Microcirculatory changes identified by photoacoustic microscopy in patients with complex regional pain syndrome type I after stellate ganglion blocks

Complex regional pain syndrome (CRPS) is a chronic pain syndrome that causes intractable pain, disability, and poor quality of life for patients. The etiology and pathophysiology of CRPS are still poorly understood. Due to a lack of proper diagnostic tools, the prognosis of CRPS is primarily based on clinical observation. The objective of this work is to evaluate a new imaging modality, photoacoustic microscopy (PAM), for assisting diagnoses and monitoring the progress and treatment outcome of CRPS. Blood vasculature and oxygen saturation (sO₂) were imaged by PAM from eight adult patients with CRPS-1. Patients' hands and cuticles were imaged both before and after stellate ganglion block (SGB) for comparison. For all patients, both vascular structure and sO₂ could be assessed by PAM. In addition, more vessels and stronger signals were observed after SGB. The results show that PAM can help diagnose and monitor CRPS.

Complex regional pain syndrome type I affects brain structure in prefrontal and motor cortex

The complex regional pain syndrome (CRPS) is a rare but debilitating pain disorder that mostly occurs after injuries to the upper limb. A number of studies indicated altered brain function in CRPS, whereas possible influences on brain structure remain poorly investigated. We acquired structural magnetic resonance imaging data from CRPS type I patients and applied voxel-by-voxel statistics to compare white and gray matter brain segments of CRPS patients with matched controls. Patients and controls were statistically compared in two different ways: First, we applied a 2-sample ttest to compare whole brain white and gray matter structure between patients and controls. Second, we aimed to assess structural alterations specifically of the primary somatosensory (S1) and motor cortex (M1) contralateral to the CRPS affected side. To this end, MRI scans of patients with left-sided CRPS (and matched controls) were horizontally flipped before preprocessing and region-of-interest-based group comparison. The unpaired ttest of the "non-flipped" data revealed that CRPS patients presented increased gray matter density in the dorsomedial prefrontal cortex. The same test applied to the "flipped" data showed further increases in gray matter density, not in the S1, but in the M1 contralateral to the CRPS-affected limb which were inversely related to decreased white matter density of the internal capsule within the ipsilateral brain hemisphere. The gray-white matter interaction between motor cortex and internal capsule suggests compensatory mechanisms within the central motor system possibly due to motor dysfunction. Altered gray matter structure in dorsomedial prefrontal cortex may occur in response to emotional processes such as pain-related suffering or elevated analgesic top-down control.

Skin biopsy in complex regional pain syndrome: case series and literature review

BACKGROUND

Accumulating experimental and clinical evidence supports the hypothesis that complex regional pain syndrome type I (CRPS-I) may be a small fiber neuropathy.

OBJECTIVES

To evaluate the use of commercially available standard biopsy methods to detect intradermal axon pathology in CRPS-I, and to ascertain if these structural changes can explain quantitative sensory testing (QST) findings in CRPS-I.

STUDY DESIGN

Retrospective review of charts and laboratory data.

SETTING

Outpatient clinic

METHODS

Skin biopsies from 43 patients with CRPS-I were stained with PGP 9.5, and epidermal nerve fiber density, sweat gland nerve fiber density and morphological abnormalities were evaluated. Thirty-five patients had quantitative sensory testing.

RESULTS

Alterations in skin innervation were seen in approximately 20% of CRPS-I patients with commercial processing. There were no patient characteristics, including duration of disease, that predicted a decreased epidermal nerve fiber density (ENFD). There was no consistent relationship between QST changes and ENFD measured by standard commercial skin biopsy evaluation procedures.

LIMITATIONS

Commercial processing of tissue does not utilize stereologic quantitative analysis of nerve fiber density. Biopsy material is utilized from a proximal and distal source only, and differences in denervation of a partial nerve territory may be missed. The functional attributes of small fibers cannot be assessed.

CONCLUSIONS

The negative results indicate that CRPS-I may be associated with changes in the ultramicroscopic small fiber structure that cannot be visualized with commercially available techniques. Alternatively, functional rather than structural alterations of small fibers or pathological changes at a more proximal site such as the spinal cord or brain may be responsible for the syndrome.

Changes with time in skin temperature of the shoulders in healthy controls and a patient with shoulder-hand syndrome

BACKGROUND

Abnormal skin temperature in the shoulder is caused by various diseases. A thermography is unable to capture temperature changes over time. In contrast, a Thermocron is an effective measuring device to monitor temperature changes over time.

PURPOSES

The purposes of this study employing a Thermocron were to measure shoulder skin temperature over time in healthy subjects and to detect shoulder skin temperature abnormalities in a patient with shoulder-hand syndrome.

SUBJECTS AND METHODS

Subjects comprised 10 healthy volunteers (20 shoulders; 4 men and 6 women, mean age 54 years). For measurements, a Thermocron was attached on both shoulders. Measurements were made from 21.00 to 07.00 the following morning at 15-minute intervals.

RESULTS

Gradual difference in right and left shoulder skin temperature was observed with the timing of measurements but no significant difference was apparent, i.e. dominant side 34.9 ± 0.8°C, non-dominant side 34.9 ± 0.9°C (P = 0.28). Presentation of a case with shoulder-hand syndrome. A 54-year-old woman with the diagnosis of rotator cuff tear underwent surgical treatment of rotator cuff repair, but the pain of the operated shoulder persisted due to phase 1 shoulder-hand syndrome. In postoperative week 3, skin temperature measurement using Thermocrons demonstrated a significant decrease in temperature on the operated side (affected side 34.3 ± 0.4°C, healthy side 35.2 ± 0.3°C; P < 0.05).

CONCLUSION

The changing of the skin temperature during night-time was successfully recorded both in the healthy subjects and a case with shoulder-hand syndrome using a Thermocron.

