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RSD - Reflex Sympathetic Dystrophy (Causalgia)
Reflex Sympathetic Dystrophy (Causalgia) is multifactorial in etiology. The common pathway contributing to symptoms is the sympathetic nervous system where a reflex arc develops between an area of injury, one of the extremities to the spinal cord, with the sensation of pain being mediated along the peripheral sympathetic nerve. Trauma can be very minor such as a small laceration of the thumb, to a severe trauma to a hand, or an upper limb or shoulder, such as an amputation, near amputation/crush injury, all of which can produce a progressing symptomatology producing severe hyperesthesia of the skin overlying the extremity, cool or cold fingers or toes, and hyperhidrosis of the extremity. Also, severe edema can develop as well.
Treatments for Reflex Sympathetic Dystrophy include early physical therapy of the extremity, early upper thoracic ganglion blocks, and in some cases the early intervention can cure the symptoms that are starting to develop. However, in others, these treatments fail to provide improvement or relief necessitating other treatment modalities which include dorsal column stimulator. After upper thoracic ganglion blocks and physical therapy have been tried and symptoms persist, other modalities which can be helpful include dorsal column stimulator, oral medications, narcotics, which provide temporary relief, but do not actually cure or play much of a role in the improvement of symptoms, then other neuro-modulating medications include Neurontin, etc, can be used. After several months of disuse of a particular extremity, severe atrophy of the muscles occurs and the extremity becomes unuseable. Sympathectomy of the upper thoracic chain has been described to be effective in improving or lessening symptoms in between 40% - 60% of patients.
An upper thoracic sympathectomy typically of the T2 to T3, and sometimes the T4 regions have been shown to be effective in improving or diminishing symptoms in between 40% to 60% of patients. The symptoms that are improved typically are again a 40% – 60% chance of improving the pain and also edema if present. There is a higher chance of improving the cool/cold extremity if present, the Raynaud’s Phenomenon, which is approximately 80% to 90%, then for patients suffering from hyperhidrosis of that extremity, it is approximately a greater than 90% chance of improving these symptoms. Symptoms of Reflex Sympathetic Dystrophy are insidious in nature, in that they can slowly intensify and can progress to include the base of the neck or shoulder, or can cross from one side to the other over time. It has also been described as spreading from an upper extremity to the lower extremities over time. If any early signs of spread are seen to the contralateral side, it is important to treat the contralateral side early on.
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