Prognostic value of triple phase bone scanning for reflex sympathetic dystrophy in hemiplegia

A Meta-Analysis and Meta-Regression of Frequency and Risk Factors for Poststroke Complex Regional Pain Syndrome

Background and Objectives: This article aimed to investigate the risk factors for poststroke complex regional pain syndrome (CRPS). Materials and Methods: We searched electronic databases including PubMed, Medline, Web of Science, Cochrane Library, and Embase up to 27 October 2021. We enrolled analytical epidemiological studies comprising cohort, case-control, and cross-sectional studies. A quality assessment was performed using the Newcastle–Ottawa Quality Assessment Scale for cohort and case-control studies and the Joanna Briggs Institute critical appraisal checklist for analytical cross-sectional studies. Binary outcomes were reported as odds ratios (ORs), and continuous outcomes were described as standardized mean differences (SMDs) with 95% confidence intervals. For the meta-regression, beta coefficient and p value were adopted. Results: We included 21 articles comprising 2225 participants. Individuals with shoulder subluxation and spasticity were found to have higher risks for poststroke CRPS. Spasticity with higher modified Ashworth scale score, lower Brunnstrom hand stage, and inferior Barthel index scores were observed in patients with poststroke CRPS. The pooled incidence proportion in nine articles was 31.7%, and a correlation was found between effect sizes and the ratio of women and the proportion of left hemiparesis. The summarized prevalence in nine cross-sectional studies was 33.1%, and a correlation was observed between prevalence and the subluxation ratio and Brunnstrom stage. Conclusions: Based on our meta-analysis, being female, left hemiparesis, shoulder subluxation, spasticity, a lower Brunnstrom stage of distal upper limb, and an inferior Barthel index are all features for poststroke CRPS. Larger studies with greater statistical power may confirm our findings and clarify some other unknown risk factors for poststroke CRPS.

Usefulness of bone scintigraphy for the diagnosis of Complex Regional Pain Syndrome 1: A systematic review and Bayesian meta-analysis

BACKGROUND

Since 2007, the Budapest criteria are recommended for the diagnosis of Complex Regional Pain Syndrome (CRPS) 1. The usefulness of bone scintigraphy (BS, index test) for the diagnosis of CRPS 1 remains controversial. Imperfect reference tests (RT) result in underestimation of the diagnostic accuracy of BS. Further, biased results can occur when a dependency between the RT and BS exists. The objective was to assess the impact of different RTs, specifically the Budapest criteria, and the assumed imperfect nature of the RT on the diagnostic accuracy of BS. Further, we analyzed the association between baseline characteristics and positive BS in patients with CRPS 1.

METHODS

Systematic literature review and Bayesian meta-analysis to assess the test accuracy of BS with and without accounting for the imperfect nature of the RT. We examined correlations (Spearman correlation coefficients / Wilcoxon tests) between baseline characteristics and the proportion of positive BS in patients with CRPS 1.

RESULTS

The pooled sensitivity was 0.804 (95% credible interval (CI) 0.225-1.0, 21 studies) and specificity 0.853 (95%CI 0.278-1.00). Sensitivity and specificity of BS increased when accounting for the imperfect nature of the RT. However, in studies using Budapest criteria as reference, the sensitivity decreased (0.551; 95% CI 0.046-1) and the specificity increased (0.935; 95% CI 0.306-1). Shorter disease duration and a higher proportion of males were associated with a higher proportion of positive BS (27 studies, disease duration <52 weeks Wilcoxon test p = 0.047, female proportion Spearman correlation -0.63, p = 0.009).

CONCLUSION

Compared to the accepted Budapest diagnostic criteria BS cannot be used to rule-in the diagnosis of CRPS 1. In patients with negative BS CRPS 1 is less likely the underlying illness. Studies using older or no diagnostic criteria should not be used to evaluate the diagnostic accuracy of BS in CRPS 1.

