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PubMed1991

Reflex sympathetic dystrophy syndrome of the hand after placement of an arteriovenous graft for hemodialysis.

Reflex sympathetic dystrophy syndrome (RSDS), a complex clinical syndrome characterized by pain and swelling of an affected extremity, is most commonly seen after trauma. We report the case of a woman with diabetes mellitus and chronic renal failure who presented with RSDS 5 months after placement of an arteriovenous (AV) graft for hemodialysis. The temporal relationship between RSDS and the vascular surgery suggests AV graft placement as the precipitating event for the development of RSDS. Treatment with systemic corticosteroids successfully relieved the patient's symptoms. We believe that RSDS should be included in the differential diagnosis of unexplained limb pain and swelling after AV graft placement.

Arm↗
PubMed2003

A new clinical severity scoring system for reflex sympathetic dystrophy of the upper limb.

A scoring system for the clinical severity of reflex sympathetic dystrophy (RSD) is proposed. The following signs and symptoms were considered to be significant: pain, reduction of finger flexion, swelling, temperature changes, discolouration, sensory disturbances, shoulder pain and loss of movement, increased sweating, and hair/nail growth changes. One point was assigned for strong expression of most of these features, half a point for moderate expression and no point if the feature was absent. A total score of 4 points was assumed, empirically, to indicate a mild degree of RSD, and the maximum score of 10 to indicate the most severe form of RSD. One hundred and forty-six patients with RSD of the hand were classified according to this system. Seventy-four patients (51%) had a score of 4-6, 51 patients (35%) a score of 6.5-8, and 21 patients (14%) a score of 8.5-10. Use of this system will allow more precise analysis of RSD patients and facilitate comparisons between studies.

Body Temperature↗
PubMed1992

Reflex sympathetic dystrophy in children. Clinical characteristics and follow-up of seventy patients.

We report on the experience with our first seventy patients who had reflex sympathetic dystrophy and were less than eighteen years old (average age, 12.5 years). In our series, the patients were predominantly girls (male to female ratio, 11:59) and the lower extremity was involved most often (sixty-one of the seventy patients). The average time from the initial injury to the diagnosis was one year, which indicates that the syndrome remains under-recognized in patients in this age-group. Conservative treatment with physical therapy, transcutaneous electrical nerve stimulation, psychological therapies including cognitive-behavioral management and relaxation training, and tricyclic anti-depressants was effective in improving the average scores for pain and function for forty patients. Sympathetic blocks were helpful for twenty-eight of thirty-seven patients. Thirty-eight of the seventy patients in the series continued to have some degree of residual pain and dysfunction. Reflex sympathetic dystrophy in children differs in presentation and clinical course from the syndrome in adults. It is best treated in a multidisciplinary fashion.

Algorithms↗
PubMed1988

Causalgic form of postphlebitic syndrome. A variety of reflex sympathetic dystrophy caused by acute deep thrombophlebitis.

The causalgic form of the postphlebitic syndrome or reflex sympathetic dystrophy resulting from acute deep thrombophlebitis is a relatively uncommon and, unfortunately, frequently unrecognized form of the postphlebitic syndrome. The usual signs of venous insufficiency are minimal, but severe burning pain is characteristic, usually increased by dependency. The diagnosis is confirmed by phlebography and the response to a lumbar sympathetic block. A lumbar sympathectomy produces permanent pain relief.

Acute Disease↗
PubMed1994

Reflex sympathetic dystrophy. A review of the literature and a long-term outcome study.

According to the literature, approximately half of all patients diagnosed with reflex sympathetic dystrophy respond to nonoperative treatment. Because no long-term studies exist, however, the relapse rate and outcome of this condition are not known. In this paper, a historical review and a brief discussion of the theories of pathogenesis of the disease are presented. The results of treatment, as documented in the literature, are also presented. This paper also reports on 10 patients with reflex sympathetic dystrophy who were treated nonoperatively and for whom a follow-up of at least 1 year was documented. The patient population and short-term results are consistent with those found in the literature. Nine of the 10 patients were contacted for long-term follow-up at an average of more than 5 years after diagnosis. A significant number of patients experienced worsening of symptoms (56%) and reported that their condition negatively affected their activities of daily living (78%). Of those who were employed prior to diagnosis, 67% reported a job change or unemployment directly related to the disease. Therefore, the long-term results of nonoperative treatment are not as encouraging as is indicated in the literature.

