Reflex Sympathetic Dystrophy

Can you imagine suffering a relatively minor injury say, a sprained knee, and as the injury heals you begin to feel pain which creeps from your leg into your buttocks, your back, your arm, your chest. The agony moves and changes from an ache, to a sting, to a burning and then burning to a bone crushing hurt that the strongest narcotic will not alleviate. If you are one of those few incredibly unlucky individuals to suffer such an injury, you probably have been diagnosed with Reflex Sympathetic Dystrophy (“RSD”).

These injuries are incredibly frustrating. There is usually no diagnostic test which will identify an injury to a particular nerve which causes it. Instead, it is diagnosed clinically based upon history, symptoms and signs. (Symptoms are what you feel; signs are what a physician observes).

There are two types of RSD otherwise known as Complex Regional Pain Syndrome (“CRPS”). Type I is not associated with a specific nerve injury and does not follow the anatomical distribution of a peripheral nerve. Type II, although having a similar group of symptoms and signs as to those of Type I, is associated with specific nerve injury.

RSD is initiated by a stimulus, as simple as a blow to the knee, which would otherwise be expected to heal readily. It may be caused by a surgical procedure. Arthroscopic surgical procedures of the knee seem to be a common precipitating cause although it may even be present, undiagnosed before the surgery. A minor sprain of a collateral ligament during arthroscopy or injury to a branch of the saphenous nerve during meniscus repair may provide the initiating stimulus. Concern has been expressed that diagnostic arthroscopy for evaluating pain in the knee is seldom justified, since this can be a cause of, or exacerbate a pre-existing RSD, particularly if evaluation can be completed using other techniques such as MRI.

Symptoms typically begin soon after the injury and in some cases may take a few weeks to become apparent. The expression of the symptoms and signs vary between patients. One may see an exaggerated pain response, burning in nature, with an intolerance to cold as the classic presentation. Patients often complain of a continuous deep pain which they localize to the bone. Light touch to the affected body part often provokes an unpleasant sensation or causes moderate to severe pain. There may be spontaneous pain like an electric shock in the limb.

What is most concerning is that patients are often disbelieved by clinicians because the symptoms and signs do not appear to follow an accepted anatomical distribution.

Diagnosis is based upon the clinical picture, the response to sympathetic blockade and the exclusion of other diagnosis such as post-operative infection, nerve injury, and the formation of a neuroma particularly related to the saphenous nerve in the knee, vascular insufficiency, neoplasms, stress fractures and missed intra-articular disorders.

There are three ways to treat RSD, namely physical therapy, the use of pharmacological agents and sympathetic blockade either by injections or operative intervention. Physical therapy could include physiotherapy, mirror visual feedback, transcutaneous electrical nerve stimulation, and acupuncture and electro-acupuncture. Pharmacologic agents include the use of simple analgesics, NSAID’s, steroids, narcotics, anti-neuropathic drugs such as Gapapentin, calcium metabolism modulator such as biphosphonates and calcitonin, propranalol and nifedipine.

If there is no adequate response to the above-referenced trial of treatment or if the patient presents with progressive symptoms for more than six weeks, a sympathetic block is carried out to confirm the diagnosis and provide treatment. If the symptoms return, in-patient treatment with an indwelling lumbar epidural catheter is undertaken to establish a continuous epidural block. Stimulation of the spinal cord can also be an operative intervention. Here, electrodes are introduced into the epidural space and connected to an external pulse generator. The generator is permanently implanted in the subcutaneous tissue.

If you or someone you love has been harmed as the result of carelessness of another, please consider Baratta, Russell & Baratta as your aggressive advocates and trusted advisors to guide you through this life changing injury.