Spinal cord stimulation as treatment for complex regional pain syndrome should be considered earlier than last resort therapy

BACKGROUND

Spinal cord stimulation (SCS), by virtue of its historically described up-front costs and level of invasiveness, has been relegated by several complex regional pain syndrome (CRPS) treatment algorithms to a therapy of last resort. Newer information regarding safety, cost, and efficacy leads us to believe that SCS for the treatment of CRPS should be implemented earlier in a treatment algorithm using a more comprehensive approach.

METHODS

We reviewed the literature on pain care algorithmic thinking and applied the safety, appropriateness, fiscal or cost neutrality, and efficacy (S.A.F.E.) principles to establish an appropriate position for SCS in an algorithm of pain care.

RESULTS AND CONCLUSION

Based on literature-contingent considerations of safety, efficacy, cost efficacy, and cost neutrality, we conclude that SCS should not be considered a therapy of last resort for CRPS but rather should be applied earlier (e.g., three months) as soon as more conservative therapies have failed.

Patterns of three-phase bone scintigraphy according to the time course of complex regional pain syndrome type I after a stroke or traumatic brain injury

We have proposed to evaluate different patterns represented on 3-phase bone scintigraphy (TPBS) according to the time course of complex regional pain syndrome (CRPS) type I (CRPS-I) after a stroke or traumatic brain injury. TPBS was performed in 50 consecutive patients for the evaluation of CRPS. We divided the patients into CRPS and non-CPRS groups based on the use of International Association for the Study of Pain criteria. We evaluated the changes on TPBS according to clinical stages based on time course. In the early acute stage within 6 weeks, minimal uptake on all TPBS phases was observed in the 90% of the patients in the CRPS-I group and in 75% of the patients in the non-CRPS group. In the acute stage of CRPS in the range of 2 to 20 weeks, moderately increased uptake was seen for 78%, 83%, and 83% of the patients in the CRPS group for the 3 phases, respectively. However, only 16% of the patients in the non-CRPS group had moderately increased uptake as seen on all TPBS phases. In the late stage of more than 21 weeks, there was no distinct difference in uptake between the 2 groups. A sequential change during the time course for the CPRS-I group was statistically significant (P < 0.05). Therefore, performance of follow-up TPBS may be useful to diagnose CPRS-I in uncertain cases of the early acute stage after a stroke or traumatic brain injury.

Complex regional pain syndrome after transradial cardiac catheterization

Complex regional pain syndrome (CRPS) is a disease with unclear pathophysiology. The condition is characterized by pain, soft tissue change, vasomotor change, and even psychosocial disturbance. It may affect the upper more than the lower extremities, and the distal more than the proximal. The trigger factors include carpal tunnel release, Dupuytren's repair, tendon release procedures, knee surgery, crush injury, ankle arthrodesis, amputation, and hip arthroplasty. Rarely, it has been associated with stroke, mastectomy, pregnancy, and osteogenesis imperfecta. Herein, we present a rare case of a patient who was diagnosed with CRPS after transradial cardiac catheterization. CRPS was first diagnosed due to hand swelling, allodynia, paresthesia, and the limited range of motion of interphalangeal, metacarpophalangeal, and wrist joints, with the preceding factor of transradial cardiac catheterization, and was then confirmed by a three-phase bone scan. After intensive physical therapy with hydrotherapy, manual soft tissue release, and occupational therapy for the hand function, there was much improvement in range of motion and hand function. There was no allodynia or painful sensation in the follow-up. After training, the functional status of this patient was adequate for daily activity.

Impact of three-phase bone scintigraphy on the diagnosis and treatment of complex regional pain syndrome type I or reflex sympathetic dystrophy

OBJECTIVE

To determine the impact of three-phase bone scintigraphy (TPBS) on the diagnosis and management of complex regional pain syndrome type I (CRPSI) or reflex sympathetic dystrophy (RSD).

