Treatment of algodystrophy using intravenous guanethidine regional block

Treatment of complex regional pain syndrome type I of the hand with a series of intravenous regional sympathetic blocks with guanethidine and lidocaine

The aim of this study was to evaluate the efficacy of guanethidine and lidocaine in the treatment of complex regional pain syndrome (CRPS) type I of the hand. Seventeen patients, aged between 33 and 72 years, suffering from CRPS type I of the hand received two series of intravenous regional sympathetic block (Bier's block) sessions with guanethidine and lidocaine according to the following therapeutic protocol: (1) 5 sessions (once every second day) composed of intravenous regional administration of 15 mg guanethidine and 1 mg lidocaine/kg body weight each and (2) 20 sessions (twice a week) composed of intravenous regional administration of 10 mg guanethidine and 1 mg lidocaine/kg body weight each. Complete disappearance of pain and return of the normal function and movement of the extremity were achieved. No side effects were observed. The above-described therapeutic protocol method resulted in excellent pain relief and full restoration of both function and range of movement of the affected extremity in 17 patients suffering from CRPS type I of the hand.

Causalgia and reflex sympathetic dystrophy: does the sympathetic nervous system contribute to the generation of pain?

The striking response of causalgia and reflex sympathetic dystrophy (RSD) to sympatholytic procedures together with signs of autonomic nervous system abnormalities suggest that the sympathetic efferent system can generate or enhance pain (sympathetically maintained pain, SMP). This concept is supported by human and animal experiments indicating that sympathetic activity and catecholamines can activate primary afferent nociceptors. Some clinical evidence, however, calls the SMP concept into question and alternative explanations have been advanced. In this review, we describe the clinical features of causalgia and RSD and the evidence for sympatholytic efficacy. The major barrier to proving the SMP concept is that all available sympatholytic procedures are problematic. We conclude that, although the weight of current evidence supports the SMP concept and its relevance to causalgia and RSD, it remains unproven by scientific criteria. More careful adherence to diagnostic criteria and well-controlled trials of sympatholysis are needed to finally settle the issue.

Does peri-operative guanethidine prevent reflex sympathetic dystrophy?

The use of intravenous guanethidine blocks is an accepted treatment for established reflex sympathetic dystrophy (RSD). Some units administer intravenous guanethidine peri-operatively with the intention of protecting their patients from post-operative dystrophy. There have been no studies confirming this protective effect of peri-operative guanethidine. Between 1992 and 1994 we performed a prospective randomized double blind study in 71 patients undergoing fasciectomy for Duputyren's disease. Peri-operative guanethidine did not prevent post-operative RSD in our series.

Regional intravenous guanethidine blocks in algodystrophy

Five-hundred-thirteen regional intravenous guanethidine blocks were carried out in 125 cases of algodystrophy (118 adults), after failure of other treatments in 120 cases (Group I) and without previous treatments in 5 (Group II). A positive result occurred in 85 cases of Group I (71%) and in the 5 cases of Group II, after 4.5 +/- 1.7 blocks. In Group I the results did not differ significantly between upper (33 cases) and lower (87 cases) limb or in regard to sex, age, duration of disease, nature of previous treatments. The presence of psychic disorders was accompanied by less frequent (p less than 0.02) positive results. The tolerance was satisfactory in 85.6% of cases: 22 moderate side effects authorized a continuation of the blocks, 22 serious ones indicated interruption, especially one case of thrombophlebitis and another one of very transitory acute ischaemia. The risk of intolerance was significantly raised (p less than 0.02) by age. The regional guanethidine blocks seemed to be a good treatment for algodystrophy after failure of other treatments.

Fasciectomy for treatment of Dupuytren's disease and early complications

This review of 103 cases of hands operated on for treatment of Dupuytren's disease demonstrates the significant increase of postoperative stiffness as related to recurrences and staging of the disease, but not to sex. On the contrary, the frequency of reflex sympathetic dystrophy after fasciectomy is sex related affecting females. The protective effect of guanethidine may be a valuable therapeutic adjunct for female patients. We propose that the disease be staged on the basis of anatomic findings, inasmuch as staging based on degree of contracture alone is insufficient for comparative studies.

[Local intravenous treatment of algodystrophy of the hand: buflomedil versus guanethidine, long term follow-up]

This report compares the results obtained after treatment of reflex sympathetic dystrophies (algodystrophies) of the hand by pharmacological segmental blocks with buflomedil (51 cases) versus guanethidine (30 cases). The results were similar for all the different stages of algodystrophies treated: 65% satisfactory to excellent results with buflomedil, versus 63% with guanethidine. The sooner the algodystrophy is treated after its onset, the better the results. On TPBS, when the technique is effective, both hemovelocity and blood pool return to normal, along with the improvement in the patient's condition. Early and delayed bone fixations evolve independently of the treatment. These techniques should always be associated with active, mild physiotherapy, and in some cases with dynamic splints in order to prevent the development of functional sequelae in the form or capsulo-aponeurotic retraction.

Calcitonin and reflex sympathetic dystrophy syndrome

Reflex sympathetic dystrophy syndrome is a difficult condition to treat. Many modalities have been proposed, all of them being clinically effective but whose efficacy is often difficult to assess, and has not been properly compared. A regimen of physical therapy (pressure therapy, antalgic electrotherapy and exercise therapy) with or without calcitonin was investigated in 24 patients randomly assigned to 2 groups, one given physical therapy alone (Group I) and the other physical therapy plus salmon calcitonin 100 MRC units daily for 3 weeks (Group II). Efficacy assessment was based on clinical (pain, oedema and movement in the affected parts), biochemical (blood and urinary phosphorus and calcium levels, plasma 25-OH-D, plasma parathyroid hormone (PTH), creatinin, alkaline phosphatases and urinary hydroxyproline) and scintigraphic parameters, as well as on the patient's ability to resume working. There was significant improvement in pain in the Group II patients after one week of treatment. As a result the authors advocate the use of calcitonin in addition to physical therapy in reflex sympathetic dystrophy syndrome - and even of calcitonin alone where physical therapy is not possible.