Activities of Daily Living↗
PubMed1999

[Prognostic aspects of scintigraphy and MRI during the first 6 months of reflex sympathetic dystrophy of the distal lower limb: a preliminary prospective study of 4 cases].

PURPOSE: The appearance of scintigraphic and magnetic resonance imaging during the evolution of reflex sympathetic dystrophy of the foot is not well known and subject to controversies. The purpose of this preliminary study is to compare these two types of investigation during the first 6 months of evolution. METHODS: 4 non-selected patients with a diagnosis of acute reflex sympathetic dystrophy of the foot (no more than 2 months of evolution and more than 3 out of 6 clinical criteria suggesting a "warm" phase) were studied prospectively. A clinical evaluation, scintigraphy and magnetic resonance imaging (MRI) were performed at diagnosis and after 3 and 6 months. All available examinations (n = 22) were analyzed independently by independent observers. RESULTS: Clinically 3 of 4 patients developed or previously had another site of sympathetic dystrophy confirmed by total body scintigraphy. After 6 months 2 of 4 patients still have a "warm" dystrophy. Bone scanning showed localized or diffuse tracer uptake and MRI showed bone and soft tissue edema when the sympathetic dystrophy was and/or remained clinically "warm". MRI bone edema moved from one location to another in 3 of 4 patients during the follow-up. There was a good correlation between bone scan and MRI images. In "warm" dystrophy, MRI was positive 5 out of 7 times and scintigraphy in all cases. Bone edema and tracer uptake faded simultaneously although the latter was more diffuse and more persistent than the former. CONCLUSION: MRI as well as bone scintigraphy are suitable for the diagnosis of warm dystrophy of the foot. Both exams remain positive when the dystrophy is still "warm" after 6 months. The radiographic evolution after 6 months still has to be evaluated.

Bone Diseases↗
PubMed1993

Case report 758. Reflex sympathetic dystrophy syndrome (RSDS).

We report the angiographic and venographic findings in a case of reflex sympathetic dystrophy syndrome (RSDS) of the lower extremity. The hypervascular intraosseous lesion which initially simulated an arteriovenous malformation provides important information about the vascular nature of this lesion.

Foot Diseases↗
PubMed1987

Scintigraphic evaluation of reflex sympathetic dystrophy: comparative study of the course of the disease under two therapeutic regimens.

A study was made of 26 patients diagnosed as phase I reflex sympathetic dystrophy. In all of them, a bone:soft tissue uptake index was quantified by scintigraphic scanning before treatment and 3 months later. Eighteen patients were treated with 100 MRC units salmon calcitonin, followed by 500 mg elemental calcium 4 hours after hormone administration. The treatment was administered 10 days a month separated by intervals free of therapy. The other 8 patients were treated without interruption with 500 mg naproxen every 12 hours. In the group treated with calcitonin and calcium, the uptake index declined from 13.3 +/- 8.2 to 4.1 +/- 1.8 (p less than 0.001). The uptake index rose from 2.1.3 +/- 17.7 to 31.1 +/- 23.0 (NS) in the naproxen group. Using the Student t-test for paired samples to evaluate individual changes, a highly significant difference was reached (p less than 0.005) in the calcitonin-calcium group. The difference was also significant (p less than 0.01) in the naproxen group, but it was negative (t = 3.620). These results confirm the efficacy of treating reflex sympathetic dystrophy with calcitonin and calcium and the superiority of this treatment as compared with nonsteroidal anti-inflammatory drugs.

Adult↗
PubMed1999

What is reflex sympathetic dystrophy?