Bone marrow edema syndrome

Bone marrow edema syndrome (BMES) refers to transient clinical conditions with unknown pathogenic mechanism, such as transient osteoporosis of the hip (TOH), regional migratory osteoporosis (RMO), and reflex sympathetic dystrophy (RSD). BMES is primarily characterized by bone marrow edema (BME) pattern. The disease mainly affects the hip, the knee, and the ankle of middle-aged males. Many hypotheses have been proposed to explain the pathogenesis of the disease. Unfortunately, the etiology of BMES remains obscure. The hallmark that separates BMES from other conditions presented with BME pattern is its self-limited nature. Laboratory tests usually do not contribute to the diagnosis. Histological examination of the lesion is unnecessary. Plain radiographs may reveal regional osseous demineralization. Magnetic resonance imaging is mainly used for the early diagnosis and monitoring the progression of the disease. Early differentiation from other aggressive conditions with long-term sequelae is essential in order to avoid unnecessary treatment. Clinical entities, such as TOH, RMO, and RSD are spontaneously resolving, and surgical treatment is not needed. On the other hand, early differential diagnosis and surgical treatment in case of osteonecrosis is of crucial importance.

Unilateral trachyonychia in a patient with reflex sympathetic dystrophy

Reflex sympathetic dystrophy (RSD) is a poorly understood neurovascular disorder characterized by pain, altered sensation, motor disturbance, soft tissue changes, vasomotor changes, and autonomic changes that occurs after trauma to an extremity. Unilateral leukonychia, Beau's lines, nailfold swelling, and nail clubbing have been an observed sequela of RSD. We present a case of a unilateral atypical trachyonychia occurring in the setting of RSD after traumatic fracture of a digit.

Exaggeration of tissue trauma induces signs and symptoms of acute CRPS I, however displays distinct differences to experimental CRPS II

As CRPS I frequently develops after tissue trauma, we proposed that an exaggerated inflammatory response to tissue trauma may underlie CRPS I. Therefore, we studied the vascular inflammatory, nociceptive and apoptotic sequelae of (i) soft tissue trauma and (ii) exaggerated soft tissue trauma in comparison to those of (iii) sciatic nerve chronic constriction injury, modeling CRPS II. Standardized soft tissue trauma (TR) was induced by means of a controlled impact injury technique in the hind limb of pentobarbital-anesthetized rats. Additional animals received soft tissue trauma and femoral arterial infusion of mediator-enriched supernatant achieved by homogenization and centrifugation of traumatized muscle tissue in order to provoke an exaggerated trauma response (ETR). Infusion of supernatant of non-traumatized muscle served as control intervention (STR, sham trauma response). Neuropathy was induced by chronic constriction injury of the sciatic nerve (CCI). Untreated animals served as controls (CO). Detailed nociceptive testing showed temporarily decreased mechanical pain thresholds in ETR animals that resolved within 14 days, while TR and STR animals, i.e. those with singular limb trauma, and controls remained free of pain. Neither cold- nor heat-evoked allodynia developed in post-traumatic animals, whereas CCI animals presented the well-known pattern of ongoing neuropathic pain. Using high-resolution in vivo multifluorescence microscopy, muscle tissue of traumatized animals revealed an enhanced inflammatory response that was found most pronounced in ETR animals. CCI of the sciatic nerve was not accompanied by tissue inflammation; however, induced myocyte apoptosis. Collectively, these data indicate that exaggeration of trauma response induces signs and symptoms of acute CRPS I. Pain perception displays differences to that in CRPS II. Apoptosis turns out to be a distinctive marker for CRPS, warranting further evaluation in clinical studies.

Glucocorticoid inhibition of vascular abnormalities in a tibia fracture rat model of complex regional pain syndrome type I

Tibia fracture in rats evokes chronic hindpaw warmth, spontaneous extravasation, edema, allodynia, and periarticular bone loss, a syndrome resembling complex regional pain syndrome type I (CRPS I). Glucocorticoids such as methylprednisolone (MP) are probably effective analgesic and anti-edematous agents in patients suffering from CRPS and this study examined the effects of chronic MP treatment in the rat CRPS I model. Bilateral hindpaw thickness, temperature, and nociceptive thresholds were determined, and the hindlimb bone density was measured using dual-energy X-ray absorptiometry (DXA). Spontaneous cutaneous extravasation and substance P infusion evoked extravasation were determined using an Evans blue vascular permeability assay. After baseline testing, the distal tibia was fractured and the hindlimb casted for 4 weeks. At 2 weeks post-fracture MP infusion was started (1 mg/kg/day for 28 days). The rats were retested at 4, 6, and 8 weeks post-fracture. Hindpaw edema and warmth after fracture were reversed by MP infusion and these effects persisted after discontinuing treatment. Furthermore, there was an increase in spontaneous protein extravasation and an enhanced substance P evoked extravasation and edema response in the hindpaw at 4 weeks that was inhibited by MP infusion. Glucocorticoid treatment had no effect on the allodynia, hindpaw unweighting, or the periarticular bone loss observed after tibia fracture. We postulate that post-junctional facilitation of substance P signaling contributes to the hindpaw warmth, edema, and the enhanced spontaneous protein extravasation observed in this CRPS I model, and that the anti-edematous effects of glucocorticoid treatment are due to inhibition of post-junctional neuropeptide signaling.

