Recurrent spontaneous hemarthrosis associated with reflex sympathetic dystrophy

Reflex sympathetic dystrophy is a mysterious entity with unclear pathogenesis. The diagnosis is largely clinical and based on signs and symptoms of pain and vasomotor dysfunction. Treatment is a challenge because the underlying mechanism remains unknown. Our patient is a 75-year-old woman 2 years after left total knee replacement who presented with her second spontaneous hemarthrosis in 3 months. After arthrocentesis, dusky discoloration, edema, hyperesthesia, and decreased range of motion of the left knee and entire distal extremity were noted. Despite analgesia and physical therapy her symptoms worsened. Radiographs of her left knee showed severe periprosthetic osteopenia and a triple phase bone scan was negative. Clinically, reflex sympathetic dystrophy was considered likely and a lumbar sympathetic block was performed. The patient improved and continued to do well after a series of blocks. This is the first reported case of recurrent atraumatic hemarthrosis associated with reflex sympathetic dystrophy.

Long-term epidural ketamine, morphine and bupivacaine attenuate reflex sympathetic dystrophy neuralgia

PURPOSE

There is considerable evidence that NMDA receptor antagonists can abolish nociceptor hypersensitivity in animals. In the present case report, two patients with reflex sympathetic dystrophy were treated with ketamine, a NMDA antagonist, morphine and bupivacaine.

CLINICAL FEATURES

Two patients were referred suffering from severe pain, allodynia, hyperaesthesia, swelling and disability over their right lower legs, diagnosed as reflex sympathetic dystrophy. They had received conventional treatments with non-steroid anti-inflammatory drugs (NSAIDs), steroids, anticonvulsant, antidepressant, epidural lidocaine sympathetectomy and rehabilitation which failed to provide satisfactory pain relief. We administered subanalgesic doses of ketamine (7.5 mg), morphine (0.75 mg) and 6 ml bupivacaine 0.1% via a lumbar epidural catheter three times per day. After several courses of treatment over three and six months, satisfactory pain relief was achieved in each patient. Both are now able to walk with slight weight bearing with the assistance of crutch. The treatment is continuing with further improvement of symptoms and signs.

CONCLUSION

Epidural coadministration of low doses of morphine, ketamine and bupivacaine provided effective pain relief in two patients. This suggests synergy from this combination that provides an alternative treatment for reflex sympathetic dystrophy.

Neurogenic inflammation in an animal model of neuropathic pain

Loose ligation of a rat sciatic nerve (chronic constriction injury (CCI) model) provokes signs and symptoms like those observed in reflex sympathetic dystrophy (RSD) patients. Primary afferent nociceptive C-fibers seem to be involved in an afferent orthodromic as well as in an efferent antidromic manner. In this study we hypothesize that consequent to development of antidromic impulses in C-nociceptive afferents, neuropeptides released from peripheral endings of these fibers, increase skin blood flow (SBF), vascular permeability, and tissue accumulation of polymorphonuclear leukocytes (PMNs). Collectively, these phenomena have been referred to as neurogenic inflammation. To investigate the presence of neurogenic inflammation in the CCI-model, we assessed skin blood flow (SBF) as well as the level of edema and accumulation of PMNs in muscle tissue obtained from the affected hindpaw. SBF was measured, by means of laser Doppler flowmetry, before ligation as well as at day 4 after ligation. At day 4, SBF measurements were performed before and after abolition of the capability of C-fibers to mediate a vasodilator response. To this end, capsaicin was applied perineurally. Increased vascular permeability was inferred from the level of edema of muscle tissue as determined by assessment of wet/dry weight ratios of muscle biopsies. PMN accumulation was investigated by enzymatic detection of myeloperoxidase (MPO) activity in muscle biopsies. Compared with preligation values, at day 4 SBF was increased more than twofold (p < 0.05). The latter response was annihilated by capsaicin application. Compared with sham operated controls, wet/dry ratios were higher in the ligated animals (1.104 vs. 1.068; p < 0.05). Likewise, when compared with sham operated controls, MPO activity was found to be increased in the ligated hindpaw (Optic Density 0.15 vs. 0.89; p < 0.001). In conclusion, the findings of this study indicate that loose ligation of a sciatic nerve induces an inflammatory response in the ipsilateral hindpaw, which most likely is mediated by release of neuropeptides from the peripheral endings of antidromically acting nociceptive C-fibres.

