Prediction of reflex sympathetic dystrophy in hemiplegic patients by electromyographic study

BACKGROUND AND PURPOSE

This study was designed to investigate the correlation between reflex sympathetic dystrophy syndrome (RSDS) in hemiplegic patients and spontaneous electromyographic (EMG) activity, as well as to determine the predictive value of spontaneous EMG activity in early diagnosis of RSDS.

METHODS

An EMG and nerve conduction velocity study of the weak upper limb was conducted on 70 hemiplegic patients at 3 to 4 weeks after cerebrovascular disease (either cerebral hemorrhage or infarction). Clinical assessment for development of the RSDS was done during the following 6 months. The correlation of RSDS development with the presence of spontaneous EMG activity and certain clinical parameters (including sex, age, side affected, cause of stroke, sensory impairment, spasticity, and shoulder subluxation) was analyzed statistically.

RESULTS

Of the 46 patients who exhibited spontaneous activity, 30 (65%) developed clinical RSDS in their hemiplegic upper extremity, whereas only 1 (4%) of the other 24 patients with no spontaneous EMG activity developed clinical RSDS within 6 months after the onset of hemiplegia (P < .001). The correlation of RSDS development with the presence of shoulder subluxation and sensory impairment in the hemiplegic side was statistically significant. Neither age, sex, severity of spasticity, nor etiology of stroke had a significant correlation with the development of clinical RSDS.

CONCLUSIONS

There is significant correlation between the presence of spontaneous EMG activity and the development of clinical RSDS in the hemiplegic upper extremity after stroke. It is concluded that spontaneous EMG activity in the hemiplegic hands of stroke patients might be a good predictor of the future development of clinical RSDS.

[A case of RSD with complete disappearance of symptoms following intravenous ketamine infusion combined with stellate ganglion block and continuous epidural block]

A 74 year-old woman with a 6-month history of RSD following herpes zoster on her right arm was treated with stellate ganglion blocks (SGB), continuous epidural block (CEB) and continuous intravenous infusion of ketamine known as one of the NMDA receptor blockers. Of the symptoms of RSD, burning pain and hyperperspiration but allodynia disappeared after the treatment with SGB 8 times and CEB for 4 days. Allodynia disappeared completely after ketamine treatment, where ketamine was infused once using a subanesthetic dose for 2 hours. It is considered that ketamine is one of the useful drugs for the treatment of neuropathic pain with allodynia.

Value of autonomic testing in reflex sympathetic dystrophy

OBJECTIVE

To attempt to characterize reflex sympathetic dystrophy (RSD) and to determine factors that would predict a response to sympathetic block.

DESIGN

We undertook a retrospective analysis on 396 patients with chronic limb pain referred for autonomic testing during a 5-year period.

MATERIAL AND METHODS

Clinical endpoints were relief of pain after sympathetic block and a composite RSD diagnostic probability score, based on the clinical attributes of allodynia, protopathia, swelling, and vasomotor alterations. We compared the results of three autonomic tests--resting sweat output (RSO), resting skin temperature (RST), and quantitative sudomotor axon reflex test (QSART).

RESULTS

Increased RSO predicted the diagnosis of RSD with 94% specificity, and the specificity was 98% when RSO was considered in conjunction with an abnormal QSART result, the best laboratory correlate (P = 0.003) of the clinical diagnosis. Shorter duration of pain correlated with a warmer limb (P < 0.001), even in the absence of RSD. Response to a single sympathetic block did correlate with the diagnosis (P = 0.031) but correlated most significantly with short duration of pain in the arm (P = 0.001) and laboratory findings in the leg, where increased RST (P < 0.001) and QSART (P < 0.001) were near-perfect predictors of response.

CONCLUSION

Sweating abnormalities correlate strongly with the clinical syndrome of RSD, and alterations in RST may be superior to clinical findings in predicting the response to sympathetic block. The findings provide physiologic support for the unproven view of a natural disease progression ("stages"), with better treatment response and a warmer extremity initially. Because certain physiologic trends occur in all patients, general alterations of autonomic function with pain are suggested.

