Reflex Sympathetic Dystrophy

1. Clinical Descriptions
   1. Pain
      1. Burning ache in a non-dermatome pattern (early)
   2. Trophic Changes
      1. Early Changes
         1. Local edema
      2. Progressive Changes
         1. Skin thins
         2. Hair coarsens
         3. Nail thickens
      3. Late Changes
         1. Muscles shorten and atrophy
         2. Joints ankylose moving distal to proximal
   3. Autonomic instability (Late)
      1. Limb cool and sweaty
      2. Sympathetic hyperactivity
   4. Sensory Abnormalities
      1. Allodynia (exquisite sensitivity to slight touch)
      2. Hyperpathia (severe pain from gentle pressure)
   5. Bony changes
      1. Patchy Osteopenia
2. Three Stages of RSD
   1. Mild (Days to weeks)
      1. Burning pain worse with movement
      2. Edema
      3. Muscle spasm
      4. Patchy Osteopenia may occur
      5. Usually self limited
   2. Moderate: weeks to months
      1. Pain of local hyperesthesia
      2. Muscle wasting
         1. May radiate up extremity
         2. May affect contralateral extremity
      3. Skin cold and pale
      4. Abnormal bone scan
      5. Requires aggressive treatment
   3. Severe: weeks to months
      1. Pain from cold and from touch of additional clothing
      2. Loss of mobility of several joints
      3. Psychiatric changes
      4. Aggressive management may be too late
3. Risk Factors
   1. Local Trauma
   2. Myocardial Infarction
   3. Routine surgery
   4. Diabetes Mellitus
   5. Malignancy with paraneoplastic syndrome
4. Imaging
   1. XRay (Changes in 85% of cases)
      1. Diffuse Osteopenia in 69% of cases (non-specific)
   2. Abnormal bone scan in 50-85% of cases
5. Management
   1. Active range of motion ("Move it OR lose it")
      1. Aggressive physical therapy with pain control
   2. Medications
      1. NSAIDS
      2. Tricyclic Antidepressant (e.g. Elavil)
      3. Corticosteroids (questionable efficacy)
      4. Tylenol
      5. Antihistamine
   3. TENS Unit (questionable efficacy)
   4. Mental health counseling for patient and family
   5. Regional IV Guanethidine
      1. Blocks Norepinephrine
   6. Sympathetic Nerve blocks
      1. Offers temporary relief
6. References
   1. Martin in Ruddy (2001) Kelley's Rheumatology, p. 503-4
   2. Raja (2002) Anesthesiology 96(5):1254-60