pathogenesis of reflex sympathetic dystrophy syndrome are currently in a state of flux. Causalgia and reflex sympathetic dystrophy syndrome are now generally felt to be on the same continuum and as a result interest for defining criteria for the latter condition has waned. The pathogenic role of adrenergic sympathetic activity has been so successfully challenged that the last international consensus conference judged inappropriate any reference to the sympathetic system in the terms used to designate these conditions, thus confirming the position long defended by most French authors. The vasomotor abnormalities may be due to antidromic release of neuromediators by the endings of polymodal C fibers. These fibers do not belong to the sympathetic system but often travel with sympathetic nerves, a characteristic that may explain the efficacy of sympathetic nerve blocks, although other possibilities exist including a placebo effect. Also, efferent sympathetic fibers may undergo activation by nonadrenergic mediators. The mechanisms capable of initiating and perseverating activation of polymodal C afferents are being actively investigated and have been found to exhibit similarities with the mechanisms underlying peripheral and central sensitization of pain-producing afferents. Growth factors, such as nerve growth factor, may play an important role in causalgia. In "reflex sympathetic dystrophy syndrome", microcirculatory stasis may contribute to the initiation or perpetuatation of the disorders. Further work on the nerve supply to the venular network and on the venoarterial reflex is needed.     

Calcitonin treatment in reflex sympathetic dystrophy: a preliminary study

Reflex sympathetic dystrophy is one of the important complications effecting the rehabilitation programmes of hemiplegic patients in a negative manner by causing pain and function loss. In this study, the aim was to investigate the effects of salmon calcitonin treatment in reflex sympathetic dystrophy that develops in hemiplegia. Forty-one patients with hemiplegia resulting from cerebrovascular events and stage 1-2 reflex sympathetic dystrophy were included in the study. Salmon calcitonin, 1 x 100 IU/day intramuscularly for 4 weeks, was administered to 25 of these patients (calcitonin group) to the other 16 patients physiological saline, 1 ml/day intramuscularly for 4 weeks, was administered (control group). At the end of the fourth week of treatment the pain score of the calcitonin group was significantly lower than that of the control group. Shoulder abduction and external rotation, wrist flexion and metacarpophalangeal extension of the calcitonin group were found to be significantly better than those of the control group. In the calcitonin group the significant decrease in pain and tenderness resulted in improvement of range of motion and motor functions.     

Urological symptomatology in patients with reflex sympathetic dystrophy

PURPOSE: We determined the effect of reflex sympathetic dystrophy on lower urinary tract function. MATERIALS AND METHODS: A total of 20 consecutive patients (16 women and 4 men) with neurologically verified reflex sympathetic dystrophy was referred for voiding symptoms, including urgency, frequency, incontinence and urinary retention. No patient had had voiding symptoms before the initial trauma that induced reflex sympathetic dystrophy. Evaluation included medical history, physical examination, video urodynamic testing and cystoscopy. RESULTS: Mean patient age was 43.4 +/- 10.2 years (range 28 to 58) and mean duration of urological symptoms was 4.9 +/- 3.6 years (range 1 to 14). Urodynamic study demonstrated a mean cystometric bladder capacity of 417 +/- 182 ml. (range 120 to 700). The urodynamic diagnoses included detrusor hyperreflexia in 8 patients, detrusor areflexia in 8, sensory urgency in 3 and detrusor hyperreflexia with detrusor-external sphincter dyssynergia in 1. In 4 women genuine stress urinary incontinence was also documented urodynamically. CONCLUSIONS: Reflex sympathetic dystrophy may have a profound effect on detrusor and sphincter function.     

Reflex sympathetic dystrophy syndrome and osteogenesis imperfecta. A report and review of the literature

A case of multifocal reflex sympathetic dystrophy (RSDS) in a patient with the tarda form of osteogenesis imperfecta is described, followed by a review of the literature. Microfractures of the trabecular bone in these patients are proposed to be the initial stimulus in the pathogenesis of RSDS by a mechanism similar to the one involved in the pathogenesis of RSDS complicating other diseases associated with bone fragility.     