Pathologic alterations of cutaneous innervation and vasculature in affected limbs from patients with complex regional pain syndrome

Complex regional pain syndromes (CRPS, type I and type II) are devastating conditions that can occur following soft tissue (CRPS type I) or nerve (CRPS type II) injury. CRPS type I, also known as reflex sympathetic dystrophy, presents in patients lacking a well-defined nerve lesion, and has been questioned as to whether or not it is a true neuropathic condition with an organic basis. As described here, glabrous and hairy skin samples from the amputated upper and lower extremity from two CRPS type I diagnosed patients were processed for double-label immunofluorescence using a battery of antibodies directed against neural-related proteins and mediators of nociceptive sensory function. In CRPS affected skin, several neuropathologic alterations were detected, including: (1) the presence of numerous abnormal thin caliber NF-positive/MBP-negative axons innervating hair follicles; (2) a decrease in epidermal, sweat gland, and vascular innervation; (3) a loss of CGRP expression on remaining innervation to vasculature and sweat glands; (4) an inappropriate expression of NPY on innervation to superficial arterioles and sweat glands; and (5) a loss of vascular endothelial integrity and extraordinary vascular hypertrophy. The results are evidence of widespread cutaneous neuropathologic changes. Importantly, in these CRPS type I patients, the myriad of clinical symptoms observed had detectable neuropathologic correlates.

Evidence of focal small-fiber axonal degeneration in complex regional pain syndrome-I (reflex sympathetic dystrophy)

CRPS-I consists of post-traumatic limb pain and autonomic abnormalities that continue despite apparent healing of inciting injuries. The cause of symptoms is unknown and objective findings are few, making diagnosis and treatment controversial, and research difficult. We tested the hypotheses that CRPS-I is caused by persistent minimal distal nerve injury (MDNI), specifically distal degeneration of small-diameter axons. These subserve pain and autonomic function. We studied 18 adults with IASP-defined CRPS-I affecting their arms or legs. We studied three sites on subjects' CRPS-affected and matching contralateral limb; the CRPS-affected site, and nearby unaffected ipsilateral and matching contralateral control sites. We performed quantitative mechanical and thermal sensory testing (QST) followed by quantitation of epidermal neurite densities within PGP9.5-immunolabeled skin biopsies. Seven adults with chronic leg pain, edema, disuse, and prior surgeries from trauma or osteoarthritis provided symptom-matched controls. CRPS-I subjects had representative histories and symptoms. Medical procedures were unexpectedly frequently associated with CRPS onset. QST revealed mechanical allodynia (P<0.03) and heat-pain hyperalgesia (P<0.04) at the CRPS-affected site. Axonal densities were highly correlated between subjects' ipsilateral and contralateral control sites (r=0.97), but were diminished at the CRPS-affected sites of 17/18 subjects, on average by 29% (P<0.001). Overall, control subjects had no painful-site neurite reductions (P=1.00), suggesting that pain, disuse, or prior surgeries alone do not explain CRPS-associated neurite losses. These results support the hypothesis that CRPS-I is specifically associated with post-traumatic focal MDNI affecting nociceptive small-fibers. This type of nerve injury will remain undetected in most clinical settings.

Factitious disorders encountered in patients with the diagnosis of reflex sympathetic dystrophy

Reflex sympathetic dystrophy (RSD) may be a misdiagnosis or at least not descriptive enough in patients with atypical hand posture and atypical edema. Seven patients with the previous diagnosis of RSD were investigated further because of inconsistent clinical picture with the underlying pathology and bizarre course of the disease. Four patients had clenched fist and three had factitious edema. These seven patients underwent psychological examination, and MMPI was applied to all. In two of these no psychological disorder was obtained according to DSM-IV. One patient could not adapt to MMPI. In two anxiety disorders, in one depression, and in one patient conversion disorder was diagnosed. We suggest that these patients are not motivated enough to improve their conditions and expectations of such patients may show some differences depending on the environment.

Chronic post-ischemia pain (CPIP): a novel animal model of complex regional pain syndrome-type I (CRPS-I; reflex sympathetic dystrophy) produced by prolonged hindpaw ischemia and reperfusion in the rat

A neuropathic-like pain syndrome was produced in rats following prolonged hindpaw ischemia and reperfusion, creating an animal model of complex regional pain syndrome-Type I (CRPS-I; reflex sympathetic dystrophy) that we call chronic post-ischemia pain (CPIP). The method involves placing a tourniquet (a tight fitting O-ring) on one hindlimb of an anesthetized rat just proximal to the ankle joint for 3 h, and removing it to allow reperfusion prior to termination of the anesthesia. Rats exhibit hyperemia and edema/plasma extravasation of the ischemic hindpaw for a period of 2-4 h after reperfusion. Hyperalgesia to noxious mechanical stimulation (pin prick) and cold (acetone exposure), as well as mechanical allodynia to innocuous mechanical stimulation (von Frey hairs), are evident in the affected hindpaw as early as 8 h after reperfusion, and extend for at least 4 weeks in approximately 70% of the rats. The rats also exhibit spontaneous pain behaviors (hindpaw shaking, licking and favoring), and spread of hyperalgesia/allodynia to the uninjured contralateral hindpaw. Light-microscopic examination of the tibial nerve taken from the region just proximal to the tourniquet reveals no signs of nerve damage. Consistent with the hypothesis that the generation of free radicals may be partly responsible for CRPS-I and CPIP, two free radical scavengers, N-acetyl-L-cysteine (NAC) and 4-hydroxy-2,2,6,6-tetramethylpiperydine-1-oxyl (Tempol), were able to reduce signs of mechanical allodynia in this model.