Analysis of 50 patients with atypical odontalgia. A preliminary report on pharmacological procedures for diagnosis and treatment

Atypical odontalgia is a distressing and unusual chronic orofacial pain condition. It is often difficult to diagnose because it is associated with a lack of clinical and radiographic abnormalities. The condition is poorly understood on a pathophysiological basis, and patients often undergo repetitive and unnecessary dental procedures in attempts to alleviate pain. In this study, 50 patients diagnosed with odontalgia were evaluated by pharmacological procedures, including topical anesthetic application and phentolamine infusion. Results of these pharmacological procedures suggest that atypical odontalgia is a neuropathic pain of the oral cavity that may have a component of sympathetically maintained pain. Therapeutic trials of topical capsaicin were carried out to assess its efficacy for pain reduction. Topical capsaicin was effective in most patients.

Recurrent compartment syndrome of the hand: a case report

A young man presented with severe symptoms and markedly elevated hand compartment pressures 5 weeks after undergoing successful decompressive fasciotomies for acute compartment syndrome. The patient's initial postoperative course was complicated by reflex sympathetic dystrophy (RSD). It is hypothesized that the vasomotor instability and the periodic vasospastic episodes associated with RSD prompted postischemic swelling and edema and led to the development of this unusual complication.

Complex regional pain syndrome

The term "complex regional pain syndrome" encompasses causalgia and reflex sympathetic dystrophy. Symptoms of burning pain with autonomic and tissue changes begin shortly after an injury, usually to a distal extremity. The diagnosis is based on the history and the clinical findings. No confirmatory tests are available, although plain radiographs or a three-phase bone scan may be helpful in diagnosing some cases. Aggressive treatment, which may include sympathetic blockade, medications, physical therapy and psychotherapy, is essential for a favorable outcome. Despite treatment, many patients are left with varying degrees of chronic pain and disability.

Effects of cutaneous histamine application in patients with sympathetic reflex dystrophy

Thirty-six patients suffering from acute reflex sympathetic dystrophy (RSD) were examined in order to evaluate nociceptive C-fibers. Axon reflex vasodilatation was induced by iontophoresis of histamine and recorded (laser Doppler flux). The strength of concomitant sensation was rated on a visual analogue scale, and the quality was characterized as itching or burning pain. Skin temperature was recorded by infrared thermography. The results were compared with investigations of unaffected limbs of patients and volunteers. The histamine-induced sensation on the symptomatic side was more often burning pain than itching (P < 0.001), and skin temperature was increased on the affected limb (P < 0.001). Axon reflex vasodilatation and the strength of sensations were unaltered. In conclusion, this study rules out a significant deterioration of afferent C-fibers in RSD, but gives evidence of sensitization of nociceptive function. This nociceptive sensitization has to be taken into consideration for effective treatment of RSD.

Sympathetic nervous system and pain: a clinical reappraisal

The target article discusses various aspects of the relationship between the sympathetic system and pain. To this end, the patients under study are divided into three groups. In the first group, called "reflex sympathetic dystrophy" (RSD), the syndrome can be characterized by a triad of autonomic, motor, and sensory symptoms, which occur in a distally generalized distribution. The pain is typically felt deeply and diffusely, has an orthostatic component, and is suppressed by the ischemia test. Under those circumstances, the pain is likely to respond to sympatholytic interventions. In a second group, called "sympathetically maintained pain" (SMP) syndrome, the principal symptoms are spontaneous pain, which is felt superficially and has no orthostatic component, and allodynia. These symptoms, typically confined to the zone of a lesioned nerve, may also be relieved by sympathetic blocks. Since the characteristics of the pain differ between RSD and SMP, the underlying kind of sympathetic-sensory coupling may also vary between these cases. A very small third group of patients exhibits symptoms of both RSD and SMP. The dependence or independence of pain on sympathetic function reported in most published studies seems to be questionable because the degree of technical success of the block remains uncertain. Therefore, pain should not be reported as sympathetic function independent until the criteria for a complete sympathetic block have been established and satisfied.