Upper limb reflex sympathetic dystrophy associated with occult malignancy

Reflex sympathetic dystrophy, characterized by pain, swelling, vasomotor instability, and trophic changes in an extremity, has been infrequently described in patients with occult malignancy. Two cases of reflex sympathetic dystrophy associated with local tumor involvement are reported. Both patients had a history of cancer in clinical remission. Despite aggressive physical therapy measures, the patients' symptoms persisted. Workup of the first patient found an apical paravertebral mass in the lung; biopsy revealed recurrent breast carcinoma. In the second case, workup found an axillary mass contiguous with the lower brachial plexus. Biopsy revealed lymphoma, a second primary malignancy. In both cases, medical treatment of the tumor was instituted, with consequent improvement of hand and shoulder function. Both patients required prolonged hospitalization and multiple procedures that might have been avoided if malignancy had been suspected. Spontaneous development of reflex sympathetic dystrophy in patients with a history of cancer should alert the physician to the possibility of occult malignancy.     

Reflex sympathetic dystrophy: result of autonomic denervation?

1. To investigate the nature of sympathetic dysfunction in the pathogenesis of reflex sympathetic dystrophy, the microcirculatory vasoconstrictive responses to dependency were investigated in the skin of the hand of 76 reflex sympathetic dystrophy patients with unilateral disease by means of laser Doppler flowmetry (in perfusion units) and capillary microscopy. The patients were divided into three stages according to their perception of skin temperature (stage I in the case of a stationary warmth sensation, stage II in the case of an intermittent warmth and cold sensation, and stage III in the case of a stationary cold sensation). The vasoconstrictive responses were induced by lowering of the affected hand. 2. As compared to controls, the mainly sympathetically mediated vasoconstrictive response at thermoregulatory level of the skin microcirculation, as measured by laser Doppler flowmetry, was attenuated at stage I (1.82 versus 1.41, P < 0.05), stage II (1.82 versus 1.09, P < 0.0001) and stage III (1.82 versus 1.14, P < 0.01), suggesting the involvement of sympathetic denervation at all stages of the reflex sympathetic dystrophy syndrome. This sympathetic denervation may also account for the observed increase in thermoregulatory skin blood flow at stage I as compared to controls (152 versus 81, P < 0.01). 3. Since sympathetic denervation has been reported to cause increased sensitivity of vascular structures to catecholamines, the decrease in thermoregulatory skin blood flow at stages II (54 versus 81, P < 0.05) and III (31 versus 81, P < 0.05), both as compared to controls, may result from hypersensitivity to catecholamines of skin microvessels. 4. The sympathetically independent vasoconstrictive response at the nutritive level of skin microcirculation, as measured by capillary microscopy, was impaired only at stage III as compared to controls (1.04 versus 2.06, P < 0.05). This divergence in microvascular reactivity upon dependency of the nutritive and thermoregulatory subsystems also supports the hypothesis of sympathetic dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)     

Occurrence and etiology of tooth caries in wearers of fixed dentures during the war]

This retrospective study was undertaken to determine the usefulness of intravenous regional anesthetic (IVRA) blocks containing ketorolac and lidocaine in the management of sympathetically-mediated pain, and to determine what factors, if any, predicted success with this technique. Sixty-one patients with reflex sympathetic dystrophy presenting to a university-affiliated teaching hospital's pain management center were evaluated. Patients underwent one or more treatments with IVRA blocks containing ketorolac and lidocaine. The duration of pain, site of extremity affected, pain symptomatology, duration of relief from the first IVRA block, absence of pain following a series of IVRA blocks and side-effects from the IVRA blocks were determined. Of the 61 patients, 16 had complete response (26 percent), 26 had a partial response (43 percent) and 19 had no response (31 percent) to the ketorolac-containing IVRA. The only symptom which predicted a failure with this therapy was allodynia. No patient had serious side effects from the IVRA block; dizziness following tourniquet release occurred in 41 percent (n = 25) of the patients. IVRA block containing ketorolac is a useful and minimally invasive technique for the management of patients with reflex sympathetic dystrophy.     

Reflex sympathetic dystrophy syndrome secondary to organophosphate intoxication induced neuropathy

Reflex sympathetic dystrophy or Sudeck's atrophy is a syndrome that can usually be followed by a traumatic insult. This disorder is accompanied by signs and symptoms of vasomotor instability, trophic skin changes, and rapid development of bony demineralization. This report presents a case with reflex sympathetic dystrophy syndrome secondary to organophosphate intoxication induced neuropathy. The patient was threated with calcitonin well.     