99mTc-HDP pinhole SPECT findings of foot reflex sympathetic dystrophy: radiographic and MRI correlation and a speculation about subperiosteal bone resorption

Reflex sympathetic dystrophy (RSD) is a common rheumatic disorder manifesting painful swelling, discoloration, stiffening and atrophy of the skin. Radiographic alterations include small, spotty subperiosteal bone resorption (SBR) and diffuse porosis, and MR imaging shows bone and soft-tissue edema. The purposes of current investigation were to assess 99mTc HDP pinhole SPECT (pSPECT) findings of RSD, to correlate them with those of radiography and MRI and to speculate about causative mechanism of SBR which characterizes RSD. pSPECT was performed in five patients with RSD of the foot. pSPECT showed small, discrete, spotty hot areas in the subperiosteal zones of ankle bones in all five patients. Diffusely increased tracer uptake was seen in the retrocalcaneal surface where the calcaneal tendon inserts in two patients with atrophic RSD. pSPECT and radiographic correlation showed spotty hot areas, that reflect focally activated bone turnover, to closely match with SBR. Further correlation with MRI showed both spotty hot areas and SBR to coincide in location with the insertions of ligaments and tendons, onto which pulling strain is constantly exerted. In contrast, the disuse osteoporosis in unstrained bones did not show any more significantly increased tracer uptake than normal cancellous bones.

Risk perception of developing complex regional pain syndrome I

This study investigated how members of a hand team perceive clinical signs after a fracture of the distal radius. The risk of developing complex regional pain syndrome I (CRPS-I) was assessed on a 100-mm straight line based on clinical signs 5 weeks, 7 weeks and 10 weeks after the accident. Members of the hand team perceived clinical signs significantly differently.

Late-onset spondyloarthropathy mimicking reflex sympathetic dystrophy syndrome

Atypical presentations are common when spondyloarthropathy develops in older patients. We report two cases initially mistaken for reflex sympathetic dystrophy syndrome (RSDS). Both the patients were men, aged 62 and 75 years, respectively, with marked painful edema of a foot. One patient reported a moderate-energy trauma as the triggering event. Severe diffuse demineralization was noted on radiographs and diffuse hyperactivity on bone scans starting at the early vascular phase. These findings suggestive of RSDS led to treatment with calcitonin, griseofulvin, and pamidronate, all of which were ineffective. Laboratory tests showed severe inflammation, promoting investigations for other conditions. Spondyloarthropathy was diagnosed based on oligoarthritis with sacroiliitis, presence of HLA B27, and a favorable response to non-steroidal antiinflammatory therapy. In older patients, edema of the foot with severe demineralization and the laboratory evidence of inflammation should suggest a spondyloarthropathy.

A comparison of sympathetic outflow to muscles between cervical spondylotic amyotrophy and ALS

To confirm the diagnostic usefulness of muscle sympathetic nerve activity (MSNA) in differentiation between cervical spondylotic amyotrophy (CSA) and amyotrophic lateral sclerosis (ALS) with cervical spondylosis (CS), MSNA, heart rate (HR) and blood pressure (BP) were recorded in 10 patients with CSA and ALS with CS, and age-matched healthy volunteers at rest and during head-up tilting. There were no differences in age, disability scores, pulmonary function, and HR or BP at rest between ALS and CSA groups. Resting MSNA was significantly greater in patients with ALS with CS than in comparison groups (P<0.001) with virtually no overlap between ALS and the CSA groups. During head-up tilting, changes in BP and MSNA were significantly less in patients with ALS than in patients with other subjects. MSNA at rest clearly differentiated CSA from ALS with CS, suggesting diagnostic utility.

[Reflex sympathetic dystrophy of childhood: one case]

INTRODUCTION

Reflex sympathetic dystrophy (Complex Regional Pain Syndrome type 1) is little known by dermatologists. We report a pediatric case of reflex sympathetic dystrophy with predominant cutaneous involvement.

CASE REPORT

A 10 year-old girl presented a warm, painful and relapsing right hand edema for seven months (three outbreaks). The hand was cyanotic, pigmented and painful. Routine blood tests were normal. Radiography and radionuclide bone scan were consistent with stage 1 reflex sympathetic dystrophy. Physiotherapy led to dramatic improvement.

DISCUSSION

Reflex sympathetic dystrophy is known since the XVIIIth century. In the last decade, progress in radiology and bone scan have provided elements for understanding the physiopathology of the disease. Microvascular abnormalities under the control of sympathetic nervous system are characteristic of different stages of reflex sympathetic dystrophy. Recently, neurovascular system experiments showed that sympathetic reflex tonus changes may be controlled by the central nervous system. Dermatologic changes of reflex sympathetic dystrophy are well known: edema and erythema in first stage, cyanosis in second stage, sclerosis and atrophia in third stage, but pediatric cases are rarely reported.

CONCLUSION

Reflex sympathetic dystrophy is a complex disease, however its physiopathology is now understood. The clinical presentation can be atypical and the dermatologist may be the first to be consulted.

Analgesic effects of ketamine ointment in patients with complex regional pain syndrome type 1

OBJECTIVE

Ketamine hydrochloride (KET), an agent used for general anesthesia, has local anesthetic effects and N-methyl-D-aspartate (NMDA) receptor antagonist action. Because recent studies emphasized the role of peripherally distributed NMDA receptors in processing the nociceptive information, we investigated whether peripheral application of the ointment containing KET is able to attenuate the symptoms of local neuropathic pain.

CASE REPORTS

We applied ointment containing KET (0.25%-1.5%) to the affected area on limbs in 5 patients with complex regional pain syndrome type I (CRPS I) and in 2 patients with type II (CRPS II). One to 2 weeks later, we observed improvement of the report of pain intensity, measured by the visual analog scale, in 4 patients with acute early dystrophic stage of CRPS I. Swelling of the affected limbs subsided as well. No apparent changes were noticed in 1 patient with chronic atrophic stage of CRPS I and in both patients with CRPS II.

CONCLUSION

Topical application of KET appears to be beneficial for the patients with acute early dystrophic stage of CRPS I because of either its local anesthetic effect or NMDA receptor antagonist action. Patients with chronic atrophic stage of CRPS I and CRPS II patients do not appear to respond to this treatment.

