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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.
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