Unilateral Beau's lines in childhood reflex sympathetic dystrophy

Reflex sympathetic dystrophy is characterized by severe pain and autonomic dysfunction in a limb, usually after an injury. We describe a patient with childhood reflex sympathetic dystrophy with unilateral Beau's lines on the nails of the affected hand. Unilateral Beau's lines have not been described previously in this condition to our knowledge, and we discuss their possible pathogenesis.

Algodystrophy in conjunction with van der Hoeve's syndrome

Van der Hoeve's syndrome is the all-round variant of Lobstein's disease (late osteogenesis imperfecta) and is characterized by the concurrent presence of osteoporosis, blue sclerae, and deafness. The literature has reported sporadic cases of a combination of algodystrophic syndrome and Lobstein's disease. Our case represents a classic example: a 50-year-old woman with blue sclerae since birth, bilateral deafness, major dental alterations, vitreous osteoporosis and a history of pathological fractures who, two years from the onset of menopause, complained of pain involving the right ankle. After admission to our Department, a diagnosis of algodystrophy combined with van der Hoeve's syndrome was made on the basis of her clinical history, objective signs and x-ray results. Treatment consisted of i.v. clodronate disodium at a dose of 300 mg daily in 250 ml saline solution for 7 consecutive days. At the end of the treatment cycle the patient reported an improvement in her symptoms with nearly total regression of right ankle pain, while swelling disappeared within a few weeks.

An unusual case of sympathetically maintained facial pain complicated by telangiectasia

A 32-year-old woman with a history of maxillary sinusitis, multiple surgical interventions in the maxillary sinus, and a hyperalgesic, erythematous skin lesion in her left infraorbital area, had severe burning pain in the left face. The dermal lesion was diagnosed as atypical telangiectasia and the sinus pathoses determined to be unrelated to her symptoms. Two diagnostic stellate ganglion blocks were performed with concurrent bilateral monitoring of blood flow in the infraorbital skin. Blood flow was significantly increased in the painful erythematous patch although no significant change in flow occurred in the unaffected contralateral skin. The changes correlated to patient's relief from pain. The patient's symptoms were subsequently controlled with an oral sympatholytic agent. This article demonstrates the usefulness of laser doppler flowmetry to establish the diagnosis of sympathetically maintained facial pain despite several confounding conditions and supports the theory that sympathetically maintained pain involves altered function of alpha-1 adrenoreceptors.

Shoulder complaints in patients with reflex sympathetic dystrophy of the upper extremity

Five hundred forty-one patients with reflex sympathetic dystrophy (RSD) of the upper extremity were prospectively studied. One hundred fifteen patients complained of pain and/or limited range of motion in the shoulder. Shoulder complaints more often occurred in women (p = .01); age and etiology were not different from patients with RSD without shoulder complaints. Physical examination showed a tendinitis of one or both tendons of the biceps muscle in 109 patients. Seventy one patients were treated with local injection of bupivacaine followed by methylprednisolone. This resulted in permanent relief of complaints in 34 patients, temporary or moderate relief in 31, no difference in 3, increase of complaints in 1 patient, and in 2 patients results were not documented. We conclude that shoulder complaints in RSD occur in a minority of patients and more often in female patients. There are no predisposing factors. The pathophysiologic mechanism for developing shoulder complaints remains unknown. In most cases complaints can be attributed to a bicipital tendinitis for which local injection of bupivacaine followed by prednisolone are both diagnostic and therapeutic.

Reflex sympathetic dystrophy. The other villain in chronic venous leg ulcers

BACKGROUND

There are no previous reports addressing a link between leg ulcers and the reflex sympathetic dystrophy (RSD) syndrome.

OBJECTIVE

The purpose of this study was to define the incidence and characteristics of a possible RSD leg ulcer syndrome.

METHODS

Leg ulcers encountered in private practice were retrospectively analyzed for the presence of 12 clinical features ("special traits"), four of them because of their known association with RSD, and eight because they were suspected of resulting from vasospastic ischemia.

RESULTS

Among 111 ulcer episodes, 35 (31.5%) were associated with RSD, 14 (12.6%) with arteriosclerosis obliterans, and 62 (55.9%) were caused by pure venous insufficiency. The mean score of "special traits" was 5.03 in the RSD category, 2.57 in the arteriosclerosis obliterans category, and 1.66 in pure venous insufficiency cases.