Reflex sympathetic dystrophy: a sympathetically mediated pain syndrome or not?

Because of the controversy concerning the manner in which the sympathetic nervous system is involved in reflex sympathetic dystrophy (RSD), its name was changed to one having no mechanistic connotations. This article reviews the relevant literature in support of not only the taxonomical changes to complex regional pain syndrome (CRPS) but also provides evidence of sympathetic dysfunction demonstrated in animal models of neuropathic pain.

[The frozen shoulder]

Painful stiffness of the shoulder is an ill-defined clinical entity that is difficult to assess and delicate to treat. The nomenclature used is broad and includes terms such as frozen shoulder, adhesive capsulitis, focal algodystrophy, stiff shoulder, contracted shoulder, and others. Apart from its idiopathic form, the disease can be initiated by trauma, infection, tumour, radiation, systemic and local metabolic disturbances. Pathoanatomically, the common denominator is an inflammatory vascular proliferation followed by thickening, scarring, and retraction of the joint capsule. The inflammatory process often starts at the rotator interval and may extend to the subacromial space. Clinical diagnosis is based on history and physical examination. Generally the onset of pain precedes the perception of a reduced range of motion by weeks or months. In early stages of the disease, the inflammatory type of pain dominates, i.e., the patient's main complaint ist pain at night. In the later stage, range of motion gradually decreases. Patients do not often complain about reduced motion, probably because of its slow onset. Treatment options are a combination of mobilisation exercises with intra-articular steroids, hydraulic distension of the joint capsule, manipulation under anaesthesia, arthroscopic and/or open arthrolysis. The appropriate choice of protocol is just as important as its correct timing. In the inflammatory phase, aggressive treatment protocols are probably contraindicated. Complications of invasive protocols are rare but deleterious and therefore have to be taken into consideration. New anti-anglogenetic agents may enhance functional results and shorten the rehabilitation phase.

Complex regional pain syndrome (type I, RSD; type II, causalgia): controversies

Introduction of the term complex regional pain syndromes (CRPS) as a replacement of the older terminology, reflex sympathetic dystrophy (RSD) and causalgia, has achieved two goals: it has focused attention on the diagnosis and treatment, and sent basic scientists back to their laboratories. The relation of sympathetically maintained pain and sympatholysis is examined, particularly as a neuropathic process that is found in many conditions, including CRPS. This review also focuses on recent observations proposing a pathologic basis in support of diagnosis and treatment of these disorders.

["Transient osteoporosis" as a special reversible form of femur head necrosis]

There is still controversy whether transient osteoporosis of the hip joint represents a distinct self-limiting disease, or reflects only an early, reversible subtype of non-traumatic osteonecrosis (ON). Transient osteoporosis has several synonyms: algodystrophy of the hip; transient marrow oedema; or bone marrow oedema syndrome--BMOES. Clinical presentation of BMOES shows mechanical hip joint pain, ON risk factors, and a diffuse bone marrow oedema in MR imaging. Histomorphological changes resemble early ON, but with diffuse sufficient repair in BMOES and focal and insufficient repair only at the border of the necrotic lesion in ON. Therefore the clinical course and outcome are significant different, with restitution occurring in BMOES, while progressive destruction of the joint takes place in ON. So far, the preferred treatment strategies are protected weight bearing for BMOES, but operative treatment for ON. In a prospective study of patients with BMOES, the clinical, radiographic, and MRI course of 43 hip joints after core decompression treatment were investigated. All patients showed immediate relief of pain after surgery and the average duration of symptoms with conservative treatment could be dramatically reduced by core decompression from 6 months down to 2 months. There were no perioperative complications. Based on our experience with over 100 BMOES patients, we are convinced that this syndrome represents not a distinct disease but an early reversible subtype of non-traumatic ON. Due to the excellent clinical results of core decompression, we recommend this operative therapeutical concept in patients with painful BMOES.

Objective and subjective assessments of temperature differences between the hands in reflex sympathetic dystrophy

OBJECTIVE

A difference in temperature between the affected and normal extremity is one of the signs or symptoms of reflex sympathetic dystrophy (RSD). These temperature differences are scored anamnestically, by palpation, or by measurements. We investigated the relationship between objective and subjective differences in skin temperature between the hands.

SUBJECTS AND DESIGN

Fifty-one patients with RSD of one upper extremity participated (mean age 55 years, range 18-80). In the first 16 we investigated the reliability of the visual analogue scale (VAS) for recording perceived differences in skin temperature. In the remaining 35 patients the relationship between the VAS and objective infrared radiometry of the hands was investigated.

SETTING

Outpatients clinics of two university hospitals.

RESULTS

The VAS was found to be reliable in terms of response stability. There was no significant correlation between the objective and subjective outcomes.

CONCLUSIONS

There is lack of correspondence between objective and subjective temperature measurements, which may be due to a normal discrepancy between objective and perceived temperature, and/or to alterations in perception due to RSD.

Psychological aspects. A series of 104 posttraumatic cases of reflex sympathetic dystrophy

Over a period of 12 years, 104 cases of posttraumatic reflex sympathetic dystrophy have been diagnosed followed up and treated according to a standard protocol, including, among other clinical items, a psychiatric examination. Apart from the traditional clinical recordings, the following has been noted: 1. All patients were over 30 years of age; 2. No relationship was found between the significance of the trauma and the severity of the dystrophy; 3. The dystrophy nearly always emerged at the time of the primary healing of the injury; 4. On psychiatric examination, 96% of the patients showed signs of chronic depression; 5. Forty-nine percent had elevated gamma GT suggestive of alcohol abuse; 6. The socioprofessional context always revealed: either a state of inactivity (jobless persons, disabled persons, childless housewives, pensioners); or an opportunity for inactivity (work injury suffered by workers, lower-rank employees, bankrupt self-employed people). There were no tradesmen, executives, lawyers, physicians, consultants, artists, sportsmen or musicians in the series, and no housewives with young children. 7. In the second phase of the survey, we decided to complement the drug therapy by systematically adding antidepressant agents. This led to a significant improvement in the course of the disease. These elements have led us to consider whether traumatic algodystrophy could be a psychosomatic disease.

