RSD Puzzle #016

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 #16
FATIGUE, WEAKNESS, AND "IDIOPATHIC PARALYSIS"

1. Chronic fatigue is a common symptom of RSD only preceded by pain, depression, insomnia, and muscle spasms or cramps. The chronic fatigue syndrome is a common neurologic condition which is caused by a large list of chronic neurologic illnesses such as multiple sclerosis, chronic pain, systemic immune diseases, head injuries, and any other systemic or brain dysfunction that gets in the way of the normal daily cerebral activity and productivity.

2. Weakness is actually an independent symptom of RSD that may or may not be accompanied by chronic fatigue. The weakness in the muscles of RSD patients is not simply because of fatigue, but it is due to the fact that the anterior horn cells and anterior lateral horn cells of the spinal cord are not functioning in coordination and getting in each others way. In RSD, the anterior lateral horn cells of the spinal cord are contributing to the secretion of alpha adinergic chemicals causing vasoconstriction, muscle spasm, and movement disorder. The movement disorder may be in the form of weakness in the extremity, muscle spasm, flexor spasm, tremor, dystonia, clumsiness, flexion of the elbow and knee with resultant inability to move around smoothly, and difficulty with coordination of rapid or repetitive movement of the extremity. The end result is weakness of the extremity.

The long standing disturbance of nerve and muscle function as mentioned above also results in gradual disuse atrophy of the extremity with the RSD being pushed into stage III with atrophy and weakness of the extremity.

3. "Idiopathic paraplegia". If the RSD is not treated aggressively or properly, and specifically if the patient starts using assistive devices such as a cane, brace, crutches, and wheelchair, the RSD weakness deteriorates rapidly resulting in the patient's inability to even stand up. This co-called "idiopathic paralysis" is usually gradual and takes weeks or months to develop.

The exceptions in regard to gradual development of idiopathic paralysis is the so-called "acute idiopathic paralysis" of RSD. This acute, practically sudden onset of paralysis in the lower extremities is the result of two forms of treatments.

A. Insertion of spinal stimulators.

B. Insertion of indwelling catheter over the sympathetic chain of ganglia in the paraspinal region in the lumbar spine region.

The commonest form of "acute idiopathic paralysis" is seen in patients receiving a spinal stimulator. This is seen in around 1/4 of the patients receiving spinal stimulator implantation in the spinal canal. If the stimulator is inserted in the area of inflammation of RSD, then the foreign body effect of the stimulator causes an acute exacerbation and flare-up of the muscle weakness and clumsiness as outlined above with resultant development of paralysis in the lower extremities. If such a phenomenon occurs with the insertion of spinal stimulators in the chronic pain patient, one should realize that the condition is a relatively severe RSD, and the stimulator should be removed immediately.

The second less common form that we are starting to see with more frequency in the past two years, is due to the insertion of the catheters into the epidural space, or the area of chain of sympathetic ganglia to prevent repeated needling of the patient for sympathetic nerve block. This occurrence is far less frequent among the spinal stimulator patients. However, when such a paralysis develops, it is essential to remove the catheter immediately and not to leave it in overnight. In the patients that the catheter is left and is not removed for a few days, the patient even develops incontinence of urine and stool.

Examination of such patients shows a sensory loss around the rectal (perineal) area which is unique in the form of "onion peeling" unilateral sensory loss which is typical of vascular involvement of the spinal cord on one side. This is simply explained on the basis of practically all the other central nervous system acute complications of RSD due to vascular spasm causing disturbance of function.

Unfortunately, such patients are accused of suffering, having "hysterical paralysis" without the examiner bothering to check the sensory function around the perineal region which is diagnostic and demands the removal of the catheter. The sooner the catheter is removed, the less likely the long term side effects.

H. Hooshmand, M.D.

The material on the Neurological Associates Pain Management Center Homepage and all it's associated, linked or reference pages is for informational and education purposes. It is not meant to take the place of your physician. Before starting, changing, or stopping any treatments or medicines consult your physician. H. Hooshmand, M.D., Neurological Associates Pain Management Center and Associates will not be held liable for any damage or loss as a result of information provided on this page or associated documentation. Again, this WEB SITE is simply published as an information source and should not be used to treat or make judgments on RSD/CRPS. All associated material on this web site may not be copied, reproduced or quoted without expressed written permission from the owner; Copyright © 1999-2006 H. Hooshmand, M.D.