SUBJECTS AND METHODS

Twenty consecutive patients with a recent clinical evidence of CRPSI were referred for TPBS as part of their routine management plan. All patients underwent neurological examinations with special attention to the evaluation of clinical features of vasomotor, sudomotor, motor and sensory dysfunction. Patients were followed prospectively. When both the clinical and TPBS results supported the diagnosis of CRPSI, patients were started on treatment.

RESULTS

Of the 20 patients, TPBS supported the diagnosis of RSD in 9 who were treated with steroids and physiotherapy. Complete follow-up was available for 7 of them and all had a satisfactory response to treatment. For the remaining 11 patients RSD was diagnosed clinically but not confirmed by TPBS. On follow-up there was no evidence that TPBS failed to identify RSD in these 11 patients.

CONCLUSION

The results indicate that TPBS confirmed the clinical diagnosis of RSD, and, more importantly, had a significant impact on its management.

The Role of Nuclear Medicine in the Evaluation of Complex Regional Pain Syndrome Type I

Chronic pain resulting from complex regional pain syndrome type I (CRPS I), formerly referred to as the reflex sympathetic dystrophy syndrome (RSDS), is a diagnostic challenge to the clinician. It involves multiple organ systems, namely peripheral as well as central nervous, vascular, soft tissue, and skeletal. It usually develops as a consequence of trauma, without nerve injury. Signs and symptoms vary depending on the time since the initiating event, and there is no confirmatory histopathologic diagnosis. This article summarizes the current consensus on the classification, pathophysiology, and diagnostic approaches, emphasizing the role of scintigraphy in the management of this multisystem disorder.

The predictive value of additional late blood pool imaging to the three-phase bone scan in the diagnosis of reflex sympathetic dystrophy in hemiplegic patients

Reflex sympathetic dystrophy (RSD) is a relative common sequel after hemiplegia. The diagnosis of RSD in hemiplegic patients presents difficult clinical problems, as the symptoms and signs of RSD are not specific and RSD may be due to reasons other than hemiplegia. Bone scintigraphy has been routinely used for the diagnosis of RSD; however, the optimal acquisition protocols, diagnostic patterns and the utility of quantitation are controversial. This prospective study was conducted to demonstrate the higher predictive value of an additional late blood pool image to the three-phase bone scan compared to the regular three-phase bone scans in RSD patients associated with hemiplegia. Thirty-four RSD patients were enrolled into the study. Bone scans according to the new protocol were obtained for all patients. Those patients with either negative or positive bone scans with no evidence of RSD were followed for 6 months. The patients had positive bone scan findings and were symptomatic at the time of the study. Of these, seven patients (58.3%) subsequently became symptomatic and five patients (41.7%) remained asymptomatic at 6 months. None of the patients with negative bone scans had symptoms of RSD on presentation except one case. We conclude that the addition of a late blood pool image increases the predictive value and has an impact on initiating early treatment in asymptomatic patients.

Prediction of reflex sympathetic dystrophy in hemiplegia by evaluation of hand edema

OBJECTIVE

To determine the predictive value of measurements of hand edema for the development of reflex sympathetic dystrophy (RSD).

DESIGN

Cohort study.

SETTING

Departments of rehabilitation medicine in 3 general hospitals and 1 rehabilitation hospital in Japan.

PARTICIPANTS

Thirty-four stroke patients.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Measurement of the circumference of the middle finger was used to evaluate hand edema. The degree of hand edema was expressed by the ratio of circumference of the middle finger (RCMF) in the affected side to that in the uninvolved extremity.

RESULTS

Eight of 34 patients developed clinical RSD from 2 to 4 months after stroke. Hand edema showed a significant relationship to the development of RSD (ie, the patients who had an RCMF of above 1.06 at 4 weeks poststroke had significantly higher incidence of RSD than those with a lower RCMF; P=.0127).

CONCLUSION

It is possible to predict the development of RSD in hemiplegia by measuring hand edema 4 weeks poststroke.