Reflex sympathetic dystrophy in children: review of a clinical series and description of the particularities in children

Few series on reflex sympathetic dystrophy syndrome (RSDS) have included children. The present series reviewed 10 affected children. The group consisted of 9 girls and one boy with an average age at onset of 11 years (5 years to 16 years). The diagnosis was based on the clinical findings of pain, dysesthesia and autonomic system dysfunction. All patients underwent x rays and bone scans. Their results showed great variation. Minor trauma was the most common trigger factor. The lower extremities were more often involved. The treatment consisted of pain relief and progressive mobilization. Less conventional treatments in children, such as calcitonin and bisphosphonate were also used. The severity and duration of the disease varied greatly among these children. Moderate pain and sympathetic dysfunction persisted often up to two years after onset. Reflex sympathetic dystrophy is more common in children than previously thought. There are differences with the adult form in presentation and clinical course: the diagnosis is often delayed, the lower extremities are more often involved, girls are affected more often and idiopathic forms are frequent. Significant emotional dysfunction is found in a majority of patients and they are best treated as inpatients by a multidisciplinary team.

A case of reflex sympathetic dystrophy (complex regional pain syndrome, type I) resolved by cerebral contusion

We present a case of refractory reflex sympathetic dystrophy (RSD) (complex regional pain syndrome, type I) whose symptoms (ongoing pain, allodynia, hyperhydrosis and temperature abnormalities) were resolved after the patient suffered a traumatic cerebral contusion in the left temporal lobe, which caused no neurological deficit. This case suggests that symptoms of some RSD patients may largely sustained by a complex network involving the brain.

Reflex sympathetic dystrophy: facts and hypotheses

Reflex sympathetic dystrophy (RSD) syndrome has been recognized clinically for many years. It is most often initiated by trauma to a nerve, neural plexus, or soft tissue. Diagnostic criteria are the presence of regional pain and other sensory changes following a noxious event. The pain is associated with changes in skin colour, skin temperature, abnormal sweating, oedema, and sometimes motor abnormalities. The clinical course is commonly divided into three stages: first (acute or hyperaemic), second (dystrophic or ischaemic), and third (atrophic) stage. The diagnosis is primarily clinical, but roentgenography, scintigraphy, thermography, electromyography and assessment of nerve conduction velocity can help to confirm the diagnosis. Although a wide variety of treatments have been recommended, the only therapies found to be effective in large studies aim at interfering with the activity of the sympathetic nervous system. To this end, efferent sympathetic nerve activity can be interrupted surgically or chemically. Alternatively, adrenoceptor blockers may be used to relieve pain. Numerous theories have been proposed to explain the pathophysiology. Sympathetic dysfunction, which often has been purported to play a pivotal role in RSD, has been suggested to consist of an increased rate of efferent sympathetic nerve impulses towards the involved extremity induced by increased afferent activity. However, the results of several experimental studies suggest that sympathetic dysfunction consists of supersensitivity to catecholamines induced by (partial) autonomic denervation. Besides, it has been suggested that excitation of sensory nerve fibres at axonal level causes release of neuropeptides at the peripheral endings of these fibres. These neuropeptides may induce vasodilation, increase vascular permeability, and excite surrounding sensory nerve fibres -- a phenomenon referred to as neurogenic inflammation. At the level of the central nervous system, it has been suggested that the increased input from peripheral nociceptors alters the central processing mechanisms.

Three-phase bone scan and dynamic vascular scintigraphy in algoneurodystrophy of the upper extremity

Algoneurodystrophy (AND) is a complex disorder with a wide spectrum of clinical presentations. Patients referred for a work-up of unilateral upper extremity AND were reviewed, and 50 patients were enrolled with sufficient documentation on history, causal event, clinical stage, and final outcome. There were 27 females, 23 males, mean age 44 years. The affected area was: shoulder 5, arm 3, elbow 3, wrist 26 and hand 13. Main precipitating events were fracture, contusion, or prior surgery. Three-phase bone scintigraphy was performed followed by a 2-phase vascular scintigraphy on another day. Typical periarticular uptake on the delayed bone scan was used to diagnose AND. Staging was done with the dynamic phase of the vascular scan. The clinicians diagnosed 30 patients positive for AND, 14 negative, and 6 equivocal. Bone scintigraphy yielded 25 positive, 20 negative, and 5 equivocal scans, i.e. sensitivity 73% and specificity 86%. Of the positive bone scans, 21 had all 3 phases positive, and 16 were concordant on vascular scintigraphy. The remaining 5 vascular scans classified 3 patients in transition (stage I-->II) and 2 in stage II. In other words, in 24% of patients vascular scintigraphy indicated restaging.

CONCLUSION

dynamic bone scintigraphy is an accurate method to diagnose AND. Vascular scintigraphy changed AND stage in one quarter of the patients. Therefore, a combination of both studies is indicated in the work-up and treatment monitoring of AND.