Reflex sympathetic dystrophy syndrome with microtrabecular fracture in a patient with osteogenesis imperfecta

A case of reflex sympathetic dystrophy syndrome (RSDS) in a patient with osteogenesis imperfecta (OI) is reported. We discuss the association of OI, manifested by microfractures of the trabecular bone due to marked bone fragility, and the appearance of RSDS. Magnetic resonance imaging (MRI) was helpful in assessing the presence and extent of the trabecular fractures.

Reflex sympathetic dystrophy. Timely diagnosis and treatment can prevent severe contractures

Reflex sympathetic dystrophy is a clinical syndrome consisting of persistent burning pain and varying degrees of vasomotor and trophic changes in an extremity after trauma. Although several mechanisms have been proposed, none have been universally accepted. Historically, treatment has involved sympathetic blockade or sympathectomy to prevent the proposed sympathetic hyperactivity. However, only a limited number of controlled studies have been conducted, and results have been controversial. The cornerstone of treatment is physical therapy to prevent the severe contractures that can result.

Development and preliminary validation of a pain measure specific to neuropathic pain: the Neuropathic Pain Scale

Neuropathic pain syndromes are commonly seen in clinical practice and are frequently used as pain models in testing new therapies. However, no pain scale exists with the primary purpose to measure pain in neuropathic syndromes. This paper describes the development and preliminary validation of the Neuropathic Pain Scale (NPS), which is designed to assess distinct pain qualities associated with neuropathic pain. Results support the discriminant and predictive validity of the NPS items. Moreover, the NPS items appear to be sensitive to treatments known to impact neuropathic pain. These findings provide support for the further development of the NPS.

Osteopenia, bone fragility and reflex sympathetic dystrophy syndrome in a man with ureterosigmoidostomy

A 68-year-old man is presented with a reflex sympathetic dystrophy syndrome (RSDS) of the right ankle diagnosed by radiography, magnetic resonance imaging and bone scintiscan. Investigations, including blood tests and bone biopsy, revealed a diagnosis of metabolic acidosis and osteomalacia. These appeared to result from a ureterosigmoidostomy performed 9 years previously for a transitional carcinoma of the bladder. Correction of the metabolic acidosis coincided with improvement in ankle pain. RSDS may be the initial presentation of osteomalacia, which in turn may be caused by the metabolic acidosis resulting from a ureterosigmoidostomy.

[A pain syndrome of compression-reflex origin: the mechanisms of its development and the means for its therapeutic management]

Complex observation and treatment of 112 patients with compressive-reflex syndromes of cervical osteochondrosis with pain as the leading clinical manifestation resulted in elaboration of the scheme of its pathogenesis. The main links of pathological process development as well as their relationships were described. The main means and methods of the correction of algesic syndrome development were determined on the basis of both own investigations and literary data. The peculiarity of this study was the inclusion of Xydiphone (the Russian-made drug from complexons group) in pathogenetic therapy. Its positive medical effect in treatment of the disease described was established.

Mannitol-induced acute renal failure

Mannitol is widely used because of its osmotic diuretic action and its presumed antioxidant properties. In pre-existent renal dysfunction, however, mannitol may accumulate leading to potentially deleterious effects. We describe a 71-year-old woman with moderate chronic renal failure due to diabetic nephropathy who developed acute anuric renal failure after mannitol administration for post-traumatic reflex sympathetic dystrophy. After haemodialysis symptoms of acute renal failure rapidly disappeared with recovery of pre-existent renal function. Daily measurement of the osmolal gap as a simple and accurate way of monitoring patients receiving mannitol infusion is emphasized. A rapid increase in the osmolar gap should prompt adjustment of the dose or even discontinuation of mannitol, especially in the case of pre-existent risk factors.

