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PubMed2001

Laparoscopic lumbar sympathectomy for lower-limb disease.

BACKGROUND: The standard procedure for sympathectomy is open surgery. The oblique retroperitoneal approach is popular because it provides good visibility, albeit at the expense of requiring a long skin incision. Chemical sympathectomy has been introduced as a less invasive means of achieving sympatholysis; however, this method is also associated with a significant incidence of incomplete block and transient denervation. Laparoscopic surgery is a new approach that simplifies various surgical procedures. The aim of our report was to evaluate the benefits of endoscopic retroperitoneal surgery for lumbar sympathectomies. METHODS: Between March 1997 and April 2000, seven patients underwent laparoscopic lumbar sympathectomy in our department (all men, with an average age or 45.1 years). The predominant presenting symptoms were unilateral pain at rest and lower-extremity coldness. Symphaectomy was performed using a retroperitoneal approach on six patients and an anterior transperitoneal approach on one patient. After laparoscopic lumbar sympathectomy, skin thermometry was carried out on all patients. RESULTS: The postoperative skin temperature of the affected leg rose to 36.6 +/- 0.5 degrees C, as compared to 33.8 +/- 0.8 degrees C preoperatively. After laparoscopic lumbar sympathectomy, none of the patients complained of neuralgia. All patients achieved sustained symptomatic relief, and no major postoperative complications were noted. CONCLUSIONS: Lumbar sympathectomy can be performed laparoscopically. Currently, our standard technique is the retroperitoneal approach. More clinical experience and long-term follow-up will ultimately determine if this will become the procedure of choice. However, we believe that a learning period is necessary for this technique to be fully mastered.

Adult↗
PubMed2003

[Complex regional pain syndrome I and II. What effects the outcome?].

INTRODUCTION: The results of clinical studies have raised doubts on the effectiveness of regional sympathetic blocks with guanethidine (IVRSB) in patients suffering from complex regional pain syndrome (CRPS). We conducted a retrospective analysis of long-term results in our patients and searched for possible factors predicting long-term outcome after IVRSB: METHODS: After approval by our ethics commission and written informed consent, 42/44 patients were included. We documented diagnosis, history, therapy and long-term result from charts. Long-term results were also obtained from a questionnaire administered to the patients. These were defined as very good (reduction of pain > or =75%), good (pain reduction <75% and > or =50%), moderate (pain reduction <50% and > or =25%) or poor (pain reduction <25%). The association of a moderate or poor outcome with the factors age, gender, duration of time until therapy, pain intensity before therapy, dose of applied guanethidine and duration of therapy was calculated by odds ratio. Confidence intervals for the odds ratios were determined by Woolfs approximation. RESULTS: After a mean duration of 18 months, the outcome was classified as very good in 14, good in 13, moderate in 5 and poor in 10 patients. An increased rate of moderate or poor outcome was associated with age<60 years (OR=4.00, CI 1.04-15.26), male gender (OR=2.93, CI 0.71-12.11) and duration of therapy>2 weeks (OR=3.27, CI 0.86-12.36). The factors duration of time until therapy, initial pain intensity and total dose of guanethidine were not associated with increased rates of moderate or poor outcome. CONCLUSION: We only seldom observed a complete functional restoration after CRPS. Male patients <60 years showed an increased risk of developing chronic pain. It remains unclear whether the risk of chronic pain reflects different responses to therapy or differences in the natural course of the disease in our patients. A meta-analysis of randomised trials of IVRSB in CRPS failed to prove the effectiveness of this intervention. If other investigations confirm our impression, future studies of CRPS-treatments should be planned and analysed with regard to the possible influence of the natural course and different risks of chronic pain among patients with CRPS.

Aged↗
PubMed2005

[Psychological abnormalities in patients with complex regional pain syndrome (CRPS)].

QUESTION: Do comorbid psychological disorders, dysfunctional pain processing, and psychosocial pain coping occur with complex regional pain syndrome (CRPS) and is a connection between clinical and psychological manifestations apparent? METHODS: In addition to securing information on case histories and performing clinical neurological examinations of chronic CRPS patients, the structured clinical interview (SCID), pain perception scale, and the Kiel Pain Inventory were employed. RESULTS: The structured clinical interview revealed evidence of a depressive episode in 65% of CRPS patients. Pain perception is similar to neuropathic pain syndromes and patient history revealed a slightly increased frequency of anxiety and affective disorders. Depressive syndrome occurred significantly more often in right-sided CRPS; otherwise, there were no significant correlations between medical history, clinical examination, and frequency of psychological disorders. However, CRPS patients with allodynia manifest clinical signs of special psychological distress. CONCLUSION: In chronic CRPS depressive syndrome frequently develops and psychological treatment can be recommended.

Comorbidity↗
PubMed2004

Bone loss in the contralateral asymptomatic hand in patients with complex regional pain syndrome type 1.

