Complex Regional Pain Syndrome (CRPS) and Sympathectomy
H. Hooshmand, M.D. and Eric M. Phillips
Neurological Associates Pain Management Center
Vero Beach, Florida
Sympathectomy may provide temporary pain relief, but after a
few weeks to months it loses its effect. Sympathectomy and the application of
Chemical Sympathectomy (neurolytic agents e.g., phenol, alcohol, etc.) should be
limited to patients with life expectancies measured in weeks or months - e.g.,
Chemical Sympathectomy (e.g., alcohol, phenol or hypertonic
saline nerve blocks) aimed at destroying the nerves are apt to fail, to cause
serious complications, and aggravation of the pain - by leaving a large scar
Complex Regional Pain Syndrome (CRPS) patients should not be
exposed to aggravation of pain due to sympathectomy, chemical sympathectomy or
Keywords: Complex Regional Pain
Syndrome (CRPS), Chemical
Sympathectomy, Reflex Sympathetic
Sympathectomy, and Radiofrequency Sympathectomy.
Sympathectomy has been applied for the treatment of causalgia
since 1916 (1). The meta analysis of sympathectomy literature for treatment of
Complex Regional Pain Syndrome (CRPS) shows high rates of failure. Long term
follow-up of 8.4 years showed 13% success (2). Only young teenage soldiers
undergoing sympathectomy and followed up to 26-60 days have very good results
(3). The rest of the literature have reported a range of 12% up to 97% success
rates. The high percentage group has been wartime soldiers which have been
diagnosed early , undergone surgery within a few days , and sent home to be lost
to follow-up (4-25). Realizing that children and teenagers (such as soldiers),
show a strong plasticity and healing power as compared to adults, and realizing
that early diagnosis and treatment is more successful, explain the beneficial,
albeit temporary, results of wartime sympathectomy (26-29). In contrast, the
sympathectomy done in stage III* has been reported to show zero percent
relief (30) (Table 1). Usually, by the time the physician resorts to the
sympathectomy procedure, the patient is in advanced stages of the disease. In
such late stages, the nervous system has lost its plasticity and cannot respond
properly to surgical sympathectomy (31,32). More over, the disease has spread,
to other parts of the body and a regional sympathectomy will not be of any
benefit to the patient (31,33-37).
To quote Nashold, referring to sympathectomy, "Ill-
advised surgery may tend to magnify the entire symptom complex"(38).
Sympathectomy is aimed at achieving vasodilation. The neurovascular instability
(vacillation and instability of vasoconstrictive function), leads to fluctuation
of vasoconstriction alternated with vasodilation in an unstable fashion (39).
Following sympathectomy the involved extremity shows regional hyper - and
hypothermia in contrast, the blood flow and skin temperature on the non-
sympathectomized side are significantly lower after exposure to a cold
environment (39). This phenomenon may explain the reason for spread of CRPS. In
the first four weeks after sympathectomy, the Laser Doppler flow study shows an
increased of blood flow and hyperthermia in the extremity (40). Then, after four
weeks, the skin temperature and vascular perfusion slowly decrease and a high
amplitude vasomotor constriction develops reversing any beneficial effect of
surgery (39). According to Bonica , "about a dozen patients with reflex
sympathetic dystrophy (RSD) in whom I have carried out preoperative diagnostic
sympathetic block with complete pain relief, sympathectomy produced either
partial or no relief (40). Postoperative examination with a sweat test and
psychogalvanic reflex revealed residual sympathetic function, and this was
confirmed with subsequent sympathetic blocks which produced both sympathetic
denervation and pain relief" (40). In the same page, Bonica wrote: "There are
other possible explanations for failure of sympathectomy to relieve the pain and
causalgia. One is that although sympathectomy relieves burning pain, it may not
affect the deep, tearing, stabbing, and bursting pain" (40).
Also, to quote Livingston, referring to Dr. James Evans,
report on sympathectomy for reflex sympathetic dystrophy. Dr. Livingston stated
that Dr. Evans is correct in stating that when a preliminary procaine block of
the sympathetics fails to afford temporary relief it is reasonable to assume
that a ganglionectomy will probably fail. I would add the fact that even when
the procaine block affords temporary relief the ganglionectomy may fail to
confer a satisfactory result. In my opinion there are three reasons why this
should be so: (i) The phase of active vasodilation which follows immediately
after a block or a ganglionectomy does not persist for long, and although relief
may be obtained during this primary phase, the pain may recur when the vessels
regain some tone. (ii) Sympathetic nerves have a remarkable ability to
regenerate. I have had the disappointing experience of seeing pain return a few
weeks after ganglionectomy and have been able to demonstrate that within two to
three months sympathetic fibers have successfully bridged a considerable
anatomic gap. (iii) These so-called sympathetic dystrophies begin as a
result of irritation at some focal or "trigger point." A sympathetic
ganglionectomy does not remove this source of irritation, and not infrequently
the pain and many of the associated dystrophic phenomena will recur even in the
absence of the sympathetic component (41).
