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PubMed2002

Complex regional pain syndrome.

Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy, is a regional, posttraumatic, neuropathic pain problem that most often affects 1 or more limbs. Like most medical conditions, early diagnosis and treatment increase the likelihood of a successful outcome. Accordingly, patients with clinical signs and symptoms of CRPS after an injury should be referred immediately to a physician with expertise in evaluating and treating this condition. Physical therapy is the cornerstone and first-line treatment for CRPS. Mild cases respond to physical therapy and physical modalities. Mild to moderate cases may require adjuvant analgesics, such as anticonvulsants and/or antidepressants. An opioid should be added to the treatment regimen if these medications do not provide sufficient analgesia to allow the patient to participate in physical therapy. Patients with moderate to severe pain and/or sympathetic dysfunction require regional anesthetic blockade to participate in physical therapy. A small percentage of patients develop refractory, chronic pain and require long-term multidisciplinary treatment, including physical therapy, psychological support, and pain-relieving measures. Pain-relieving measures include medications, sympathetic/somatic blockade, spinal cord stimulation, and spinal analgesia.

Acetates↗
PubMedDate not supplied

Treatment of complex regional pain syndrome of the lower extremity.

Complex regional pain syndrome, formerly known as reflex sympathetic dystrophy or causalgia, is a difficult therapeutic problem for the orthopaedic surgeon treating an affected lower extremity. Despite many divergent and often conflicting theories, the cause of the severe pain, alterations in regional blood flow, and edema is unknown. Interventions that have proved successful for treating similar conditions in the arm and hand frequently do not relieve pain similarly in the lower extremity. Common treatment regimens target individual components of this symptom complex, namely, sympathetic or afferent nerve hyperactivity, vasomotor instability, or regional osteoporosis. Despite widespread use of some of these treatments, few controlled clinical trials quantify their effectiveness. This challenging syndrome is best managed by a multidisciplinary team, including chronic pain management specialists, physical therapists, and orthopaedic surgeons.

Complex Regional Pain Syndromes↗
PubMed1992

Survivorship and clinical evaluation of cementless, meniscal-bearing total ankle replacements.

A porous-coated, cementless, congruent-contact, meniscal-bearing total ankle replacement with a centrally placed trochlear groove and a cylindrical articulating axis representing the lateral talar curvature was developed and used clinically over a 10-year period. An initial clinical series of 40 ankle replacements involved the use of cobalt-chromium-molybdenum tibial and talar components with sintered-bead porous coating of 275-mum pore size and a shallow-sulcus trochlear groove with a central fixation fin for the talar onlay component. The congruent meniscal bearing, made of ultrahigh molecular-weight polyethylene (UHMWPe), was flat superiorly and matched the shallow-sulcus and cylindrical geometry inferiorly. Two bearings in two patients subluxed laterally and required revision within 2 years. The overall cumulative survival at the 10-year interval for this group using revision as an end point was 94.75%. The clinical results, using a strict ankle evaluation scoring scale, demonstrated 85% overall good to excellent results. Three patients required further treatment for intermalleolar exostoses, one patient required a debridement for infection, two ankles had medially subluxed bearings, eight ankles developed talar component subsidence, and two patients suffered from chronic reflex-sympathetic dystrophy. A second clinical series of 14 ankle replacements involved the use of polished titanium-nitride-coated titanium-6 aluminum-4 vanadium tibial and talar components with sintered-bead porous coating of 350-mum pore size and a deep-sulcus trochlear groove with two lateral fixation fins for the talar onlay component. The bearing element was similar to the initial series except that it had a deeper engagement in the trochlear groove to prevent subluxation.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1996

"Fever in the Hand"

A 14-year-old female adolescent was being treated for malnutrition secondary to anorexia nervosa. She complained of severe "shooting" pain, swelling, and color and temperature changes in her left (dominant) hand. She had recently suffered a fall during a hockey game and pounded on the table during a "temper tantrum." On exam, the left hand was cyanotic, edematous, and cold, with severe hyperesthesia. A bone scan showed marked reduction in flow to the left hand. She underwent eight sympathetic ganglion blocks resulting in transitory Horner's syndrome. Favorable plethysmographic changes occurred and her recovery was complete. Her eventual diagnosis was reflex sympathetic dystrophy syndrome.

Journal Article↗
PubMed2000

[Ineffective and recurrent cases of thoracoscopic sympathectomy for hyperhidrosis and intractable pain].

