Contralateral Horner's syndrome following stellate ganglion block.
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Anesthesia, Local↗
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Bone atrophy in complex regional pain syndrome patients measured by microdensitometry.
PURPOSE: To determine the usefulness of quantitative measurement of bone atrophy in the diagnosis and the long-term follow-up of patients with complex regional pain syndrome (CRPS). The bone-sparing effect of a 5-hydroxytriptamine (5-HT2) antagonist was also studied. METHODS: Bone mass was measured by computerized micro-densitometry at the middle position of the second metacarpal. The effect of repeated stellate ganglion blocks (SGBs) three times per week with mepivacaine (n = 11), administration of a 5-HT2 antagonist (sarpogrelate hydrochloride, 300 mg a day po) (n = 12), and combined therapy (n = 10) were compared by micro-densitometry and conventional visual analogue scale (VAS) for analgesia after three months of treatment. RESULTS: In CRPS patients, metacarpal index (cortical bone thickness), maximum bone density (cortical bone density), minimum bone density (trabecular bone density), and average bone density were reduced on the affected side (14.1%, 12.1%, 25.0% and 19.3% respectively). The rate of reduction in bone mass correlated with the duration of the disease (P < 0.05). Therapy with the 5-HT2 receptor antagonist (with or without repeated SGBs) decreased pain intensity (from 6.10 to 3.81 with SGB, from 6.30 to 2.91 without SGB, respectively; P < 0.01) and bone atrophy evaluated by micro-densitometry (P < 0.05). In contrast, repeated SGBs alone reduced pain intensity (from 6.30 to 2.91; P < 0.01) but did not ameliorate bone atrophy. CONCLUSION: Bone micro-densitometry is useful in the assessment and follow-up of CRPS and for evaluation of treatment. The 5-HT2 antagonist, sarpogrelate hydrochloride, is a promising treatment for CRPS patients.
Administration, Oral↗
[100 years Sudek syndrome].
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Fractures, Bone↗
[Unstable distal radius fracture. (Comment on "Results of palmar plate osteosyntheses of unstable radius fractures" by C. Dumont et al., Der Chirurg (2003) 74: 827-833, with concluding statement by the author].
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Bone Plates↗
[Dystonia following peripheral trauma: clinical findings and diagnostic criteria].
Dystonia is a rare neurological complication after peripheral trauma. Incidence and pathophysiology of post-traumatic dystonia are not known. Predisposing factors are sympathetic reflex dystrophia, pre-existing movement disorders or a family history of movement disorders. The main diagnostic goal is to exclude other causes of secondary dystonia. Objective criteria for posttraumatic dystonia are not established, and therefore differentiation from psychogenic dystonia frequently remains difficult. Careful psychiatric examination is obligatory. Clinical criteria are consistency of the symptoms over time and the presence of symptoms compatible with organic dystonia. Polygraphic EMG examinations provide objective correlates of the movement disorder, but exact EMG criteria for the diagnosis of dystonia have yet to be established.
Adult↗
[Sympathetically maintained pain (SMP): phentolamine test vs sympathetic nerve blockade. Comparison of two diagnostic methods].
The objective of our study was to clarify whether the phentolamine test is as suitable as sympathetic blockade in diagnosing cases of sympathetically maintained pain. The specificity and the sensitivity of both procedures were examined within a prospective and randomized study. Both a local sympathetic blockade and an intravenous phentolamine infusion were carried out in 29 patients with persistent pain in the area of the upper or lower extremities. A significant improvement was defined as reduction of pain of at least 50%. There were no complications in either test procedure. The phentolamine test registers sympathetically maintained pain well when it has a positive result (specificity of 83%). However, the phentolamine test shows only a low sensitivity of 69%. The phentolamine test, on the other hand, can be realized very easily and safely. Therefore, based on the results obtained, it is recommended that the phentolamine test be applied for primary diagnosis. In case of a negative result, further diagnosis should follow subsequently, for example with local sympathetic blockade.
Adrenergic alpha-Antagonists↗
[Drug therapy in complex regional pain syndrome type I].
Pharmacologic treatment options for complex regional pain syndrome (CRPS) type I are discussed and drug effectiveness is graded according to the level of evidence available. Various drug strategies in the treatment of CRPS type I, i.e. NSAIDs, corticosteroids, free radical scavengers, antidepressants, anticonvulsants, local anesthetics, opioid analgesics, clonidine, capsaicin, NMDA receptor antagonists, calcitonin, bisphosphonates, GABA(B)-agonists, alpha-blockers, IVRA (bretylium/ketanserin), IVRA (clonidine), IVRSB, local anesthetics sympathetic blockade, GLOA and iloprost are discussed.