In the literature there is no unanimity with respect to the diagnosis of reflex sympathetic dystrophy (RSD). Frequently, the diagnosis is established on mere clinical grounds. In our opinion, however, bone scintigraphy is of major importance for the diagnosis. Using this examination, true RSD can be clearly differentiated from other conditions which are incorrectly diagnosed and treated as RSD. If the bone scan is not suggestive of RSD, the clinical picture, radiological examination and vascular scan may lead to the correct diagnosis. This may be a pseudodystrophy, in which a hypovascularization is found right from the start, while in true RSD there is initially a hypervascularization. Other conditions which may be confused with RSD are causalgia, neurotic compulsive postures, hysterical conversion, malingering and even self-mutilation. In the spontaneous course of RSD three phases can be distinguished. Stage I is the warm or hypertrophic phase, stage II the cold or atrophic phase. Per definition the third phase corresponds to stabilization or, in rare instances, to healing. By means of the vascular scan the correct stage can be determined, and the results of treatment evaluated. Finally it should be noted that in children the condition is completely different from true RSD, as it concerns a pseudodystrophy or disuse-related dystrophy. This condition may also be seen in adults and adolescents, usually females. The bone scan is always negative. In this way bone scintigraphy constitutes the means to answer the question as to what RSD is and what it is not. An algorithm for the differential diagnosis is presented.

Adolescent↗
PubMed1993

Reflex sympathetic dystrophy after operative procedures on the lumbar spine.

Between July 1987 and April 1991, reflex sympathetic dystrophy developed in eleven patients after a posterior operation on the lumbar spine. The average age of the patients was forty-four years (range, twenty-eight to sixty years). The preoperative diagnosis had been lumbar spondylolisthesis or lumbar instability, associated with degenerative disc disease or with osteoarthrosis of a facet joint. Ten patients had posterior stabilization with bilateral arthrodesis and interpedicular fixation, with use of plates or screws; the remaining patient had a posterior hemilaminotomy of the fourth and fifth lumbar vertebrae, partial discectomy, and foraminal decompression of the fifth lumbar-nerve root. After the operation, all patients had burning pain, vasomotor dysfunction, and dystrophic changes in the lower limb and foot; in four patients, the symptoms were bilateral. The symptoms began four days to twenty weeks after the operation. The patients were followed for nine months to four years. Treatment was most successful in four of six patients who had had at least one nerve-block of the sympathetic lumbar trunk in addition to physiotherapy.

Adult↗
PubMed1992

Reflex sympathetic dystrophy in the foot: clinical and scintigraphic criteria.

To establish strict clinical criteria for reflex sympathetic dystrophy (RSD) of the foot and to characterize any associated scintigraphic pattern, the authors performed three-phase radionuclide bone scanning in 51 patients prospectively referred because RSD was a diagnostic consideration. To establish sensitivity and specificity data, the cases of an additional 100 consecutive patients referred for a variety of foot problems were retrospectively reviewed. The authors defined RSD of the foot as a pain syndrome characterized by diffuse nonanatomic, often unrelenting pain; autonomic-vasomotor signs including warm or cool skin temperatures and moist-sweaty or dry-scaly skin; and a positive response to a lumbar sympathetic block. Patients with RSD have a characteristic delayed bone-scan pattern consisting of diffuse increased tracer throughout the foot, with juxta-articular accentuation of tracer uptake. Overall, sensitivity in this study was 100%; specificity, 80%; positive predictive value, 54%; and negative predictive value, 100%. False-positive images were obtained in patients with infection, diabetes, and chronic pain. Specificity was 66% in the subgroup of patients who underwent sympathetic block, with a positive-predictive value of 88%. There were no differences in scan pattern related to duration of symptoms prior to imaging.

Adult↗
PubMed1993

A psychosocial and behavioral comparison of reflex sympathetic dystrophy, low back pain, and headache patients.

Based primarily on anecdotal evidence, patients with reflex sympathetic dystrophy (RSD) have often been suspected of having a high degree of psychosocial disturbance prior to the onset of symptoms as well as in reaction to the disorder. In the present study, patients presenting to a pain center with RSD were compared to patients with low back (LBP) and headache pain (HAP) on a variety of self-reported demographic, behavioral, pain, and mood measures. Typical of most patients experiencing chronic pain, all three groups demonstrated elevations indicative of pain, emotional distress, and behavioral disturbance. However, although the RSD patient group reported the highest level of pain intensity, the most employment disruption, and contained the highest percentage of patients receiving financial compensation, this same group paradoxically reported less emotional distress on the Symptom Checklist-90R than did LBP and HAP patients. This paradox may be due to the lesser chronicity of the RSD patients as well as to their apparently experiencing a more sympathetic response from doctors, employers, and insurance carriers than their LBP and HAP counterparts. On balance, the present data do not support the hypothesis the RSD patients, relative to other pain patients, are uniquely disturbed in psychosocial functioning.

