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PubMedDate not supplied

Reflex sympathetic dystrophy of the knee. Causes, diagnosis, and treatment.

Sixty patients with the diagnosis of reflex sympathetic dystrophy of the knee were evaluated retrospectively at our institution. The average followup was 2 years. Fifty-five (92%) patients treated with outpatient sympathetic blockade had resolution of the symptoms attributed to reflex sympathetic dystrophy. The time from onset of symptoms to initiation of treatment did not affect the ultimate outcome. The prognosis was most closely related to the presence or absence of an anatomic lesion that would continue to act as a painful stimulus. Eighty-one percent (29 of 36) of patients who had a significant anatomic lesion or surgical correction of a lesion had a complete resolution of their knee symptoms. However, only 21% (5 of 24) of patients with a persistent anatomic lesion in the knee had complete resolution. Fourteen patients required preliminary sympathetic blockade therapy before the underlying cause could be identified. This study emphasizes the need for establishing a precise diagnosis before contemplating any surgery of the knee, including arthroscopy. Arthroscopic procedures were the most common event precipitating reflex sympathetic dystrophy in this study.

Adolescent↗
PubMed1993

Reflex sympathetic dystrophy in an adolescent.

The clinical course of an adolescent with reflex sympathetic dystrophy of the foot is presented. The potential problems of establishing objective diagnostic criteria for reflex sympathetic dystrophy are related to the dynamic nature of the disorder. Serial radiographic studies, radionuclide scans, and quantitative densitometric measurements may be useful in combination; isolated cold stress testing and laser Doppler fluxmetry are useful in assessing thermoregulation and vasomotor instability. A regimen of amitriptyline and phenytoin plus physical therapy with stress loading was useful in this patient, but in many patients the course is progressive, leading to chronic pain and debilitation.

Blood Flow Velocity↗
PubMed1999

Reflex sympathetic dystrophy in pregnancy: nine cases and a review of the literature.

OBJECTIVE: To better understand the diagnosis of reflex sympathetic dystrophy of the lower extremities in pregnant women. SUBJECT: Disease analysis using a retrospective series of nine cases and a review of the literature (57 patients and 159 sites of reflex sympathetic dystrophy). RESULTS: This disorder should be considered in any painful pelvic girdle syndrome or lower extremity pain. The hip is involved in 88% of cases. Symptoms develop in the third trimester of pregnancy, between the 26th and the 34th weeks. Magnetic resonance imaging (MRI) provides an early, accurate, and very specific diagnosis, although standard radiography continues to be the first-line diagnostic tool. Fracture occurs in 19% of patients. The etiology and pathophysiology remain unclear, although pregnancy itself appears to play a significant role in this disease. Although locoregional mechanical factors partly explain reflex sympathetic dystrophy. Hypertriglyceridemia appears to be a risk factor. This disorder develops independently, but the conclusion of pregnancy appears to be necessary for cure. Reflex sympathetic dystrophy does not appear to affect the course of the pregnancy. Indications for cesarean delivery remain obstetrical and should be discussed when a fracture is involved. Simple therapeutic management using gentle physical therapy provides rapid and complete recovery in 2-3 months. CONCLUSION: Reflex sympathetic dystrophy during pregnancy remains poorly understood and underestimated. Only joints of the inferior limbs are involved. MRI appears to be the best diagnostic tool. Pathogenesis remains unclear. Fractures are not rare. Treatment should be non-aggressive.

Adult↗
PubMed2005

[Regional transient osteoporosis, and reflex sympathetic dystrophy: the same disease?].

Complex regional pain syndrome, reflex sympathetic dystrophy, regional, transient and migratory osteoporosis, are known as a spectrum of medical conditions that present with pain, edema, erythema, localized osteoporosis and sometimes sympathetic dysfunction. Many factors which are present in these conditions, such as clinical presentation, radiologic findings and a variety of still unclear physiopathologic mechanisms are correlated. We propose that all these conditions are different periods of the same pathology.

Adult↗
PubMed1995

Reflex sympathetic dystrophy. A common clinical avenue for somatoform expression.

Reflex sympathetic dystrophy (RSD) and causalgia appear to reflect identical pictures even though the latter is related to nerve injury and the former is not. Overriding past and present skepticism about a role for the sympathetic system in their cause and treatment, the International Association for the Study of Pain still recommends sympathetic blocks and sympathectomy for both causalgia and RSD. Such fallacy is traceable to fragmentary clinical observations, to ad-hoc experiments, and to traditional neglect of the placebo phenomenon in chronic "neuropathic" pain patients.

Causalgia↗
PubMed1994

Reflex sympathetic dystrophy syndrome.

There has been increasing interest in reflex sympathetic dystrophy syndrome (RSDS) over the past decade. This trend has continued over the past 2 years with the publication of a number of reports and studies, many of which are reviewed here. Progress has been made in understanding RSDS, with the demonstration of increased alpha-adrenergic receptor activity in peripheral nerves following injury. Release of alpha-adrenergic agonists from sympathetic nerve terminals may then cause nociceptor activation and pain. Use of phentolamine, an alpha-adrenergic receptor inhibitor, in a diagnostic test may provide a more specific method for recognizing RSDS.