The reflex sympathetic dystrophy syndrome in patients who have had a spinal cord injury

Patients suffering from a spinal cord injury often present with a pain syndrome. Although the reflex sympathetic syndrome is a common diagnosis in some forms of neurological disease such as patients with a stroke, it is less frequent in those with a spinal lesion. The authors report eight patients with reflex sympathetic dystrophy who had a spinal cord injury. The diagnosis and treatment are discussed along with a review of literature.     

Epidural spinal cord stimulation for treatment of chronic pain--some predictors of success. A 15-year experience

BACKGROUND: We have used epidural spinal cord stimulation (SCS) for pain control for the past 15 years. An analysis of our series of 235 patients has clarified the value of specific prognostic parameters in the prediction of successful SCS. METHODS: Patients were followed up for periods ranging from 6 months to 15 years with a mean follow-up of 66 months. The mean age of the 150 men and 85 women in the study was 51.4 years. Indications for SCS included failed back syndrome (114 patients), peripheral vascular disease (39 patients), peripheral neuropathy (30 patients), multiple sclerosis (13 patients), reflex sympathetic dystrophy (13 patients), and other etiologies of chronic intractable pain (26 patients). RESULTS: One hundred and eighty-nine patients received permanent devices; 111 (59%) of these patients continue to receive satisfactory pain relief. Pain attributable to failed back syndrome, reflex sympathetic dystrophy, peripheral vascular disease of lower limbs, multiple sclerosis, and peripheral neuropathy responded favorably to spinal cord stimulation. In contrast, paraplegic pain, cauda equina syndrome, stump pain, phantom limb pain, and primary bone and joint disease pain did not respond as well. Cases of cauda equina injury had promising initial pain relief, but gradually declined after a few years. After long-term follow-up, 47 of the 111 successfully implanted patients were gainfully employed, compared with 22 patients before implantation. The successful patients reported improvements in daily living as well as a decrease in analgesic usage. Multipolar stimulation systems were significantly more reliable (p < 0.001) than unipolar systems. Complications included hardware malfunction, electrode displacement, infection, and tolerance. CONCLUSION: Aside from etiologies of pain syndromes as a prognostic factor, we have identified other parameters of success. In patients who have undergone previous surgical procedures, the shorter the duration of time to implantation, the greater the rate of success (p < 0.001). The diagnosis of failed back syndrome must be considered a confounding factor in our analysis. Those patients whose pain did not follow a surgical procedure had better responses to SCS than patients who had multiple surgical procedures prior to their first implant. The advent of multipolar systems has significantly improved clinical reliability over unipolar systems. Age, sex, and laterality of pain did not prove to be of significance.     

Reflex sympathetic dystrophy syndrome associated with phenobarbital

Reflex sympathetic dystrophy syndrome (RSDS) is clinically characterized by pain and edema of one or more extremities, trophic skin changes and vasomotor instability. Although the pathogenesis is unknown, it could be caused by an abnormal reflex of the sympathetic nervous system. Different studies haven't yet confirmed the classical division in three clinical phases (warm, of vasomotor instability and cold). Barbiturates are the precipitating event in 10-30% of cases. We describe the clinical features of a patient with RSDS associated with phenobarbital who needed corticosteroid treatment. The Technetium diphosphate bone scan (Tc 99m DPD) is very useful because there is an increased radionuclide uptake in the involved areas during the early phases of the disease and precedes in some weeks the radiologic signs. The Magnetic Resonance Imaging (MRI) may be useful because of the early signs it shows. The patient may develop contractures and atrophy of the involved extremities in spite of the indispensable withdrawal of the drug.     

Significance of the BTA test in bladder cancer: a multicenter trial. BTA Study Group Japan

Complex regional pain syndrome (CRPS) is a progressive, chronic illness that is enigmatic because the mechanisms for its pathogenesis have yet to be determined. Syndromes synonymous with CRPS are reflex sympathetic dystrophy, reflex neurovascular dystrophy, causalgia, algoneurodystrophy, sympathetically maintained pain, clenched fist syndrome, and Sudek's syndrome. The diagnosis of CRPS is categorized into three stages: acute, dystrophic, and atrophic. CRPS is most often precipitated by peripheral trauma (crushing injuries, lacerations, fractures, sprains, burns, or surgery) to soft tissue or nerve complexes. The pathogenesis for CRPS has been speculated as being either a disease process of the peripheral nerves, a disease process of peripheral soft tissue, or a disease process of the spinal cord. Patients suffering from CRPS may be limited in their ability to function in a self-directed, independent fashion. A longitudinal study of CRPS on 1,348 patients revealed that 96% of the study subjects still suffer some pain and disability regardless of the duration of the disease or course of treatment. Although the primary etiology for CRPS is not clearly understood, key progress has been made in terms of establishing a psychological as well as therapeutic treatment plan once the diagnosis has been made.     