Clinical criteria and treatment of segmental versus upper extremity reflex sympathetic dystrophy

The effectiveness of a multimodal treatment protocol in the long-term management of upper extremity reflex sympathetic dystrophy (RSD), as well as of isolated finger involvement, was analyzed. In the present series, 62 patients diagnosed with RSD were treated and followed for a mean of 22.2 +/- 1.5 months. The findings in the present study indicate that: 1) RSD occurs predominantly in females (female:male, 3:1); 2) regional dystrophy is twice as common as segmental dystrophy; 3) segmental dystrophy is most often associated with minor traumatic dystrophy, whereas regional dystrophy is more evenly distributed among the various clinical types; 4) patients with regional dystrophy score their pain significantly higher; and 5) segmental and regional dystrophy respond with equal satisfaction to the multimodal treatment regimen. In conclusion, the weight of the available evidence strongly suggests that RSD is a complex multifaceted disease entity which responds well when managed with a multimodal treatment program aimed at the various interacting components of the disorder. Furthermore, the finding that segmental dystrophy did not behave differently from the treatment protocol compared to extensive upper extremity RSD, suggests that the anatomic location of the syndrome may not significantly alter the course of the disease during treatment.

Complex regional pain syndrome type I (RSD): pathology of skeletal muscle and peripheral nerve

BACKGROUND

Reflex sympathetic dystrophy (RSD) (recently reclassified as complex regional pain syndrome type I) is a syndrome occurring in extremities and, when chronic, results in severe disability and untractable pain. RSD may be accompanied by neurologic symptoms even when there is no previous neurologic lesion. There is no consensus as to the pathogenic mechanism involved in RSD. To gain insight into the pathophysiology of RSD, we studied histopathology of skeletal muscle and peripheral nerve from patients with chronic RSD in a lower extremity.

METHODS

In eight patients with chronic RSD, an above-the-knee amputation was performed because of a nonfunctional limb. Specimens of sural nerves, tibial nerves, common peroneal nerves, gastrocnemius muscles, and soleus muscles were obtained from the amputated legs and analyzed by light and electron microscopy.

RESULTS

In all patients, the affected leg showed similar neurologic symptoms such as spontaneous pain, hyperpathy, allodynia, paresis, and anesthesia dolorosa. The nerves showed no consistent abnormalities of myelinated fibers. In four patients, the C-fibers showed electron microscopic pathology. In all patients, the gastrocnemius and soleus muscle specimens showed a decrease of type I fibers, an increase of lipofuscin pigment, atrophic fibers, and severely thickened basal membrane layers of the capillaries.

CONCLUSION

In chronic RSD, efferent nerve fibers were histologically unaffected; from afferent fibers, only C-fibers showed histopathologic abnormalities. Skeletal muscle showed a variety of histopathologic findings, which are similar to the histologic abnormalities found in muscles of patients with diabetes.

Clinical signs and symptoms of acute reflex sympathetic dystrophy in one hindlimb of the rat, induced by infusion of a free-radical donor

The acute phase of reflex sympathetic dystrophy (RSD) is characterized by the classical signs and symptoms of inflammation (rubor, calor, dolor, tumor and impaired function). As free radicals are involved in acute inflammation, we studied the effects of free radicals in an animal model, especially as to signs and symptoms found in acute RSD. Awake rats were given continuous intra-arterial infusion (1 ml/h) in the left hindlimb, with saline (n = 6) or the free-radical donor tert-butylhydroperoxide (tert-BuOOH, 25 mM, n = 6). During a 24-h infusion period the skin temperature, volume, skin color, function and pain reactions of the paws were observed. After 24 h the rats were killed and both gastrocnemius muscles were histologically analyzed. Infusion with tert-BuOOH induced in the left paw an increased skin temperature, increased volume, redness of the plantar skin, impaired function and increased pain sensation, while these acute RSD signs and symptoms were absent in the saline infused animals. The alterations in pain sensation (spontaneous, mechanical and thermal pain) were similar to findings in the neuropathic animal model. The gastrocnemius muscles of the saline infused rats and the contralateral gastrocnemius muscle of the tert-BuOOH infused rats showed no histological tissue damage. In the left gastrocnemius muscle free-radical-related damage was visible. Induction of free-radical formation in one hindlimb of awake rats mimics the acute signs and symptoms of acute RSD, with alterations in pain sensation as found in the classical neuropathic animal model of RSD, as well as in acute RSD patients.

[Sudeck disease--pathology, clinical aspects and therapy]

In our opinion the etiology of Sudeck's disease (acute reflex bone atrophy) plays a decisive role in therapeutic planning. The therapy is based on clinical and radiological findings. Physiotherapy addresses the symptom complex of pain, hyperemia, edema formation, and limitations of movement which act in a vicious circle and its intensity is modified according to the prevailing clinical and possibly also radiological findings. A strict coupling of the therapy to a classification according to stage is not recommended. Pharmacological therapy is merely a supporting element and focuses on the sympathetic overexcitability. The best therapy for Sudeck's disease is prophylaxis. Interventions collected under the general term early functional mobilization are, especially after surgical measures, a major factor in the avoidance of neurovegetative dysregulation in the sense of sympathetic reflex dystrophy.

Synovial effusion in reflex sympathetic dystrophy: an additional sign for diagnosis and staging

PURPOSE

To improve the present MRI criteria for diagnosis and staging of reflex sympathetic dystrophy (RSD) by including increased joint fluid as an additional MRI sign of RSD.

DESIGN AND PATIENTS

One hundred and fourteen extremities (69 affected and 45 contralateral controls) in 57 consecutive patients with RSD were evaluated using a 1.5-T unit. T1- and T2-weighted pulse sequences, often with fat suppression, were used before and after administration of intravenous contrast enhancement (Gd). Following T2-weighted image digitization the volume of synovial fluid was measured with a computer model.