Regional osteoporosis was seen radiographically in clinically affected areas in patients with complex regional pain syndrome type 1 (CRPS1). The aim of the this study was to investigate whether bone loss developed in the contralateral hand in patients with unilateral CRPS1 of the hand. Thirty-two patients with CRPS1 of the hand were included in this study. Bone mineral density was measured in the left proximal femur and both ultradistal radiuses, using dual-energy X-ray absorptiometry. The subjects were classified as grades 1 to 3 according to the T-score of both ultradistal radiuses (densitometric grades): grade 1, both radiuses were normal; grade 2, bone loss was determined only in the affected radius; and grade 3, there was bone loss in both radiuses. Twenty (62.5%) patients had bone loss in the affected hand; 11 patients (34.4%) had bone loss only on the affected side and 9 patients (28.1%) had bone loss on both sides. The mean duration of the period between the diagnosis of the injury and the measurement of bone density was 1.9 +/- 0.6 months in patients with grade 1, 3.1 +/- 1.0 months in patients with grade 2, and 5.5 +/- 2.2 months in patients with grade 3. The Spearman test showed a significant correlation between the period of injury and the densitometric grade ( R = 0.774; P = 0.0001). In conclusion, the current study of patients with CRPS1, showed that the bone loss in the asymptomatic contralateral hand developed at a later stage than that in the affected hand. This bone loss was less frequent and of a lower degree in the asymptomatic contralateral hand than in the affected hand. The bone loss in the asymptomatic contralateral hand could be explained by the loss of sympathetic tone in CRPS1 and contralateral sympathetic innervation.

Absorptiometry, Photon↗
PubMed2005

Efficacy of salmon calcitonin in complex regional pain syndrome (type 1) in addition to physical therapy.

The aim of the study was to assess the efficacy of salmon calcitonin, which was suggested as effective in the treatment of complex regional pain syndrome type 1 (CRPS 1). Patients who had suffered trauma to their upper extremities and developed CRPS 1 were included into this randomised, controlled single-blind study. The diagnosis was made according to the clinical examination and scintigraphy. The evaluation parameters were: pain [visual analogue scale (VAS)], the angle of dorsiflexion (DF) and palmar flexion (PF) of the wrist, distance between the fingertip and distal palmar crease (FT-DPC), allodynia, hyperalgesia and trophic changes. One group received paracetamol 1500 m/day and the other group salmon calcitonin 200 IU/day for 2 months. All of the patients participated in a physical therapy and exercise programme. A total of 35 patients were divided into two groups, who were found to be similar for age, body mass index, period of trauma, period of rest in a plaster splint or bandage, the duration of symptoms, VAS, DF and PF angle, FT-DPC, presence of allodynia, hyperalgesia and trophic changes (p>0.05). The control examination showed similar results for allodynia, hyperalgesia and trophic changes, whereas remarkable improvement was observed in the rest of the parameters within groups. On the other hand, between the two groups there was no significant difference in any of the parameters (p>0.05) This randomised, single-blind study showed that all of the patients with acute CRPS 1 in their upper extremities after trauma, who were treated with either paracetamol or calcitonin along with physical therapy, recovered in all parameters significantly, but without any difference between groups. We can conclude that calcitonin does not make any favourable contribution in the treatment of patients with acute CRPS 1; physical therapy combined with only a simple analgesic is an efficient means of therapy.

Acetaminophen↗
PubMed2005

Sympathetic dysfunction as a temporary phenomenon in acute posttraumatic CRPS I.

OBJECTIVE: Sympathetic testing was carried out in patients in the acute phase of "complex regional pain syndrome type I" (CRPS I) shortly after trauma to the upper limb. Repeated measurements were used to detect changes in peripheral sympathetic function during the course of the disease. MATERIAL AND METHODS: In a busy trauma center, 10 consecutive patients who developed CRPS I following trauma or surgery of the upper limb were diagnosed according to the 1999 modified IASP diagnostic criteria for CRPS I. Clinical signs and symptoms and bilateral hand temperature (infrared thermometry) were recorded. Vasoconstrictor response to sympathetic provocation (inspiratory gasp, contralateral cooling) at the tip of the middle finger of both hands was measured employing laser Doppler flowmetry (LDF). Sympathetic reaction was quantified by the magnitude of blood flow decrease after provocation (SRF parameter). RESULTS: The diagnosis CRPS I could be established 63 days (46-72 days) post-injury. The mean follow-up time after diagnosis was 83+/-15 days. Pain measured by a visual analog scale (VAS 0-10) showed an average of 5.0+/-2.0 at the time of diagnosis and decreased to 1.7+/-1.9 at the last examination. Edema and active range of motion improved substantially during the follow-up period. On the ipsilateral hand marked sympathetic dysfunction was seen early after the onset of CRPS I (mean SRF parameter: 0.14+/-0.01), slowly returning to normal sympathetic reaction three months after the onset of symptoms (mean SRF parameter: 0.42+/-0.21). Diminished sympathetic function was seen even on the contralateral hand. CONCLUSIONS: Sympathetic dysfunction is regularly seen at the onset of CRPS I and normalizes during the course of the disease. This temporary phenomenon suggests a posttraumatic sympathetic deficit playing a decisive role in the genesis of CRPS I.