Analgesics↗
["Transient osteoporosis" as a special reversible form of femur head necrosis].
There is still controversy whether transient osteoporosis of the hip joint represents a distinct self-limiting disease, or reflects only an early, reversible subtype of non-traumatic osteonecrosis (ON). Transient osteoporosis has several synonyms: algodystrophy of the hip; transient marrow oedema; or bone marrow oedema syndrome--BMOES. Clinical presentation of BMOES shows mechanical hip joint pain, ON risk factors, and a diffuse bone marrow oedema in MR imaging. Histomorphological changes resemble early ON, but with diffuse sufficient repair in BMOES and focal and insufficient repair only at the border of the necrotic lesion in ON. Therefore the clinical course and outcome are significant different, with restitution occurring in BMOES, while progressive destruction of the joint takes place in ON. So far, the preferred treatment strategies are protected weight bearing for BMOES, but operative treatment for ON. In a prospective study of patients with BMOES, the clinical, radiographic, and MRI course of 43 hip joints after core decompression treatment were investigated. All patients showed immediate relief of pain after surgery and the average duration of symptoms with conservative treatment could be dramatically reduced by core decompression from 6 months down to 2 months. There were no perioperative complications. Based on our experience with over 100 BMOES patients, we are convinced that this syndrome represents not a distinct disease but an early reversible subtype of non-traumatic ON. Due to the excellent clinical results of core decompression, we recommend this operative therapeutical concept in patients with painful BMOES.
Adult↗
[The frozen shoulder].
Painful stiffness of the shoulder is an ill-defined clinical entity that is difficult to assess and delicate to treat. The nomenclature used is broad and includes terms such as frozen shoulder, adhesive capsulitis, focal algodystrophy, stiff shoulder, contracted shoulder, and others. Apart from its idiopathic form, the disease can be initiated by trauma, infection, tumour, radiation, systemic and local metabolic disturbances. Pathoanatomically, the common denominator is an inflammatory vascular proliferation followed by thickening, scarring, and retraction of the joint capsule. The inflammatory process often starts at the rotator interval and may extend to the subacromial space. Clinical diagnosis is based on history and physical examination. Generally the onset of pain precedes the perception of a reduced range of motion by weeks or months. In early stages of the disease, the inflammatory type of pain dominates, i.e., the patient's main complaint ist pain at night. In the later stage, range of motion gradually decreases. Patients do not often complain about reduced motion, probably because of its slow onset. Treatment options are a combination of mobilisation exercises with intra-articular steroids, hydraulic distension of the joint capsule, manipulation under anaesthesia, arthroscopic and/or open arthrolysis. The appropriate choice of protocol is just as important as its correct timing. In the inflammatory phase, aggressive treatment protocols are probably contraindicated. Complications of invasive protocols are rare but deleterious and therefore have to be taken into consideration. New anti-anglogenetic agents may enhance functional results and shorten the rehabilitation phase.
Arthroscopy↗
Changes in bone mass and bone turnover following distal forearm fracture.
Bone loss occurs close to a fracture and is associated with increased bone turnover. Fracture healing itself results in increased markers of bone turnover. But the exact patterns of these changes after different fractures are unclear. We aimed to investigate the changes in bone density and biochemical markers following distal forearm fracture. Twenty women (mean age 63 years) were recruited following fracture of the distal radius and ulna. Bone mineral density (BMD) of the hand and forearm were measured by dual-energy X-ray absorptiometry (DXA) and quantitative ultrasound (QUS) of the fingers was measured at 0, 6, 12, 26 and 52 weeks after fracture. Serum and urine samples were collected at 0, 3 and 7 days and at 2, 4, 6, 12, 26 and 52 weeks after fracture to measure markers of bone turnover. For bone formation we measured: bone alkaline phosphatase (iBAP), osteocalcin (Oc), procollagen type I N-terminal propeptide (PINP); and for bone resorption: tartrate-resistant acid phosphatase (TRAcP), free deoxypyridinoline (iFDpd), N-telopeptides of type I collagen (NTx). We used the nonfractured limb to calculate values for baseline BMD and amplitude-dependent speed of sound (AD-SoS). There was a decrease in BMD at the hand and in AD-SoS of the fingers after forearm fracture (p<0.001). This bone loss was maximal for BMD by 6 weeks at 9% (p<0. 001) and remained decreased at 52 weeks. AD-SoS decreased at 12 weeks by 3% (p<0.01) and recovered completely by 52 weeks. Bone formation markers increased between 2 and 4 weeks by 13-52% (p<0. 001), and were still elevated at 52 weeks. Bone resorption markers increased between 2 and 6 weeks by 18-35% and returned to baseline at 52 weeks (TRAcP remained elevated). We conclude that BMD decreased distal and immediately proximal to the fracture line when measured with DXA and QUS. Bone loss after distal forearm fracture did not recover by 52 weeks and most bone turnover markers did not return to baseline.
