Reflex Sympathetic Dystrophy/Chronic Regional Pain Syndrome
Sympathetic or other regional pain syndromes are poorly understood and challenging to treat. Initially called Causalgia, at the time of the Civil War, and later renamed Reflex Sympathetic Dystrophy or RSD, and now known as Complex Regional Pain Syndrome, chronic regional pain syndrome, or CRPS, this pathologic complex remains a syndrome rather than a distinct disease entity. In fact it was renamed for that reason and for the fact that its pathophysiology remains largely unelucidated. Two types of chronic regional pain syndrome are generally recognized, Type 1 where no identifiable nerve injury is present and Type 2 where a distinct nerve insult is identifiable. Diagnoses must be based on exam, history, symptoms and response to therapy, as commonly utilized diagnostic tests are, for the most part, useless except for rare patients. EMG and electrodiagnostic tests are negative with the exception of the QNS test in certain instances, thermography may be useful but is nonspecific and not generally validated, Bone Scans are almost always negative except in the most advanced cases when treatment is even less likely to be effective. The hallmark of the syndrome presentation is that symptoms are very much out of proportion to the nature of the injury and often to that of it's initial physical manifestations. Besides pain and altered local function, patients have sleep pathology which is distinct from a purely pain mediated sleep disturbance, and memory issues are common. This highlights that the pathology has systemic components. The treating physician must really look very closely for telltale subtle changes of local skin temperature, sweating, color, tone, signs of edema, hair growth and restrictions of movement and for abnormal sensations to touch or temperature change. In general, the longer the symptoms have been present, the less likely an acceptable outcome is to be expected. In some cases an insignificant injury such as a paper cut, or a period of immobilization due to casting, has triggered the syndrome pathophysiology. The longer and more severe the affected area is isolated, guarded and underutilized, the worse the expected outcome. Hence treatment with interventional, physical therapeutic, and medical management can be crucial to optimize patient outcome. Patients treated at our centers have had generally good outcomes in terms of pain and function. Importantly, it is obvious that many Migraine and Cluster headache patients have sympathetic mediated pathologies involved in their headache syndromes, and have benefitted from our proprietary treatment options.