RSD Puzzle #019

H. Hooshmand, M. D.

DIPLOMATE AMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY

BOARD CERTIFIED IN ELECTROENCEPHOLOGRAPHY

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INTRACTABLE NEUROLOGY

EPILEPSY, PAIN, MS

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RSD PUZZLE #19
RSD and Other Organs

"Can RSD affect other internal organs?"

RSD is not usually limited to one part of an extremity or one extremity. Usually, the pathological sympathetic function spreads to adjacent areas.

The first areas becoming involved are the pathway of the sympathetic nerves between the end organ (e.g, foot or hand) and the spinal cord. This results in an inflammation and irritation of the nerves all the way from the end organ to the spinal cord. This is manifested by muscle spasm in the cervical and lumbar spine region, secondary back and neck pain, headache, dizziness, and tinnitus (buzzing in the ears).

This provides excellent treatment opportunities. In the path of the areas of inflammation, the posterior sensory nerve branches corresponding to the level of the involved nerves and secretes substance P (a painful substance half the molecule of endorphine and practically identical to jalopena pepper extract). This secretion of substance P under the skin in the paraspinal regions can be identified by exerting equal pressure on the two sides of the vertebra, and observing the so-called "red reflex". Pressure on the normal areas causes no reddish discoloration. On the other hand, pressure on the areas of sensory nerve irritation causes a reddish discoloration of the skin which is accompanied by Travaill's Jump Sign. This area of reddish discoloration can be easily blocked and dissipated by injection of local anesthetic such as Marcaine and if the condition is chronic and severe, one can add a small amount of Celestone or Depo - Medrol® to it. This nerve block provides excellent relief of pain and reversal of constriction of the blood vessels.

The next area of involvement of RSD is the spinal cord itself. This is manifested by movement disorder, muscle spasm, weakness of the extremity, as well as urgency and frequency of urination and disturbance of erection.

Invasive procedures such as the insertion of a spinal stimulator can flare-up such an involvement of the spinal cord and it can cause "idiopathic paralysis" due to flare-up and constriction of blood vessels to the spinal cord. The same can be noted in rare cases of insertion of a catheter for sympathetic nerve blocks in the paravertebral or epidural regions.

The next is the visceral involvement with RSD. In RSD the skin is usually cold and the deep structures are hot and have an exaggerated blood circulation. This results in osteoporosis, fracture of the bones, areas of swelling and fluid formation between the bones and joints identified on MRI, and severe pain as well as weakness in the deep structures. This causes a high risk of amputation for the patient. Amputation is totally unnecessary and should never be performed. Just simple weight bearing under the effect of a strong analgesic such as Stadol along with the use of moist heat and epsom salt, exercise and massage for the extremity to reverse the vasoconstriction on the surface and to increase the circulation in the deep structures corrects this situation without the need for amputation. Amputation in RSD is a slow, painful, gradual suicide.

The next structures being involved in some cases of RSD are the blood vessels to the kidney with resultant episodes of sudden brief and temporary bleeding through the kidney accompanied by a marked elevation of blood pressure. The same principle can cause attacks of nose bleeds, severe headache, dizziness, passing out spells as well. Application of Clonodine Patch in the area of the kidney in the flank (in the back) usually results in good relief of such spasm and inflammation of the blood vessels. The patient should be treated with Dibenzyline or Hytrin which are life saving in such patients.

The involvement of other sympathetic midline connections and plexi such as celiac (abdominal pain, peptic ulcer, nausea, vomiting, and weight loss), superior and inferior mesenteric plexi (diarrhea, abdominal cramps, and weight loss), and cardiac plexus (chest pain, abnormal heart beat, tachycardia, and heart attack), and carotid and vertebral plexi (severe vascular headaches, dizziness, tinnitus, attacks of falling spells, and syncopal attacks), should be identified as such and should be treated with the help of Clonodine Patch, Hytrin, or Dibenzyline as well as proper treatment applied to the source of RSD (definitely avoiding ice, but encouraging exercise, moist heat, epsom salt and hot water, and newer antidepressants as the best analgesics of choice for RSD).

The involvement of the same midline plexi (see the enclosed diagram) explains the reason for the involvement of other organs symmetrical on the opposite side such as the opposite hand or opposite foot or opposite side of the head in regard to headache and face pain or involvement of the removed areas such as involvement of right hand because of left knee injury).

Because of the above complex phenomenon and because of the fact that in RSD the sympathetic nerves follow the path of the blood vessels rather than somatic nerve roots resulting thermotomal rather than dermatomal sensory nerve distribution (mistaken for hysterical sensory loss) may cause a complex clinical picture that baffles the clinician and forces the clinician to blame the patient as being hysterical, hypochondriac, and blaming the serious warning signs of RSD as "functional and not organic". The end result is the deadly phrase "it is all in your head" which practically almost all RSD have had to put up with in the course of their treatment. Then the patient is sent to the psychiatrist who tries to shut the patient up with strong tranquilizers, benzodiazepams, Haldol, Valium, Xanax, Halcion, Ativan, Tranxene, etc., with further disastrous results by aggravating RSD due to inactivity, and due to the stress of strong addicting benzodiazipams affecting the formation of brain's own endobenzodiazepams and endorphines.

It is about time to learn and understand that sympathetic system is complex, bilateral, diffuse. Its job is alerting mechanism to alert the entire body against stress and its manifestations are complex and multifaceted.

Just because the bone scan is negative (at best 55-65% of RSD patients have positive bone scans)[1] it does not mean that the patient's symptoms and signs are a figment if imagination (unfortunately approximately 80% of RSD patients are females and more likely discriminated against).

Yesterday I ran into one of my old classmates in a medical meeting and he said "I hate RSD." I told him so do I and all the patients, but we have to understand and manage it.

H. Hooshmand, M.D.

1. Lee GW, Weeks PM: The role of bone scintigraphy in diagnosing reflex sympathetic dystrophy. J Hand Surg [Am]. 1995; 20:458-463.

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