RESULTS

Effusions were detected in 61% of the extremities suspected of RSD and in 44% of the contralateral control joints. The mean fluid quantity measured in the symptomatic articulation was 201 mm3. MRI diagnosis of RSD based on previously described criteria was done in 62% of the patients, yielding a sensitivity of 60%. Effusions were present in 79% of the false negative MRI cases. Retrospectively considering the presence of fluid as a potential positive criterion for RSD increases the sensitivity by 31% (to 91%).

CONCLUSIONS

Joint effusions are probably associated with early stages of RSD. Adding effusion to the list of radiological criteria for RSD increases the sensitivity of MRI from 60% to 91%.

Evidence for immune system involvement in reflex sympathetic dystrophy

Skin biopsies from patients with reflex sympathetic dystrophy were immunostained using a variety of antisera. An incidental finding with S100 staining was the presence of numerous Langerhans cells in the epidermis. All patients had significant pain at the time of biopsy, and all had symptoms refractory to treatment. The potential implications of this finding are discussed.

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.

Sudeck's atrophy in Lyme borreliosis

A patient with disseminated Lyme borreliosis is reported. The patient suffered from erythema migrans and radicular pain. Serologic tests routinely performed (IFT, ELISA, Western blots with different strains and Borrelia-LTT) were negative. However, Borrelia burgdorferi (genotype Borrelia afzelii) was cultivated from a skin biopsy. Western blot with the patient's isolate and sera showed strong reactivity only with the 60 kDa protein. In spite of immediate diagnosis and intravenous antibiotic treatment according to current recommendations he developed pain in the right ankle, which was resistant to further antibiotic and anti-inflammatory therapy. Sudeck's atrophy was diagnosed by X-ray. Treatment with calcitonin brought immediate relief from pain and led to radiographically demonstrable recalcification.

An X-ray absorptiometry study of reflex sympathetic dystrophy syndrome

X-ray absorptiometry (Lunar DPX) was performed before and after treatment to determine bone mineral content and density, as well as fat-free mass and body fat, in 28 males and 11 females with a mean age of 37 years who met Doury's criteria for reflex sympathetic dystrophy syndrome. Mean disease duration was eight months. Before treatment, as compared to the unaffected limb, bone mineral content was decreased by 8.8%, bone mineral density by 9.6%, and fat-free mass by 6.2%, whereas body fat was increased by 6%. These differences were largest in those patients with the longest disease durations. The severity of bone loss was not correlated with the outcome, the severity of roentgenographic lesions, or whether the patient was evaluated at the warm or cold stage of the disease process. Study parameters were unchanged after three months both in patients who were and were not improved. After nine to 12 months, increases in bone and fat-free mass were seen in those patients whose clinical manifestations had subsided.

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.

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.

Effect of chronic autoimmune nerve growth factor deprivation on sympathetic neuroaxonal dystrophy in rats

Nerve growth factor (NGF) deficiency has been proposed as a possible pathogenetic mechanism underlying the sympathetic autonomic neuropathy which develops in clinical and experimental diabetes and aging. To determine if long-term NGF deficiency alone would reproduce the distinctive sympathetic neuropathology of streptozocin-induced diabetes or aging in rats, nondiabetic animals were deprived of NGF for 12 months using an autoimmune paradigm. Neuroaxonal dystrophy (NAD), the neuropathologic hallmark of experimental sympathetic diabetic neuropathy and aging, was not increased in frequency in prevertebral superior mesenteric or paravertebral superior cervical ganglia in comparison to age-matched controls. Residual neurons in chronically NGF deprived sympathetic ganglia did not show significant atrophy, chromatolysis, active neuronal degeneration or intraganglionic debris. Postganglionic noradrenergic axons in ileal mesenteric nerves also failed to develop NAD in chronic autoimmune NGF-deprived rats as they would have in animals diabetic for the same duration. These results suggest that simple, isolated NGF deficiency maintained for long periods of time in nondiabetic animals is not sufficient to produce NAD in the pattern of experimental rat diabetes and aging.

[Three phase bone scintigraphy of reflex sympathetic dystrophy and its change with sympathetic blockade]

We examined three phase bone scintigraphy performed at various stages, covering 13 patients with reflex sympathetic dystrophy (RSD) of limbs. In three patients, changes following sympathetic nerve block were examined. In stage-1, radiation count in the affected limbs increased markedly in phases 1 to 3 as compared with the values in healthy limbs. In stage-2, radiation count decreased in phase-1, showed about the same level in phase-2, and maintained an increased level in phase-3. In stage-3, count decreased in phase-1 and 2, and showed about the same level in phase-3. In patients who received a chemical sympathectomy in its early stage, the count was found to have returned to normal level over a short period of time from phase 1 to 3. Three phase bone scintigraphy was considered useful in understanding the pathologic condition of RSD and follow-up evaluation of treatment mainly consisting of sympathetic nerve block.

Avascular necrosis of the hamate

Avascular necrosis of the hamate is a rare condition, only one case having been reported in the literature (Van Demark and Parke, 1992). This reflects the relative rarity of fractures of the body of the hamate and the arrangement of the intraosseous vascular anatomy. A case is presented, which was diagnosed by MR Imaging and treated surgically.

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.

Reflex sympathetic dystrophy with prominent involvement of the nail apparatus

After closed hand trauma, a 17-year-old boy had acute inflammatory changes that resembled bacterial whitlows of the third and fourth right fingers. Clearing of the inflammatory changes was followed by the development of cyanosis, hyperhidrosis, and roentgenographic evidence of patchy osteoporosis in the involved extremity. Findings of a biopsy specimen revealed that the inflammatory lesions in the proximal nail folds were caused by proliferation of capillary vessels embedded in edematous loose connective tissue. This is the first report of cutaneous histopathologic findings in the first stage of reflex sympathetic dystrophy, although similar features have been described in synovial and bone biopsy specimens of patients with reflex sympathetic dystrophy.