Reassessment of the incidence of complex regional pain syndrome type 1 following stroke

Previous literature has suggested that reflex sympathetic dystrophy, also known as complex regional pain syndrome (CRPS) type 1, is a relatively common finding after a stroke. However, much of this data was obtained before patients routinely received early intensive inpatient rehabilitation. The purpose of this study is to reevaluate the incidence of CRPS type 1 following an acute first stroke. Subjects admitted to an acute rehabilitation setting for stroke with no other concomitant neurologic or orthopedic injuries between October 1, 1996, and May 31, 1997, were studied. At admission and once a week until discharge, subjects were evaluated for shoulder pain, decreased passive range of motion of the shoulder, wrist/hand pain, edema, and skin changes. If three of these five criteria were positive, the subjects underwent a triple-phase bone scan (TPBS). Bone scan findings consistent with CRPS type 1 were taken as confirming the diagnosis. Of 64 subjects, 13 underwent bone scans, with only one positive result. Thus our study revealed a 1.56 percent incidence of CRPS type 1 following a first stroke. This incidence is much lower than the historically accepted 12.5 percent. We speculate that this low figure is related to early comprehensive rehabilitation that included proper upper extremity positioning and early mobilization with sensory stimulation.

Reflex Sympathetic Dystrophy in the Upper Extremity

The diagnosis and treatment of pain are among the most challenging problems facing orthopaedic surgeons, and reflex sympathetic dystrophy is probably the most frustrating and difficult pain syndrome to manage. Pain, swelling, and autonomic dysfunction are cardinal signs of the condition. Although the pathogenesis is still unclear, many theories have been proposed. Because reflex sympathetic dystrophy is sympathetically mediated, diagnosis can be confirmed on the basis of response of the pain to sympathetic blockade. Treatment may include an appropriate exercise program, a-adrenergic blocking agents, mood-elevating drugs, calcium channel blockers, intravenous regional blocks, and stellate ganglion blocks. Recent additions to therapy include electroacupuncture, transcutaneous electrical nerve stimulation, and biofeedback. Prognosis is, at best, guarded with this perplexing condition, but the best response is obtained when diagnosis is made early (within the first 2 or 3 weeks after injury) and treatment is initiated during the first stage of the disease.

Complex regional pain syndrome

Reflex sympathetic dystrophy is a complex progressive and potentially devastating condition generally affecting the extremities. Because clinical presentation is variable, diagnosis can be difficult. Recently, the Special interest Group of Pain and the Sympathetic Nervous System of the International Association for the Study of Pain developed a new taxonomy to help acknowledge and differentiate the features of reflex sympathetic dystrophy and causalgia. These are categorized under the heading of complex regional pain syndrome. Sympathetically maintained pain is also recognized as a separate component to this group of conditions. The authors present this new taxonomy and present cases of each condition.

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.

Reflex sympathetic dystrophy following arterial blood gas sampling in the intensive care setting

A 54-year-old woman developed signs and symptoms consistent with reflex sympathetic dystrophy in her left upper extremity following arterial puncture. Diagnosis was confirmed by bone scan, and sympathetic blockade with intravenous regional bretylium completely relieved her severe, intractable pain.

The role of bone scintigraphy in diagnosing reflex sympathetic dystrophy

Three-phase bone scintigraphy is used often to diagnose reflex sympathetic dystrophy of the hand. This study presents an analysis of the literature relating three-phase bone scanning to reflex sympathetic dystrophy in the upper extremity. The data show a wide variability in scintigraphic accuracy in patients with clinically obvious reflex sympathetic dystrophy. The results of bone scintigraphy correlate best with the clinical diagnosis of reflex sympathetic dystrophy within the first 20-26 weeks of onset. Even then, the sensitivity in the most recent series approximates 50%. After 26 weeks, there is a poor correlation between three-phase bone scanning and reflex sympathetic dystrophy. Consequently, three-phase bone scintigraphy should not be used as a major criterion in diagnosing reflex sympathetic dystrophy. The diagnosis of reflex sympathetic dystrophy remains a clinical diagnosis made by an experienced hand surgeon.