RSD Puzzle #013

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

BOARD CERTIFIED IN ELECTROMYOGRAPHY

BOARD CERTIFIED IN AMERICAN BOARD OF ELECTODIAGNOSTIC MEDICINE

INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

An International Referral Center dedicated to Treatment, Education and Research

RSD PUZZLE #13
Choices Of Blocks For RSD

"They have tried stellate ganglion block on me, but because of complications they could not do it. Is there any hope for any other blocks?"

Stellate ganglion blocks, even in the hand of the best experts, have a failure rate of around 25%[1]. The stellate ganglion which is the main relay station of the sympathetic nerve connections from the head, face, neck, and upper extremities, is in a hazardous location in the neck, and the attempt for the block is fraught with significant complications.

There are other types of blocks available and practical. These consist of:

A. Non-invasive chemical blocks.

B. Epidural and paravertebral nerve blocks.

In our experience, and the experience of Doctor Schwartzman, the epidural blocks are safe, and have a high success rate in the treatment of RSD patients. In the past four years, the number of patients that we have referred to the anesthesiologists for paravertebral ganglion blocks, stellate blocks, and Bier blocks has dropped precipitously. We have spared close to 40% of the patients from ending up having invasive sympathetic ganglion blocks.

The epidural and paravertebral nerve blocks are done under local anesthesia, and the area of nerve block is identified with a careful examination of the cervical and lumbar spine regions in the RSD patients. One clue that is quite helpful is the presence of "jump sign" and the presence of "red reflex". The "jump sign" refers to the fact that pressure in certain area in the cervical or lumbar spine results in sudden muscle contraction oft he paravertebral muscles and reproduction of the patient's pain in the form of headache, neck pain, or low back pain.

The "red reflex" refers to identification of the area of nerve irritation by touching and applying pressure to the paravertebral muscles in the neck and back. The equal pressure applied to the two sides of the spine identifies one or more than one areas of reddish discoloration of the skin along with pain and tenderness over the same areas. These areas of reddish discoloration have been found to be due to secretion of substance P which is a painful and irritating chemical substance. After identification of this "red reflex", the area is injected with local anesthetic and if necessary anti-inflammatory medication.

The paravertebral and epidural nerve blocks have been quite helpful in the management of RSD. The patient is immediately referred to physical therapy department after the nerve blocks for heat, massage, ultrasound, exercise, and other proper treatments, but NO ICE.

The second form of nerve block, the systemic chemical nerve block, is usually achieved by the use of alpha blockers such as Clonidine (Clonidine Patch), Dibenzyline, Hytrin, an alpha II blocker by the name of Yohimbine. The Clonidine Patch has been quite helpful and successful in controlling the pain behind the cervical or lumbar spine regions and has been very well tolerated by the patients.

Such nerve blocks (epidural or paravertebral), are quite instrumental in better management of RSD patients.

H. Hooshmand, MD

1. Bonica JJ: Causalgia and other reflex sympathetic dystrophies. Post Grad Med 1973; 53:143-148

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