Reflex sympathetic dystrophy with mutilating ulcerations suspicious of a factitial origin

Reflex sympathetic dystrophy (RSD) is a poorly understood posttraumatic pain syndrome associated with dysfunction of the sympathetic nervous system. Pain is often out of proportion to the extent of injury. Progression of the disease may lead to dystrophic and atrophic changes resulting in total disability of an affected limb. Skin findings are highly variable and nonspecific and may rarely include bullae and ulcerations. We describe a mutilating case of RSD with unusual and severely disfiguring ulcerations that necessitated amputation of the right arm. Shortly after the amputation, ulcerations began appearing on the left arm. We suspect a factitial component but have been unable to prove or disprove it. We propose that some ulcerations in patients with RSD may be factitial in origin.

[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.

alpha 1-adrenoceptors in normal and hyperalgesic human skin

1. Evidence of an adrenergic component of cutaneous hyperalgesia has recently been obtained in animal models of painful peripheral neuropathy. These findings have prompted speculation that an increased density or sensitivity of peripheral alpha-adrenoceptors contributes to sensory abnormalities and chronic neuropathic pain in conditions such as reflex sympathetic dystrophy. However, it is not known whether alpha-adrenoceptors are present at the site of nociception, either in hyperalgesic or normal skin. 2. We used the selective radioligand 125I-hydroxyphenyl-ethyl-aminomethyl-tetralone (HEAT) to label alpha 1-adrenoceptors, and quantitative autoradiography to assess the relative density of these receptors in skin samples from seven normal individuals and from the hyperalgesic and pain-free limbs of five patients with reflex sympathetic dystrophy. The distribution of autoradiographic grains over the epidermis and dermis was investigated in 10 microns serial transverse sections. 3. alpha 1-Adrenoceptors were identified in the epidermis and dermal papillae of normal individuals, and in the hyperalgesic and pain-free skin of patients with reflex sympathetic dystrophy. The density of alpha 1-adrenoceptors was greater in the epidermis and dermal papillae than further down in the dermis. 4. The mean density of alpha 1-adrenoceptors was significantly greater in the hyperalgesic skin of patients than in the skin of normal individuals (35.4 grains/1000 microns2 compared with 15.5 grains/ 1000 microns2, P < 0.01). The mean density of alpha 1-adrenoceptors in the pain-free skin of patients (26.9 grains/1000 microns2) fell midway between receptor density in hyperalgesic skin and in the skin of normal individuals, and did not differ significantly from either. 5. Our findings indicate that alpha 1-adrenoceptors are present in the epidermis, and suggest that their numbers may be increased in the hyperalgesic skin of patients with reflex sympathetic dystrophy. Further studies need to identify the dermal and epidermal cell types that express high densities of alpha 1-adrenoceptors, and to investigate their normal function and role in neuropathic pain.

Spontaneous fusion of the midfoot following reflex sympathetic dystrophy. A case report and review of the literature

Reflex sympathetic dystrophy syndrome (RSDS) is a well-defined entity, caused by many clinical conditions, leading to pain, stiffness, and vasomotor changes in the affected region. In this case, a 49-year-old man presented with a history of right foot pain secondary to a fall. Plain radiographs did not reveal any fractures or bony fusions. Upon follow-up, a history consistent with that found in RSDS was given. Radiographs at 7 and 11 weeks revealed increasing osteopenia, lytic lesions, and absent joint spaces in the first through third metatarsocuneiform articulations suggesting ankylosis. Other possible causes of ankylosis, including infection, inflammatory and metabolic conditions, were excluded.

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.

The role of sympathetic activity in neuropathic orofacial pain

Seventeen patients with neuropathic orofacial pain are presented with reference to precipitating events, pain descriptions, response to treatment, and other aspects of their histories and clinical presentation. Stellate ganglion blocks were done on 14 patients. Ten of 14 patients reported temporary relief of pain with stellate ganglion blocks. Five of these patients noted more prolonged improvement in pain, two reported no change, and two experienced a temporary increase in pain. It is argued that sympathetically maintained pain involving orofacial locations does occur and that stellate ganglion blocks may benefit a subgroup of these patients. It is noted that current diagnostic categories are inadequate to describe a subgroup of these patients. New categories are suggested, and further study is recommended.