We reported the cases of thoracoscopic sympathectomy, that is, six cases of hyperhidrosis, three of post herpetic neuralgia, and four of reflex sympathetic dystrophy, including recurrent or incompletely resected or ineffective ones. Recently this procedure for hyperhidrosis had been performed frequently because of its effectiveness, less pain, early discharge and cosmetic aspect. For an ineffective case of hyperhidrosis abdominal respiration which emphasized the exhalation and using an upper abdomen decreased the sweating. The balance of autonomic nerve system, toward parasympathetic dominant, was thought to be improved by conscious respiration. The decrease of sweating right after the operation in a case of incomplete resection indicated that intraoperative maneuver could restrict the sympathetic nerve. This procedure for a pain control could be less effective than that for hyperhidrosis, so an adequate preoperative informed consent was thought to be necessary.

Adolescent↗
PubMed2000

Interstitial cystitis and the potential role of gabapentin.

Gabapentin, an antiepileptic agent, is a safe and versatile medication also used in the adjunctive treatment of painful disorders. These include neuropathic pain, such as postherpetic neuralgia, diabetic neuropathy, and the pain of reflex sympathetic dystrophy. Interstitial cystitis, a painful disease entity, shares many common features of these chronic pain states, and the use of gabapentin can assist in pain control. Gabapentin, as an adjunctive agent, may reduce use of cotherapeutics such as narcotics. Two patients with interstitial cystitis improved functional capacity within their activities of daily living and received adequate pain control with the addition of gabapentin to their medication regimen.

Acetates↗
PubMedDate not supplied

Factitious disorders mimicking systemic lupus erythematosus.

Factitious disorders are one of the most difficult challenges to the sagacity of the physician. Self-inflicted injuries and diseases have been recognized since Biblical times. In the Middle Ages, hysterics were known to place leeches in their mouths to simulate hemoptysis and to abrade their skin to reproduce skin conditions. Münchausen syndrome, originally described in 1951, is the term applied to persons who seek medical care by feigning illness in the absence of any organic medical or surgical disease. Since the first report of the syndrome, many case reports have documented the performance of unneeded operations and the administration of dangerous drugs to these patients. Rheumatologic manifestations in this syndrome are rare, and include septic arthritis, osteomyelitis, destructive arthropathy, reflex sympathetic dystrophy and systemic lupus erythematosus (SLE). We reviewed the English literature for the past 29 years and found only 8 patients with Münchausen syndrome who simulated SLE. It is interesting to consider the damage mechanisms (some of the patients satisfied 4 or more of the criteria for the classification of SLE) and how a complex disease with a broad spectrum of manifestations such as lupus can be simulated, the only limits being the patient's knowledge and imagination.

Adolescent↗
PubMed2000

On pins and needles? Pediatric pain patients' experience with acupuncture.

INTRODUCTION: Despite its increasing use as a complementary therapy to treat pain, acupuncture is rarely considered by pediatricians, in part due to perceptions that it will not be acceptable to pediatric patients. We wished to describe pediatric pain patients' experience with acupuncture treatment for chronic pain. DESIGN: Retrospective case series. METHODS: Subjects were pediatric pain patients referred by the Pain Treatment Service at Children's Hospital in Boston, who went to a pediatric acupuncturist. A research assistant not involved in the patient's care conducted the survey by telephone. Data were analyzed qualitatively and descriptively. RESULTS: Of 50 eligible patients, 47 families were reached by telephone; all agreed to be interviewed. Patients had a median age of 16 years at the time of referral, 79% were female, and 96% were white. The most common three diagnoses were migraine headache (n = 7), endometriosis (n = 6), and reflex sympathetic dystrophy (n = 5). Patients had a median of 8 treatments (range: 0-60) within 3 months (range: 0-48 months); 85% of families paid out-of-pocket. Acupuncture therapies included needle insertion (98%), heat/moxa (85%), magnets (26%), and cupping (26%). Most patients and parents rated the therapy as pleasant (67% children/60% parents), and most (70% children/59% parents) felt the treatment had helped their symptoms; only 1 said that treatment made symptoms worse. CONCLUSION: Pediatric patients with chronic, severe pain found acupuncture treatment pleasant and helpful. Additional, prospective studies are needed to quantify the costs and effectiveness of acupuncture treatment for pediatric pain.

Acupuncture Therapy↗
PubMed2000

Complications of a simple procedure: de Quervain's disease revisited.

We reviewed the results of 22 operations performed on 21 patients for the relief of de Quervain's disease over the last six years. At a mean follow-up of 34 months (range 4-78 months), 18 of 22 wrists had complete relief of their original symptoms. One patient required reoperation because of inadequate decompression, and two others await further surgery. Most operations (14 out of 22) were performed under local anaesthesia, and 17 out of 22 used a longitudinal incision. The use of a longitudinal incision was associated with a significant risk of complications: four patients had a poor cosmetic result, and six showed evidence of superficial radial nerve injury. Two patients had a wound infection, and one developed reflex sympathetic dystrophy. Although surgical decompression for de Quervain's disease is effective in curing the symptoms in most patients, using a longitudinal incision is associated with poor wound healing and damage to the terminal branches of the radial nerve.