Humans↗
PubMed1988

Reflex sympathetic dystrophy and cigarette smoking.

Although the cause of reflex sympathetic dystrophy (RSD) remains unknown, hyperactivity of the sympathetic nerves and secondary vasospasm may be pathogenic in this syndrome. A retrospective epidemiologic study of RSD was done on 53 in-patients from 1978-1985. Cigarette smoking was strikingly increased in patient frequency in RSD (68% versus 37% of hospitalized controls, p less than 0.0001). Eighty-seven percent of the patients had a history of trauma or surgery, and 38% had other associated diseases. Cigarette smoking is statistically linked to RSD and may be involved in its pathogenesis by enhancing sympathetic activity, vasoconstriction, or by some other unknown mechanism.

Adolescent↗
PubMed1993

Recurrent reflex sympathetic dystrophy as a manifestation of systemic lupus erythematosus.

Reflex sympathetic dystrophy (RSDS) is a syndrome of hyperesthesia and vasomotor disturbance of an extremity, often following trauma or an inflammatory process. We describe a patient with systemic lupus erythematosus (SLE) and recurrent RSDS involving all 4 extremities at various times during her illness. Treatments, including corticosteroid use, physical therapy and at times sympathetic nerve blockade led to the resolution of each episode. We suggest the diagnosis of RSDS be considered in patients with connective tissue diseases who present with atypical pain syndromes not attributable to their primary illness.

Adolescent↗
PubMed1991

[Neurologic aspects of clinical manifestations, pathophysiology and therapy of reflex sympathetic dystrophy (causalgia, Sudeck's disease)].

The symptomatology of reflex sympathetic dystrophy (RSD), a diagnostic term which today includes causalgia and M. Sudeck, is characterized clinically by a triad of autonomic (sympathetic), motor and sensory disturbances. They develop following a noxious event--though independent of its nature and location--in a generalized distribution pattern at the distal site of the affected extremity. Pathophysiologically, a complex disturbance of the sympathetic vasoconstrictor system is involved, which mediates the dominant symptoms of RSD, namely the spontaneous pain and the swelling. This disturbance is thought to be initiated by nociceptive impulses, occurring in conjunction with the preceding noxious event, and to be maintained reflexly, in a form of a vicious circle, by means of the typical pain sensation accompanying the RSD-syndrome. From these ideas, an important part of the RSD therapy is deduced; i.e. the early interruption of the neuronal sympathetic activity by means of a sympathetic blockade. Such a blockade can interrupt the pain and at the same time also the vicious circle of RSD. Altogether, for the RSD syndrome there are relevant neurological aspects with respect to its clinical symptomatology, its pathophysiology and its therapy.

Autonomic Nerve Block↗
PubMed1991

Reflex sympathetic dystrophy. Objective clinical signs in diagnosis and treatment.

Diagnosis and follow-up treatment of reflex sympathetic dystrophy is difficult because of the subjective, nonspecific nature of its primary symptom, burning pain. Early diagnosis and aggressive treatment of reflex sympathetic dystrophy with epidural nerve blocks improves clinical resolution. Temperature difference between extremities and dependent cyanosis are reliable objective signs for clinical diagnosis and the evaluation of progress for treatment for reflex sympathetic dystrophy.

Adolescent↗
PubMed1996

Haemodynamic changes in early phase reflex sympathetic dystrophy.

We studied six patients with early phase reflex sympathetic dystrophy (RSD). Osteoporotic changes were noted in the bones of the affected limb. Despite higher temperatures indicated by thermography, laser speckle image sensing showed no increase in blood flow on the skin surface. Digital subtraction angiography showed arteriovenous shunting or increased density of perfused vessels. Based on these results, we speculate that in RSD persistent vascular contraction caused by pain leads to the formation of arteriovenous shunts in the affected limb with an ischaemic state in the peripheral subcutaneous tissue which is indicated by pain and swelling.

Angiography, Digital Subtraction↗
PubMed1983

Reflex sympathetic dystrophy in a 14-year-old female.

Reflex sympathetic dystrophy (RSD) consists of an extremity with (1) burning or causalgic pain, (2) limitation of motion, (3) edema with or without pitting, (4) dystrophic skin changes, (5) vasomotor phenomena and (6) patchy osteoporosis on x ray. This disease is rare in adolescents, but of patients with RSD up to 8% are between 11 and 19 years of age. Most cases in this age group resolve after immobilization, analgesics or steroid therapy, surgical ganglionic blockade or sympathectomy. This case report is of a 14-year-old girl who was treated with all these measures, but continues to have significant residual deformity.

Adolescent↗
PubMed1989

Epidural spinal cord stimulation in the management of reflex sympathetic dystrophy.