In my opinion the most significant feature of this paper is
the fact that 11 of 12 patients treated with procaine block alone were
completely cured of their pain. These 11 patients represent almost 20 percent of
this whole series. The fact that procaine blocks gives a satisfactory
result without the need to resort to a surgical excision indicates to me that
the syndrome represents a disturbed physiology which the injection acts in some
mysterious manner to correct. I am always in favor of trying repeated procaine
blocks of the sympathetics before resorting t the use of alcohol or a surgical
excision of the ganglions for three reasons: (i) I hesitate to excise
sympathetic ganglions which in their normal state must serve useful functions,
some of which functions we may not understand. (ii) When a surgeon
excises the sympathetic chain he has removed the point of attack at which the
syndrome is most vulnerable. (iii) Since I believe that this is a
disturbance of physiology, I would prefer to treat it with physiologic methods
rather than surgical excisions. This paper emphasizes two points which are of
great importance to the clinician who undertakes to treat painful dystrophies.
One of these is that the sympathetic nerves play an important part in sustaining
the dystrophy and represent the most logical point of surgical attack. The
second point is equally obvious in this paper, that is, a sympathetic
ganglionectomy is not a cure-all for painful dystrophies (41).
CHEMICAL SYMPATHECTOMY (ALCOHOL BLOCKS)
Chemical Sympathectomy (Alcohol blocks)
which are chemical blocks in the form of phenol, alcohol, etc., are the most
dangerous and destructive forms of nerve blocks. They are also called "lytic"
blocks which better describe them. The term "lytic" refers to "lysis" which
refers to a meltdown of every soft tissue in the target area of the block
including nerves, connective tissue, etc. This destruction is not limited to the
area of injection-because nothing keeps the alcohol from destroying the "bad
nerves", but it also destroys the adjacent perfectly normal nerves.
Incidentally, intervention or destructive lytic nerve blocks or sympathectomy
are done on damaged nerves. The nerve is nothing but the conveyer of the
impulse. In CRPS, the disease originates from microscopic sensory nerves in the
wall of the small blood vessels. The large trunk of the nerve fibers that are
the target of nerve blocks or sympathectomy, are just the messengers. Destroying
the messenger is not going to solve the problem, but it is going to add a new
source of pain. Alcohol causes extensive scar formation of the soft tissues
including the nerves and such scar formation becomes a new source of severe pain
far worse than the original pathology. Alcohol blocks, sympathectomy, or
neurectomy (cutting nerve fibers) only adds assault to the injury. Such
destructive procedures relieve the pain for a few weeks to a maximum two months,
only for the pain to return with more intensity and in a larger area of the
Any destruction of nerve fibers should be definitely avoided.
These procedures are all doomed to fail and are dangerous.
On the other hand, performing epidural nerve blocks or
paravertebral nerve blocks which flood the nerves in the muscle or in epidural
space with a combination of local anesthetic and a small amount of
anti-inflammatory medication (such as Depo-Medrol ®, Kenalog, or Celestone) do
not destroy the nerves. They simply block the input of painful chemical such as
substance P from the extremity into the spinal cord. They don’t anatomically
destroy any of the nerve fibers and they provide excellent relief lasting
anywhere from 2-3 months. In the meantime, during that 2-3 months with proper
physical therapy and massage and other measures should preclude the necessity of
repeating such nerve blocks in at least 80% of the patients.
Not only should surgical procedures, chemical sympathectomy
and neurectomy be avoided, but also application of ice on the extremity by the
virtue of destroying the myelin covering of the nerve (the protective sheaths of
the nerve) should always be avoided (42).
All the above statements refer to benign, complex,
chronic pain. Obviously, if the patient suffers from cancer and has a few months
to live, any of these blocks will give the patient a few months of relief and
are palliative. In cancer patients any surgical procedure that gives a temporary
relief to the patient is justifiable, humane, and should be done. CRPS (RSD)
patients do not suffer from cancer. They are quite young. They have 4-5 decades
of life ahead of them, and should not be exposed to such destructive procedures
which cause more pain than the original disease(4).
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