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 #27
"I HAVE HAD BLOCKS AND OTHER TREATMENTS THAT DID NOT WORK"

Unfortunately, the above statement is too self-repeating and does not prove that the condition is hopeless. The majority of RSD patients are treated in a piece-mill and partial fashion. Usually, the patient has a few invasive stellate ganglion or lumbar sympathetic blocks with the effect lasting for a short period of time and after 2-3 trials arbitrarily it is decided that the patient has had enough nerve blocks. During the time the patient undergoes nerve blocks, other forms of treatment are not applied simultaneously. If the therapy is continued, usually it is challenged and its beneficial effect is neutralized by the use of ice or alternated heat and ice. Obviously, what ever good the sympathetic nerve block is doing to increase the circulation to the extremity by blocking the sympathetic dysfunction, it is completely neutralized by the use of ice which reinforces constriction of the blood vessels over the skin and counteracts the sympathetic nerve block.. In addition, the patient is kept on the same addicting medications such as addicting tranquilizers or strong narcotics which in and of themselves perpetuate the anxiety and pain.

During the sympathetic blocks, the patient is not treated on antidepressants. As a matter of fact, it is shocking to see how rarely the patients with RSD are treated with antidepressants on a long term basis. Antidepressants are not given to RSD patients because they are depressed. Somewhere around one- fourth of the RSD patients do not suffer from any form of depression. However, they need antidepressants, too.

Antidepressants are not given for depression, but BECAUSE ANTIDEPRESSANTS ARE TREATMENT OF CHOICE FOR CHRONIC PAIN. In this regard the principle of the use of antidepressants is similar to the principle to the use of aspirin for heart attack or stroke. Aspirin is supposed to be an arthritis medication, but additionally it is one of the most effective modes of
treatment for heart attack or stroke. Improper medicine may be capable of exerting more than one therapeutic role in the body.

No single RSD treatment can be written off as a failure unless other modes of treatment are simultaneously and properly applied. The patient should be on antidepressant, proper exercise and physical therapy without application of ice, the patient could be on plenty of pain medications that are less likely to be addictive (such as Talacen, Nubain, Stadol, or Ultram), and the patient should definitely be taken off addictive benzodiazepams. The addictive narcotics and benzodiazepams cause a rebound phenomenon (withdrawal pain). The best example of this rebound phenomenon is that the patient may have a focalized regional CRPS (complex regional pain syndrome of RSD) involving the right foot and yet every four hours after withdrawal from the intake of Percocet or Lortab may develop the severe headache, neck pain, and pain in every part of the body due to withdrawal effect of the addicting pain medications. The patient develops pain all over the body because of withdrawal regardless of how many sympathetic nerve blocks the patient is having. The withdrawal from addicting benzodiazepams (Valium, Halcion, Ativan, Xanax, Tranzene, Librium, etc) results in generalized muscle spasm and low threshold for pain as well as moderate depression.

The same patient after undergoing a few nerve blocks is then exposed to treatments such as spinal stimulator or infusion pump. We have already discussed the futility of the use of the spinal stimulator in RSD Puzzle #23.

However, even a treatment as powerful as infusion pump is apt to fail if the patient is already loaded with intake of strong narcotics.

In conclusion, regardless of how extensively and repeatedly the patient has had different independent modalities of RSD treatment, the patient should be started from scratch with multiple treatments of antidepressant as an analgesic for chronic pain, effective pain control with the addition of non-addicting strong narcotic medications, muscle relaxants especially in the form of Baclofen (Lioresal), and nerve blocks.

The nerve blocks should not be just simply limited to a few sympathetic ganglion blocks or Bier block, but they should also include epidural and paravertebral nerve blocks.

The epidural and paravertebral nerve blocks are quite effective as a maintenance form of nerve block. They block not only the somatic nerve, but also the sympathetic nerves as well.

H. Hooshmand, M.D.