Eighteen subjects with intractable pain due to reflex sympathetic dystrophy (RSD) underwent treatment by epidural spinal cord stimulation (SCS). All the patients had previously undergone multiple sympathetic blocks and/or surgical sympathectomy with either no results or only temporary therapeutic effects. Four subjects did not experience any beneficial effects during a 1-week trial and the electrode was removed, and 14 patients had the system internalized surgically. In 4 cases two separate systems (electrode + pulse generator) were implanted, in order to cover distant areas of the body involved by the disease (neck, shoulders, upper extremities, trunk and lower extremities). Follow-up varies from 4 to 14 months. In the implanted group, pain relief was absent in 3 patients, minimal in 1, moderate in 5 and good in 6. Pain relief was strictly limited to the body parts covered by the parasthesiae induced by SCS. In 3 patients, SCS produced visible changes in the swelling of the painful extremities. None of the patients was made neurologically worse. In 7 patients there were technical problems related to electrode breakage or migration, change in the pattern of paresthesiae and poor connection due to body fluid infiltration. All the problems were corrected surgically under local anesthesia. SCS has some value in the management of refractory RSD pain in selected cases. Because of the limited series and follow-up, its value in the comprehensive management of RSD requires further investigation.

Adolescent↗
PubMed2001

Reflex sympathetic dystrophy with hidradenitis suppurativa exacerbation: a case report.

Reflex sympathetic dystrophy (RSD) or complex regional pain syndrome type 1, is characterized by spontaneous pain or allodynia and hyperalgesia disproportionate to the inciting event, multiperipheral nerve involvement, edema, vasomotor or sudomotor change, and possible loss of function. It has been described in relation to various insults, including a number of infectious and inflammatory conditions. We report a case of a patient who developed RSD 1 week after an exacerbation of hidradenitis suppurativa, a rare chronic inflammatory disease of apocrine sweat glands. The patient responded well to a combination of range-of-motion exercises, thermal modalities, and oral steroids. Hidradenitis suppurativa should be considered when searching for an etiology of new onset RSD.

Aged↗
PubMed1994

X-ray bone densitometry in the diagnosis and followup of reflex sympathetic dystrophy syndrome.

OBJECTIVE: To establish bone involvement in reflex sympathetic dystrophy syndrome (RSDS). METHODS: Bone mineral density (BMD g/cm2) and bone mineral content (BMC g) were measured by dual X-ray absorptiometry. We studied 12 patients with phase I RSDS and 18 controls. RESULTS: BMD and BMC were significantly lower in the involved side of patients (28.4 and 45.1%, respectively) compared with the contralateral normal limb. Controls only showed a minimal variation of 2.17% in BMD and 4.38% in BMC between right and left measures. The difference between patients and controls was highly significant (p < 0.001). A second measurement of BMD and BMC was made in 8 patients following treatment (prednisone or calcitonin) and showed increments in both variables, which was significant in the affected limbs (20.1%). CONCLUSION: We believe that X-ray bone densitometry is a highly sensitive and specific technique to evaluate bone mass in patients with RSDS and aid in diagnosis and treatment monitoring.

Absorptiometry, Photon↗
PubMed1988

Reflex sympathetic dystrophy of the knee after sensory nerve injury.

Reflex sympathetic dystrophy (RSD) of the knee is an extremely difficult problem to treat. This study examined the possible relationship between isolated injury to the infrapatellar branch of the saphenous nerve (IPBSN) and the etiology and natural course of RSD. Thirty-five patients with clinically significant sympathetic dystrophy of the knee were examined retrospectively. All patients (100%) had clinical evidence of insult to the IPBSN. Thirty-three patients (94%) were found to have vasomotor instability as measured by isolated cold stress testing (ICST). All patients in this population of 33 were treated with vasoactive therapies. Subjective improvement was noted in 20 patients (p = NS). Initial ICSTs of improved and unimproved patients were compared. Baseline temperatures were significantly warmer in patients who improved with therapy (p less than 0.05), and a warmer trend was evident throughout all phases of the test in those who improved compared with those who did not. Eighty percent of patients treated within 1 year improved with one or more vasoactive therapies, whereas only 44 percent improved when treatment was started after 1 year, indicating a significant population difference (p less than 0.05).

Adult↗
PubMed1998

Reflex sympathetic dystrophy of the lower limbs after kidney transplantation.

Reflex sympathetic dystrophy syndrome (RSDS) is a rarely described complication after different types of organ transplants. Three out of 147 kidney recipients treated at our center during the last 6 years developed severe bilateral symmetrical pain in the ankles and knees, with great difficulties in walking 2-3 months after kidney transplantation. Clinical examination revealed periarticular soft tissue swelling and vasomotor changes with no effusion. Patchy osteoporotic patterns were seen radiographically in clinically affected areas. Scintigraphy showed increased epiphyseal uptake of 99mTc with a periarticular distribution. Clinical symptoms, radiographic, and scintigraphic signs were compatible with so-called RSDS. The exact cause of the syndrome remained obscure. All patients received standard immunosuppression with cyclosporine A (CyA), azathioprine, and prednisone. Symptoms of RSDS improved when doses of CyA were reduced and blood levels declined; patients were treated with calcitonin and calcium channel blockers simultaneously. Non-steroidal antiinflammatory drugs were not effective in symptom relief. In all three cases, most probably spontaneous complete recovery was achieved over the course of 2-8 months; no one patient progressed to aseptic osteonecrosis.

Adult↗