Adult↗
PubMed1998

[Neurolysis of the median nerve at the wrist with 2-portal endoscopic technique. Analysis of 102 consecutive cases].

Based on a retrospective clinical series, the authors evaluated the results of endoscopic nerve release according to Chow's technique, particularly in terms of the complications. The population consisted of 96 patients, corresponding to 102 hands, operated between January 1993 and January 1996. Paraesthesiae had completely resolved at 3 months in 87.2% of cases, while 29.7% of patients complained of discomfort in the hypothenar region. At last review, with a mean follow-up of 13.5 months, paraesthesiae had completely resolved in the same proportion of patients. 93.3% of patients with discomfort in the hypothenar region reported complete cure and 94 patients (92.2%) declared to be satisfied. Eighteen patients were operated on both sides. None of them preferred the conventional technique either in the short-term or in the long-term. One case of section of the superficial palmar arch, one case of severe reflex sympathetic dystrophy, one neurological complication (1%) in the form of dysaesthesia in the middle finger, persisting at last follow-up, one incomplete opening of the extensor retinaculum subsequently repaired via an open approach. Chow's technique presents certain advantages in terms of postoperative comfort, but the safety of this technique must be ensured by prevention of neurovascular complications, based on respect of 3 golden rules: thorough training in the technique, preferably in the anatomy laboratory, open conversion at the slightest doubt concerning visibility of the extensor retinaculum and compliance with the absolute contraindications of the technique.

Adult↗
PubMed1998

[Osteosynthesis of distal radius fractures by by flexible intramedullary nailing (Geneva experience)].

In 1949 Leslie Rush described a new method of management of Colles' fractures by means of a rigid medullary nail. Claude Py in 1969 followed this concept but used two flexible intramedullary pins. After briefly recalling the biomechanical principle and operating technique, the authors outline their series of 39 extra- and intra-articular fractures (10 males and 29 females) operated between March 1995 and April 1996 with an average follow-up of 6.5 months (1.5-14.5 months). The radiological and functional results are discussed: 55% of the cases showed good anatomical reduction whereas 59% achieved a satisfactory functional result. The advantage of this operating technique lies in its simplicity. Nevertheless, considerable experience is necessary owing to the relatively high complication rate (secondary displacement, tendon or nerve lesions, reflex sympathetic dystrophy). However, this method requires only a limited amount of time and remains a good indication for extra-articular and simple articular fractures. In the case of severe posterior comminution, the use of cancellous bone graft can help to prevent secondary dorsal impaction and its repercussion on distal radio-ulnar function.

Adult↗
PubMedDate not supplied

[Complex regional pain syndrome: the need for multidisciplinary approach].

INTRODUCTION AND DEVELOPMENT: The title complex regional pain syndrome is being introduced to cover the painful syndromes which formerly were described under the headings reflex sympathetic dystrophy and causalgia. The pain may be sympathetically maintained or sympathetically independent. The incidence of disease with respect to age shows a peak at 50 years, but may be present at any moment of live. The clinical picture of an affected extremity is characterized by autonomic (vasomotor, sudomotor, edema), sensory (allodynia, hyperpathia, hyperalgesia, hyper or hypoesthesia) and motor symptoms. The diagnosis is generally made by clinical examination and with the use of diagnostic aids, such as plain film radiographs, three-phase bone scan, thermography, and diagnostic sympathetic blockade with local anesthetics, guanethidine test, phentolamine test or ischemia test. With regard to the pathophysiology of the disease, although some investigators suggest that these patients suffer from a psychogenic problem, research with animals with experimental neuropathies has revealed several phenomena like that seen in human suggesting the organicity of the disease. The mainstay of treatment, specially in severe cases, is a multidisciplinary approach. The goal is restoration of normal function. Treatment includes adequate pain relief, complete physical therapy program and psychiatric evaluation.

Adrenergic Agents↗
PubMed1999

[First experiences with retroperitoneoscopic lumbar sympathectomy].

We present our initial experience with retroperitoneoscopic lumbar sympathectomy in a series of 5 men aged 25-45 years. 3 suffered from ischemia of the lower limbs due to Buerger's disease, 1 had severe reflex sympathetic dystrophy and 1 had vasculitis with severe, non-healing lower leg ulcers. The right retroperitoneal space was developed with a dissecting balloon-trocar introduced via a small lateral muscle-splitting flank incision. 2 additional 5 mm trocars were used for instrumentation and clipping. L2-L3 or L3-L4 ganglia were resected; mean operating time was 120 minutes. Only oral analgesics were needed for postoperative pain control and oral food intake was resumed the following morning. The procedure was successful in all and was without complications. Mean hospital stay was 2 days. All patients reported significant relief of ischemia or dystrophic pain and/or improvement in trophic changes in the extremities. In the patient with leg ulcers, the largest was successfully covered with a skin graft. The retroperitoneoscopic approach to lumbar sympathectomy successfully combines the advantages of minimal invasive surgery and the reliability and effectiveness of well-established open sympathectomy.