CONCLUSION

It is concluded that an RSD leg ulcer syndrome does indeed exist and that it is common and easy to diagnose. Verification by prospective studies is called for.

[Pain of autonomic nervous system origin]

Reflex sympathetic dystrophy (algodystrophy) is a descriptive term used to designate a clinical phenomenology, which appears after a trauma, often a minor one; it is thought that the sympathetic nervous system plays an important role in its physiopathology. The same applies to sympathetic maintained pain appearing after a lesion of a peripheral nerve (causalgia). There is no agreement as to which are the criteria necessary to make the diagnosis and as to what is the physiopathology of these syndromes. Research in this field is very active today.

Abnormal thermoregulatory responses in patients with reflex sympathetic dystrophy syndrome

OBJECTIVE

To look for asymptomatic thermoregulatory abnormalities in the noninvolved limbs in patients with well established reflex sympathetic dystrophy syndrome (RSDS). The study was prompted by the observation of development of severe upper limb Raynaud's phenomenon in a young woman with a history of RSDS affecting both lower limbs.

METHODS

Eleven patients and 11 age and sex matched control subjects underwent a standard thermal stress test: cold water immersion of a hand unaffected by RSDS in water at 15 degrees C for one min. All controls had had injuries uncomplicated by RSDS.

RESULTS

Lag time (the lag phase between the end of the cold challenge and the onset of rewarming) was significantly increased (p < 0.01) in the patient group (median 5.67 min, range 0.50 to > 15) compared to the control group (median 0.50 min, range 0.50 to 12.92). The median maximum temperature recovery was lower in the patient group (81.6%, range 0 to 170.4) than in the control group (119.3%, range 49.1 to 153.1).

CONCLUSION

Our findings support an association between RSDS and a generalized abnormal response to cold challenge. Further studies are required to examine the temporal relationship underlying this. Early screening for thermoregulatory dysfunction of patients after fractures might allow identification of patients at risk of developing RSDS.

Intraspinal delivery of opiates by an implantable, programmable pump in patients with chronic, intractable pain of nonmalignant origin

The use of intraspinal therapy for the management of intractable pain from nonmalignant causes has not been widely discussed. An implantable, externally programmable infusion pump was used for intraspinal delivery of morphine sulfate to 15 patients with intractable pain from reflex sympathetic dystrophy, arachnoiditis after spinal surgery, or an unknown cause. Dosage patterns were individualized. At follow-up ranging from 2 to 44 months, pain relief was reported as excellent by 8 patients, good by 3, and fair by 4. Six patients have returned to work. Two patients chose to terminate therapy. Few complications occurred, but most patients needed increasingly larger doses over time to maintain pain relief. Intraspinal infusion of morphine sulfate by use of an implanted, externally programmable pump is safe and effective in selected patients with intractable pain of nonmalignant origin.

Hypertrichosis and algodystrophy: an hypothesis to explain this uncommon association

Various skin changes have been described in algodystrophy, but the association of hypertrichosis with this condition is poorly documented. We describe a patient who developed algodystrophy after a mild inflammatory arthritis, in association with a number of skin manifestations, including hypertrichosis. We suggest a mechanism to explain this particular association.

Probable cervical midline epidural septum complicating the treatment of a patient with upper extremity sympathetically maintained pain

We present a woman who developed left arm sympathetically maintained pain (SMP, or "shoulder-hand syndrome") as a result of brachial plexus injury. After confirmatory diagnosis with both stellate local anesthetic block and intravenous phentolamine infusion, the patient had a cervical epidural catheter placed and a local anesthetic infusion started. After numerous unilateral blocks were obtained, a cervical epidurogram demonstrated a probable cervical midline epidural septum. Catheter placement was adjusted, and a successful chemical sympathectomy was performed for 6 days. This resulted in significant relief of the patient's shoulder pain as well as almost complete resolution of the patient's left arm SMP symptoms. This case represents, to our knowledge, the first documentation of the use of phentolamine for the diagnosis of SMP secondary to pathology at a site proximal to that of symptomatology, as well as the first documentation of presumptive cervical midline epidural septum.