Acid Phosphatase↗
Changes in bone mass and bone turnover following ankle fracture.
Bone loss and increased bone turnover are recognized local changes after a fracture, but the exact patterns of these changes after different fractures are unclear. We aimed to investigate the changes in bone density and biochemical markers following ankle fracture. Fourteen subjects (7 postmenopausal women and 7 men, mean age 63 years) were recruited following fracture of the distal tibia and fibula. Bone mineral density (BMD) of the ankle and proximal femur were measured by dual-energy X-ray absorptiometry (DXA) and quantitative ultrasound (QUS) of the calcaneus at 0, 6, 12, 26 and 52 weeks after fracture. Serum and urine samples were collected at 0, 3 and 7 days and at 2, 4, 6, 12, 26 and 52 weeks after fracture to measure markers of bone turnover. For bone formation we measured: bone alkaline phosphatase (iBAP), osteocalcin (Oc), procollagen type I N-terminal propeptide (PINP); and for bone resorption: tartrate-resistant acid phosphatase (TRAcP), deoxypyridinoline (iFDpd), N-telopeptides of type I collagen (NTx). We used the nonfractured limb to calculate values for baseline BMD and QUS. There was a significant decrease in BMD at the ultradistal ankle (p<0.001), the trochanteric region of the hip (p<0.01) and QUS of the heel after ankle fracture. This bone loss was maximal for ultradistal ankle BMD by 6 weeks at 13% (p<0.001) and for the trochanter by 26 weeks at 3% (p<0.01). The ankle BMD returned to baseline at 52 weeks but the trochanter BMD did not. Velocity of sound (VOS) decreased at 6 weeks by 2% (p<0.01) and broadband ultrasound attenuation (BUA) by 15% (p<0.01). VOS recovered completely by 52 weeks, but BUA did not return to baseline. Bone formation markers increased significantly between 1 and 4 weeks by 11-78% (p<0.01), and iBAP returned to baseline at 52 weeks but PINP and Oc remained elevated. Bone resorption markers did not increase and NTx was decreased at 52 weeks. We conclude that BMD decreased distal and immediately proximal to the fracture line when measured with DXA and QUS. Ankle BMD and heel VOS recovered at 52 weeks (trochanteric BMD and heel BUA did not) and the bone turnover markers returned toward baseline.
Absorptiometry, Photon↗
Mean sustained pain levels are linked to hemispherical side-to-side differences of primary somatosensory cortex in the complex regional pain syndrome I.
Chronic back pain as well as phantom-limb pain is characterized by a close relationship between the amount of cortical reorganization and the magnitude of pain. In patients with positively assessed complex regional pain syndrome type I (CRPS I), we found a positive correlation between representational changes of primary somatosensory cortex (SI) and mean sustained pain levels. We investigated seven right-handed patients with CRPS I of one upper limb by means of somatosensory evoked potential (SSEP) mapping. Cortical representation of the CRPS-affected hand was significantly smaller than that of the contralateral healthy hand, giving rise to a substantial side difference. Subjective pain levels experienced over the last 4 weeks were estimated according to the visual analogue scale (VAS). Individual expansion of hand representation contralateral to the CRPS-affected limb was significantly correlated with mean pain intensity. Accordingly, low pain levels were linked to small representational side-to-side differences, while subjects with a distinctive hemispherical asymmetry reported the highest pain levels. Follow-up studies using functional imaging methods might be instrumental in providing a better understanding of this issue.
Adult↗
Usefulness of ultrasound in Sudeck's atrophy of the foot.
Quantitative ultrasound (QUS) of bone has been proposed as an inexpensive and radiation-free device method of assessing skeletal status. QUS has been widely used in the assessment of osteoporosis. Until now only few data are available on the usefulness of QUS in different disorders, such as Sudeck's atrophy. To evaluate the ability of QUS in the diagnosis and monitoring of regional osteoporosis, we investigated 19 patients (12 women and 7 men, age range 30-65 years) with osteoporosis of the foot (Sudeck's atrophy), as evidenced by X-ray study and Technetium-99 bone scan. In all patients we measured speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness of the calcaneus using Lunar Achilles Ultrasound, both in the affected and unaffected foot. Bone mineral density at the lumbar spine, by DXA (Hologic QDR 1000), was also performed. QUS was repeated after 3 and 6 months of treatment with salmon calcitonin (100 IU I.M. every second day). At baseline, SOS, BUA, and stiffness, expressed as T-score, were -1.9, -2.4, and -2.4 in unaffected feet and -2.9, -5.1, and -4.3, respectively, in affected feet. The difference between the unaffected and affected foot was significant for SOS, BUA, and stiffness (P < 0.001). No significant difference was found in QUS parameters in the unaffected foot during the study period. After 3 and 6 months of treatment, SOS increased in the affected foot by 0.2% and 0.3%, BUA increased by 6. 2% and 8.2%, and stiffness by 7.5% and 11.1%, respectively. In conclusion, BUA and stiffness seem to be influenced more than SOS by Sudeck's atrophy; QUS, namely, BUA and stiffness, significantly increase with calcitonin treatment. In conclusion, QUS is a sensitive tool in the diagnosis of Sudeck's atrophy of the foot and is adequate for measuring improvement in bone status following treatment.