Adult↗
PubMed2005

Tonic dystonia: an uncommon complication of reflex sympathetic dystrophy syndrome. A review of five cases.

Tonic dystonia is an underrecognized complication of reflex sympathetic dystrophy syndrome (RSDS) characterized by an increase in muscle tone at the site of injury. Case-reports.- We describe five cases of tonic dystonia complicating RSDS of the lower extremity. There were four women and one man, with a mean age of 52 years. In addition to the typical features of RSDS, the patients had fixed equinovarus of the foot with hyperextension or hyperflexion of the great toe. In two patients, examination after spinal anesthesia showed that the deformity was reducible. Spontaneous resolution of the dystonia occurred in one patient. Another patient failed to experience meaningful improvement after a motor block followed by botulinic toxin injections. In two patients, the same treatment was followed by a slight improvement. Treatment options are still being evaluated in the last patient. Discussion.- Tonic dystonia is an underrecognized complication of RSDS that often develops after a minor injury yet causes prolonged pain and disability. Spread of the dystonia to other sites is not infrequent. The underlying mechanisms remain unclear but may involve dysfunction of the central or peripheral nervous system or psychogenic factors. Suggested treatments include motor block, intrathecal baclofen, sympathetic block, and sympathectomy. However, none of these treatments has been proved effective. Conclusion.- The five cases described here provide useful information on RSDS-associated tonic dystonia, a condition that runs a protracted course and remains difficult to manage.

Adult↗
PubMed1986

Reflex sympathetic dystrophy syndrome: an unusual mode of presentation of osteomalacia.

We report 2 patients with reflex sympathetic dystrophy syndrome (RSDS) associated with renal tubular osteomalacia. In both patients, RSDS was the presenting manifestation. Treatment of the underlying condition with calcitriol resulted in healing in both patients. These cases prompted us to undertake a retrospective study of 24 consecutive patients with osteomalacia (6 of renal tubular origin, 18 related to vitamin D deficiency), and of 259 consecutive patients with RSDS. Among those with osteomalacia, radiologic lesions strongly suggestive of RSDS were found in 5 patients (21%), 4 of whom had renal tubular defects, and only 1 had vitamin D deficiency. In the group with RSDS, 1 patient (0.4%) was found to have osteomalacia of renal tubular origin. Thus, radiologic findings suggestive of RSDS are frequent in patients with osteomalacia, especially that of renal tubular origin. On rare occasions, the full-blown clinical picture of RSDS may obscure the diagnosis of osteomalacia.

Aged↗
PubMed2003

Scoring system in the assessment of the clinical severity of reflex sympathetic dystrophy of the hand.

A scoring classification for assessment of the clinical severity of reflex sympathetic dystrophy (RSD) and rating the presence and clinical expression of each feature is proposed. The following were included: pain, reduction of finger flexion, swelling, temperature changes, discoloration, sensory disturbances, shoulder pain and loss of movement, increased sweating, and hair/nail growth changes. For most of these features one point was assigned for strong expression, half a point for moderate expression, and zero points if the feature was absent. A score of four points was assumed, empirically, to indicate a minimal degree of RSD, and the maximum score of 10.5 to indicate fully symptomatic condition. One hundred forty-six patients with RSD of the hand were classified according to those criteria. Seventy-four patients (51%) had a score of 4-6, 51 patients (35%) of 6.5-8, and 21 patients (14%) of 8.5-10. This classification was then used to investigate the influence of clinical severity of RSD on the intensity of uptake of the tracer in three-phase bone scintigraphy. No correlation between RSD score values and intensity of fixation of the radionuclide was found.

Diagnosis, Differential↗