Adult↗
PubMedDate not supplied

[Severe chronic pain with allodynia in Parkinson's disease: a case report].

We report a 61-year-old man with Parkinson's disease, who had a 3-year history of severe chronic pain with allodynia in the lower extremities prior to motor symptoms. He always had tingling pain around the ankles, and tactile sensation induced severe burning pain expanding to the toes and thighs, so his pain was considered to be allodynia. Pain and motor symptoms were ameliorated by L-dopa therapy and exacerbated by withdrawal of L-dopa. Pain is known to occur in Parkinson's disease, but severe pain rarely occurs. To our knowledge, allodynia, which is usually recognized in causalgia or reflex sympathetic dystrophy, has never been reported in Parkinson's disease. Patients with Parkinson's disease may complain severe causalgia-like pain as an initial symptom.

Chronic Disease↗
PubMed2001

[Pathogenesis of complex regional pain syndrome (CRPS)].

Neuropathic pain results from injury to neural structures within the peripheral or central nervous systems. Such injury promotes spontaneous and ectopic firing of nerves as well as reorganization of the nervous system. Neuropathic pain persists chronically. Patients who suffer from neuropathic pain exhibit persistent or paroxysmal pain without apparent immediate cause or pain hypersensitivity after tissue damage. This hypersensitivity is manifest as hyperalgesia and allodynia. Complex regional pain syndrome, CRPS is a category of neuropathic pain and is further divided into type I(reflex sympathetic dystrophy: RSD) and type II(causalgia). CRPS is characterized by localized autonomic dysregulation in the affected area with vasomotor and/or sudomotor changes, edema, colour difference, sweating abnormality, and atrophy.

Brain↗
PubMed2001

Results of distal radial fractures treated by intra-focal pin fixation.

INTRODUCTION: Kapandji described intra-focal pin fixation of distal radial fracture in which the pins pass through the fracture line and anchor to the far cortex. These pins aid reduction of the fracture and maintain reduction by buttressing the distal fragments. MATERIALS AND METHODS: Between January 1996 to December 1997, 186 distal radial fractures were treated with intra-focal pin fixation. One hundred and seventy-seven patients were available for review after an average follow-up of 30.8 months, ranging from 24 to 36 months. In 133 fractures, a trans-styloid pin was inserted to supplement the intra-focal pin fixation. The fractures were classified according to AO classification into 126 A2, 9 A3, 39 C1 and 3 C2. The anatomical results were evaluated by using Sarmento's criteria and the functional results by Mayo wrist score. RESULTS: Radiological union was achieved in 123 fractures by 2 months, 51 fractures by 3 months and 3 fractures by 4 months. Anatomical results were excellent in 46 fractures, good in 118, fair in 10 and poor in 3. Functional results were excellent in 54 cases, good in 109, fair in 9 and poor in 5. Complications included 2 cases of reflex sympathetic dystrophy and 2 cases of rupture extensor pollicis longus. CONCLUSION: Intra-focal pinning with or without supplementation of a trans-styloid pin is an effective method for treating unstable fractures of the distal radius.

Adolescent↗
PubMed2002

[Two-pin L fixation of fractures of the fifth metacarpal neck].

The authors present a retrospective review of 48 fractures of the fifth metacarpal neck in 48 patients, who underwent internal fixation using the two-pin L procedure. These fractures were treated between 1994 and 2000, in 5 female and 43 male patients with an average age of 27 years (range 14 to 58). Fighting and sporting accidents were the main etiology of injury. The indication for surgical treatment was volar displacement of over 30 degrees. The two-pin L procedure consists of stabilizing the fragments after reduction using one intra-medullary pin 2 mm in diameter introduced through a proximal approach, and a transverse distal pin 1.2 mm in diameter from the fifth toward the fourth metacarpal. All treatments were performed under nerve block. Early mobilization was authorized. Patients did not need any physiotherapy. Activity was resumed after three weeks, and the average time to the removal of pins was five weeks. In eight cases, it was necessary to remove the transverse distal pin around 21 days after surgery because of displacement of the pin causing pain under the skin. At three months follow-up, bone union was obtained in all cases, with a perfect range of motion of all finger joints, without any pain or reflex sympathetic dystrophy. The two-pin L procedure appears to be a reliable technique, which provided union in an anatomic position in all our cases, and also allowed early mobilization and provided good functional results.

Adolescent↗