Somatic or sympathetic block for reflex sympathetic dystrophy. Which is indicated?

Patients with reflex sympathetic dystrophy (complex regional pain syndromes) are often referred to pain medicine physicians for assistance in providing pain control during rehabilitation of their painful upper extremity. When deciding which pain control technique to use in an individual patient, physicians must consider both somatic and sympathetic blocks. Each of these nerve blocks has advantages and disadvantages that may be tailored to an individual patient's pain state and rehabilitation program to optimize recovery.     

Massive swelling of the tongue in two patients following the repair of cleft palate]

A laser Doppler perfusion imager (LDPI) for evaluation of skin blood flow is presented and its use illustrated in two cases with a presumptive diagnosis of reflex sympathetic dystrophy (RSD) treated with local anesthetic sympathetic blocks. Among the advantages are the good spatial resolution over the area measured (12 x 12 cm) and that measurements can be done without contact with the skin. Generating a complete image takes 4.5 min but if higher temporal resolution is needed continuous measurements at one point are possible by use of another software routine.     

Thoracoscopic sympathectomy: the U.S. experience

OBJECTIVE: 48 patients underwent TSSYM. Charts of patients undergoing thoracoscopy were reviewed to assess the safety and efficacy of thoracoscopic sympathectomy (TSSYM). DESIGN: A retrospective review was undertaken at four United States medical centers. RESULTS: TSSYM was performed for reflex sympathetic dystrophy in 27 patients, hyperhydrosis palmaris in 15 patients, and Raynaud's upper extremity ischemia and splanchnic pain in 2 patients each. Anesthesia with one lung ventilation was used. 2.9 ports were used per patient and 0.8 chest tubes were placed per patient. All patients underwent resection of the sympathetic chain, usually with a clip along the bottom of the resected chain. Laser, electro-ablation and electroresection were not used by any of the surgeons in his series. The mean length of hospital stay was 1.8 days. CONCLUSIONS: TSSYM is a safe and effective technique for treatment of a variety of thoracic disorders.     

M-CAVI, a neoadjuvant carboplatin-based regimen for the treatment of T2-4N0M0 carcinoma of the bladder

Dupuytren's disease is a proliferative fibroplasia that can lead to a significant contracture of the metacarpophalangeal (MCP) and interphalangeal (IP) joints, causing a functional disability. Surgical excision of the Dupuytren's tissue and release of the contracted joints may be necessary to restore function. Most patients require hand therapy postoperatively. Postoperative complications have been reported at 17%. These include excessive inflammation, hematoma, ischemic skin necrosis, infection, granuloma formation, transient paresthesia, scar contracture, persistent proximal interphalangeal (PIP) flexion contracture, distal interphalangeal (DIP) hyperextension deformity, joint stiffness, poor flexion and grip strength, pain, and reflex sympathetic dystrophy (RSD). The hand therapist plays a vital role in the early detection and treatment of many of these complications.     

Posterior transsphincteric approach for the surgery of the rectum

We report the angiographic and venographic findings in a case of reflex sympathetic dystrophy syndrome (RSDS) of the lower extremity. The hypervascular intraosseous lesion which initially simulated an arteriovenous malformation provides important information about the vascular nature of this lesion.     

Setting an uncorrected visual acuity standard for police officer applicants

The Madelung deformity can result in pain and decreased function of the wrist and hand. None of the surgical techniques available has been shown consistently to improve grip strength, range of movement or relieve pain. In this prospective study we have treated 18 patients with the Madelung deformity (25 wrists) by wedge subtraction osteotomy of the radius and shortening of the ulna. Our results show statistically significant improvement in grip strength and range of movement of the wrist and forearm. Pain improved in 80% of the patients and 88% were satisfied with the appearance. One patient had a wound infection and another developed reflex sympathetic dystrophy. Two had some recurrence due to continued growth of the ulna and it is recommended that the procedure be delayed until skeletal maturity, or else combined with epiphysiodesis of the ulna.