RSD Puzzle #031

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

Nerve blocks are done in the following forms:

1. Sympathetic ganglion blocks.

5a. Treatment with alpha I (Clonidine, Dibenzyline, Hytrin) or alpha II (Yohimbin).

5b. IV Phentholamine

Two principles should be kept in mind. Sympathetic nerve blocks- without other forms of treatment for RSD-are apt to fail. The sympathetic nerve blocks should be combined with physical therapy, moist heat, exercise, and the use of newer (Trazodone or SSRI) antidepressants as well as detoxification.

A lot of people mistake diagnostic blocks for therapeutic blocks. A simple diagnostic block with the use of local anesthetic doesn't last more than a four hours. This is not necessarily a treatment but simply a confirmation of SMP. The therapeutic blocks not only contain the local anesthetic but also should contain some other chemicals to help the blocks last longer (chemicals such as celestone or Depo-Medrol®).

To simply treat the patient with a painful diagnostic or therapeutic sympathetic block and to expect the patient to improve without other forms of treatment is unrealistic and is apt to fail. Every chronic pain patient (such as RSD) should be first treated with antidepressants as the ideal analgesic.

The second principle to keep in mind is that as the condition becomes chronic and a combination of SMP and SIP (sympathetically independent pain) develops, other forms of blocks especially epidural nerve blocks, paravertebral nerve blocks, trigger point injections, and regional somatic nerve blocks become excellent additional tools for treatment of RSD. These blocks should not be given into the areas of severely painful scars that initiated RSD. They should be given proximal to the area of nerve and scar that is tender to touch.

Injection of the area of the scarred nerve (due to scar of original trauma or the scar of surgery) is extremely painful, and flares-up the RSD. This flare-up is not simply in the form of severe incapacitating pain but it is accompanied by inflammation, development of skin rash, swelling of the tissues in the area of traumatic injection. It simply aggravates and traumatizes the nerve causing the scar which started the RSD to begin with. The best way to achieve this nerve block is to block the proximal part of the nerve immediately above the area of the scar.

The treatment for RSD in early stages should start with physiotherapy, antidepressants, and sympathetic nerve block and should be reinforced and followed by topical or regional somatic block, especially epidural and nerve canal blocks such as spinal canal or myelin canal nerve blocks. The role of the treatment should be to achieve control of the pain with repeated alternating sympathetic and somatic blocks. This buys enough time to control the condition with the help of more long term and permanent control of pain such as the use of antidepressants, anticonvulsants (Tegretol or Neurontin), and physiotherapy, mobilization, and application of heat.

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.