Acute Disease↗
PubMed2005

Leukocytes in Complex Regional Pain Syndrome type I.

OBJECTIVE: The pathophysiology of Complex Regional Pain Syndrome type I (CRPS I) is unclear. An inflammatory reaction may cause the syndrome in which leukocytes may play an important role. MATERIALS AND METHODS: In this pilot study of six patients with acute warm CRPS I, we performed radiolabeled autologous leukocyte scans of both hands, in order to assess leukocyte accumulation. Comparison was made with the unaffected limb, and with three control patients with a Colles fracture without CRPS I. RESULTS: Images of the CRPS I patients obtained 4 h after leukocyte injection provided the clearest results. At 4 h post-injection, there was clear, asymmetrical leukocyte accumulation in the affected extremity with a mean ratio of 1.49+/-0.19. In control patients, no asymmetry was observed between hands (mean ratio 1.09+/-0.06), indicating the absence of specific leukocyte accumulation. There was a statistically significant difference between CRPS I and control subjects 4 h post injection (p=0.012). CONCLUSION: We found a significantly increased accumulation of leukocytes in patients with CRPS I. This is the first study to show a possible role for leukocytes in the pathophysiology of acute CRPS I.

Adult↗
PubMed2000

Complex regional pain syndrome type I in cancer patients.

Complex regional pain syndrome type I (CRPS-I) is infrequently associated with various malignancies, and may lead to severe pain in already debilitated patients. The causal relationship between CRPS-I and paraneoplastic syndrome, controversies in diagnosis and treatment, and new treatment modalities are presented.

Analgesics↗
PubMed2007

Chronic pain after surgery: what can we do to prevent it.

The development of chronic pain after surgery is not an uncommon event. Despite increased attention devoted to this topic in the recent medical literature, little is known about the underlying mechanisms, natural history, and response to therapy of each syndrome. Central nervous system plasticity that occurs in response to tissue injury may contribute to the development of persistent postsurgical pain. As evidence continues to accumulate concerning the role of central sensitization in the prolongation of postoperative pain, many researchers have focused on methods to prevent central neuroplastic changes from occurring through the use of preemptive or preventative analgesic techniques. Effective preventative analgesic techniques may be useful in reducing not only acute pain but also chronic postsurgical pain and disability. This review examines the efficacy of using a variety of analgesic techniques aimed at preventing or reducing chronic pain after surgery. Specific chronic postsurgical pain syndromes evaluated include complex regional pain syndrome, phantom limb pain, chronic donor site pain, post-thoracotomy pain syndrome, and postmastectomy pain syndrome.

Chronic Disease↗
PubMed1980

The treatment of Sudeck's atrophy in the upper limb by sympathetic blockade.

The incidence of Sudeck's atrophy as a sequel to injury in the upper limb has been estimated in relation to casualty attendances in a 3-year period. Seventeen patients were treated at varying intervals after the onset of the condition either by stellate ganglion block or by regional intravenous guanethidine. The results are compared and the advantages of each method are discussed.

Adult↗
PubMed1993

Post-traumatic osteoporosis and algodystrophy after external fixation of tibial fractures.

The incidence of two forms of post-traumatic osteoporosis and algodystrophy in the ankle region of 20 patients with displaced diaphyseal fractures of the tibia treated with external fixation were studied. Acute localised osteoporosis (ALO) occurred in 14 (70 per cent) and 5 (25 per cent) developed algodystrophy. ALO was significantly less frequent in matched patients treated by internal fixation or by external plaster-of-Paris (POP) cast. Regional osteoporosis (RO) was most common in POP patients. The presence of ALO may indicate the development of algodystrophy following tibial fracture. Our findings suggest that external fixation may predispose to ALO and algodystrophy.

Acute Disease↗
PubMed1995

Reduction of post-traumatic osteoporosis after external fixation of tibial fractures.

Disuse osteoporosis following tibial fractures is associated with pain and prolonged rehabilitation. In a prospective study, 22 patients with stable tibial fractures treated in plaster of Paris were compared with 15 patients in whom unstable tibial fractures were treated by external fixation. All patients were allowed to bear full weight from the day after the injury. The patients treated with plaster of Paris had the less severe fractures but still had a greater number of the higher grades of osteoporosis. We found a significantly lower degree of osteoporosis in the external fixator group. A comparison of the median percentage bearing weight in the two groups of patients showed greater percentage bearing weight in the external fixator group at four and eight weeks after the injury. We suggest that the reduction of post-traumatic osteoporosis is due to improved early function and weight bearing in patients treated by external fixation.

Adolescent↗