Adult↗
Partial transient osteoporosis of the hand.
OBJECTIVE: To describe the radiographic and scintigraphic findings of partial transient osteoporosis (PTO) of the hand. To discuss the relationship of PTO and other localized demineralizing diseases. DESIGN AND PATIENTS: Three patients with PTO that affected two or three digits of the hand are reported. Two patients were middle-aged women and the third was a young man. All presented with a history of trauma to the hand. All patients experienced localized burning pain, swelling and vasomotor changes including redness of the skin, hyperhidrosis and signs of vasomotor instability of the involved fingers. Plain radiography and bone scanning were used in the diagnosis and follow-up of these cases. RESULTS: All patients had a radial distribution of the osteoporosis that involved adjacent rays. In all patients two rays were involved. The radiographic changes manifested as minimal patchy osteoporosis involving the cortical, cancellous, subarticular and subperiosteal bone with no articular involvement. The increased uptake on scintigraphy coincided with the radial distribution of the osteoporosis. All patients improved on physical therapy and were symptom-free approximately 6 months after the initial injury. These patients were followed up for more than 2 years. CONCLUSION: PTO of the hand is an uncommon disease with typical clinical and radiographic findings. Bone scintigraphy confirms the partial involvement of the hand.
Adolescent↗
[Pregnancy-induced algodystrophy].
Pregnancy-induced algodystrophy is per se a rare, possibly too rarely diagnosed disease, since patients with algodystrophy may be misdiagnosed as having unspecific backache, musculoskeletal problems, and ligament pain associated with pregnancy. However, when clinical signs of beginning algodystrophia are present, immediate investigations and therapy are necessary for relief of pain and in order to prevent complications. The aim of this paper is to summarize our current knowledge on this disease. Furthermore, the clinical course and diagnostic evaluation are described in two cases with pregnancy-induced algodystrophy. The authors question the common distinction between pregnancy-induced and post-pregnancy algodystrophy, which result in a disturbed bone and calcium metabolism, but discuss both entities similary.
Calcitonin↗
I-123-metaiodobenzylguanidine uptake of the forearm shows dysfunction in peripheral sympathetic mediated neurovascular transmission in complex regional pain syndrome type I (CRPS I).
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3-Iodobenzylguanidine↗
Computer-assisted skin videothermography is a highly sensitive quality tool in the diagnosis and monitoring of complex regional pain syndrome type I.
The use of thermography in the diagnosis and evaluation of complex regional pain syndrome type 1 (CRPS1) is based on the presence of temperature asymmetries between the involved area of the extremity and the corresponding area of the uninvolved extremity. The interpretation of thermographic images is, however, subjective and not validated for routine use. The objective of the present study was to develop a sensitive, specific and reproducible arithmetical model as the result of computer-assisted infrared thermography in patients with early stage CRPS1 in one hand. Eighteen patients with CRPS1 on one hand and 13 healthy volunteers were included in the study. The severity of the disease was determined by means of pain questionnaires [visual analogue scale (VAS) pain and McGill Pain Questionnaire], measurements of mobility (active range of motion) and oedema volume. Asymmetry between the involved and the uninvolved extremities was calculated by means of the asymmetry factor, the ratio and the average temperature differences. The discrimination power of the three methods was determined by the receiver-operating curve (ROC). The regression between the determined temperature distributions of both extremities was plotted. Subsequently the correlation of the data was calculated. In normal healthy individuals the asymmetry factor was 0.91 (0.01) (SD), whereas in CRPS1 patients this factor was 0.45 (0.07) (SD). The performance of the arithmetic model based on the ROC curve was excellent. The area under the curve was 0.97, the P value was <0.001, the sensitivity 92% and specificity 94%. Furthermore, the temperature asymmetry factor was correlated with the duration of the disease and VAS pain. In conclusion, in resting condition, videothermography is a reliable additive diagnostic tool of early stage CRPS1. This objective tool could be used for monitoring purposes during experimental therapeutic intervention.
Adult↗