Segmental reflex sympathetic dystrophy: clinical and scintigraphic criteria

Clinical and scintigraphic criteria are proposed for the diagnosis of segmental reflex sympathetic dystrophy. Eight patients met previously described clinical criteria for reflex sympathetic dystrophy with involvement limited to only a portion of the hand. The delayed phase of the three-phase radionuclide bone scan was found to be highly sensitive (100%) for this small group of patients. Consecutive bone scans (n = 127) performed during a 6-month period for a variety of upper extremity problems were reviewed, and a segmentally diffuse pattern of tracer uptake was found to be highly specific (98%) for segmental reflex sympathetic dystrophy. Recognition and documentation of a more localized form of reflex sympathetic dystrophy will allow earlier recognition and treatment, which is an important factor in a successful outcome for managing pain dysfunction disorders.     

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.     

Bisphosphonate therapy of reflex sympathetic dystrophy syndrome

Four cases of post-operative ulnar nerve mononeuropathy are reported. In all the cases a severe sensory and motor loss was strictly limited to ulnar nerve territory. The electrophysiological examination: needle examination, motor and sensory nerve conduction studies and even more somatosensory potential evoked from ulnar nerve after stimulation above elbow allowed to eliminate a lesion at the elbow and to asses the lesion at wrist, arm, axilla or plexus. Full recovery occurred once and partial recovery twice. We considered that these ulnar lesions are neuralgic amyotrophies of Parsonage and Turner according to the epidemiological, clinical, evolutive and electrophysiological data.     

Role of neuropeptides in pathogenesis of reflex sympathetic dystrophy

In 1993, a study was undertaken at the Hand Clinics of Loyola University Medical Center in Chicago to investigate the role of the neuropeptides in the pathogenesis of Reflex Sympathetic Dystrophy. All of the patients had recurrent or continuous pain, swelling, and stiffness of one or both extremities following either acute trauma or surgical intervention. All of the patients showed a markedly increased level of bradykinin as well as calcitonin gene-related peptide. The levels of bradykinin were four times as high as the controls. A few showed increased levels of the other neuropeptides. With these results, we agree with Veldman, Goris and others who consider Reflex Sympathetic Dystrophy to be an exaggerated regional inflammatory disorder.     

Validation of thermography in the diagnosis of reflex sympathetic dystrophy

OBJECTIVES: To examine the validity of several thermogram-derived indices of autonomic functioning in the diagnosis of reflex sympathetic dystrophy (RSD). DESIGN: A series of chronic pain patients were classified diagnostically based on thermogram results using discriminant function analysis, and validity measures (e.g., sensitivity, specificity) were used to determine the accuracy of computerized thermographic pixel analysis in discriminating RSD from other pathology. SETTING: The study was conducted at the Rush Pain Center, a multidisciplinary outpatient pain clinic. PATIENTS: A series of 46 chronic pain patients referred for suspected sympathetically mediated pain. INTERVENTIONS: All patients underwent computerized thermographic examination under a baseline condition after acclimating to a climate-controlled room, immediately after a cold challenge was applied to the contralateral uninvolved extremity (4 degrees C for 90 s) and 20 min after the cold challenge. OUTCOME MEASURES: Temperature during the three experimental periods, degree of temperature asymmetry between affected and nonaffected limbs during the three periods, response to cold challenge, and recovery following cold challenge were measured. RESULTS: Temperature asymmetry accurately discriminated between RSD and non-RSD patients, with the most accurate asymmetry measures obtained at baseline. Responses to cold challenge and actual temperature values did not discriminate between RSD and non-RSD pain patients. CONCLUSIONS: Thermography can be a useful component of RSD diagnosis. In situations where sensitivity and specificity are equally important, an asymmetry cutoff of 0.6 degree C appears optimal. If specificity (i.e., accurately ruling out non-RSD cases) is more important, a cutoff of 0.8 degree C or 1.0 degree C may be considered as well.     

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.     

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.     

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.     

Migraine headache following stellate ganglion block for reflex sympathetic dystrophy

The alteration of extracranial blood flow in conjunction with clinical signs of autonomic nervous system dysfunction have led to various explanations concerning the pathophysiology of migraine headache. Reflex sympathetic dystrophy, a painful disorder of the sympathetic nervous system, can be treated by blocking the sympathetic nerves located in the stellate ganglion, resulting in vasodilation, ptosis, miosis, and anhydrosis. In theory, these changes could trigger a migraine headache attack secondary to autonomic dysfunction reflecting an imbalance between sympathetic and parasympathetic nervous systems. This may be especially true in a patient with a previous history of meningitis that may have resulted in a disorder of cerebrovascular regulation. We report a 56-year-old man with no previous history of migraine who developed migraine with aura after a stellate ganglion block. These episodic headaches occurred with decreasing frequency and severity for over 6 months, with eventual complete resolution. This interesting phenomenon has not been reported in the English literature and may help to better understand the pathophysiology of migraine.     

Calcitonin and otosclerosis: a preliminary clinical note

Otosclerosis is a disorder characterized by alternating periods of bone resorption and formation as a result of a disturbance in the enzymatic balance of the otic capsule and stapedial footplate. In some cases, calcitonin administration improved the metabolic abnormalities associated with the disease. This hormone inhibits bone resorption produced by osteoclasts and facilitates osteoblastic accretion. The authors describe the results obtained in a patient with aggressive otosclerosis who experienced an improvement in hearing and tinnitus after treatment with salmon calcitonin.     

Reflex sympathetic dystrophy in childhood: a case report

A case report is presented of a 15-year-old girl with reflex sympathetic dystrophy (RSD). She was referred to hospital because of left upper limb pain. Her left upper limb was cold, edematous and blue with a limited active range of movement. The serum concentration of noradrenaline was lower on the painful side than on the healthy side, and neurotropin, which has an antinociceptive effect to hyperalgesia, was clearly effective. Early diagnosis and management is essential in the treatment of RSD and administration of neurotropin is a useful and non-invasive treatment without severe adverse effects.     

An 11-year-old girl with reflex sympathetic dystrophy successfully treated by thoracoscopic sympathectomy

A facile one-pot synthesis of (E)-4-hydroxy-2-alkenals such as (E)-4-hydroxy-2-nonenal, (E)-4-hydroxy-2-heptenal, and (E)-4-hydroxy-2-hexenal was achieved from the corresponding (2E,4E)-2,4-alkadienals by reduction-oxygenation with molecular oxygen and triethylsilane in the presence of cobalt(II) porphyrin as a catalyst followed by treatment with trimethylphosphite.     

Severe complications of reflex sympathetic dystrophy: infection, ulcers, chronic edema, dystonia, and myoclonus

To study the relationship of IA-2 antibodies (IA-2A) to other autoantibodies and genetic risk markers in insulin-dependent diabetes mellitus (IDDM), 758 children and adolescents younger than 15 years of age (mean age 8.4 years) with newly diagnosed diabetes were analysed for IA-2A, GAD antibodies (GADA) and insulin autoantibodies (IAA) with radiobinding assays, for islet cell antibodies (ICA) with immunofluorescence and for HLA DR alleles by serology. IA-2A were detected in 85.9% of cases with no association with gender or age. An overwhelming majority of the patients (71.3%) tested positive for three or more antibodies, and 90.7% for at least two. Fifty-four subjects (7.1%) had one antibody detectable, whereas only 2.1% of the patients tested negative for all four. A higher proportion of patients was positive for IA-2A and/or GADA than for ICA alone (95.5 vs 84.2%, p < 0.001). The prevalence and level of IA-2A were increased in cases carrying HLA DR4/non-DR3 compared with other DR combinations. The results indicate that almost all patients with newly diagnosed childhood IDDM can be identified by screening with these four autoantibodies. The combination of IA-2A and/or GADA had a higher sensitivity for IDDM than ICA alone. The close association between IA-2A and HLA DR4, the strongest single allele predisposing to IDDM, suggests that IA-2A may be a more specific marker of beta-cell destruction than GADA, which have been shown to associate with the DR3 allele and thyroid autoimmunity.     

Reflex sympathetic dystrophy: the clinician''s perspective

An experimental study was undertaken in dogs with carbon tetrachloride (CCl4) intoxication to describe and follow the changes in the ultrasound appearance of the liver. Characteristic ultrasound features (enlarged liver, increased echogenicity with fine, tightly-packed echoes, and loss of echogenicity of the portal vein walls) were seen from day 2 of the experiment, culminating between days 2 and 7. Subsequently the liver gradually and almost completely regained its normal ultrasound appearance. Ultrasonographic findings corresponded to the severity of the clinicopathological parameters, and changed parallel with the results of liver biopsies. Histology of the biopsy samples revealed acute centrolobular lipid accumulation with necrobiosis and necrosis in the hepatocytes in the first stage of the disease. In the second stage, a secondary reparatory-inflammatory process and reparation in the interstitial tissue were seen. In some dogs, ill-defined hyperechoic foci were observed within the liver during the regenerative phase. Hepatic ultrasonography seems to be a reliable and relatively sensitive method for monitoring liver dystrophy with necrobiosis and lipid accumulation and to follow the course of steatosis in clinical cases. Ultrasound-guided biopsy can further improve the diagnostic accuracy of ultrasonography in liver dystrophy.     

Reflex sympathetic dystrophy syndrome: an update

A classification of acute dysfunctions of the vital organs and systems in cases with multiple organ failure is proposed. It is suggested to assess the function as satisfactory, compensatory sufficiency, decompensated insufficiency, or failure. Clinical laboratory criteria of such rating are offered. Experience gained in the use of this classification is presented.     

Pain, negative mood, and perceived support in chronic pain patients: A daily diary study of people with reflex sympathetic dystrophy syndrome.

Chronic pain patients show substantial psychological distress, including depressed mood, anxiety, and anger. Nevertheless, the causal role of negative mood in the course of chronic pain conditions remains unclear. This study prospectively investigated the relationship between daily pain, negative mood, and social support in 109 people with reflex sympathetic dystrophy syndrome. Participants completed 28 daily diaries that included questions about pain, mood, and perceived support. Time-lagged within-subject analyses indicated that pain led to increases in depressed, anxious, and angry mood. Depressed mood, but not anxiety or anger, contributed to increases in pain. Perceived support had both main and buffering (interaction) effects on negative mood and a main effect on pain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)