RSD Puzzle #057

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 #57
THE STAGES AND OUTCOME OF RSD

The best study about the outcome of RSD and the advanced stages of RSD has been written by Dr. Poplawski from Canada which was published in 1983. He showed that RSD diagnosed in the first 2 years has a chance of successful treatment in 80% of the patients and after two years each year drops the percentage of the success significantly[1].

As I have discussed in my book on the subject of RSD, there are more than three stages in RSD. The first stage is dysfunction, the second is dystrophy, and the third is atrophy. The fourth stage is when the disease becomes chronic enough and it's serious enough that the patient develops disturbance of immune system, hypertension, chest pain, stroke, and heart attack, and is at higher risk than the general population for high blood pressure and cancer. In the fourth stage, there is a high mortality due to suicide due to side effects of improper operations and improper treatments[2].

In over 500 RSD patients that we have studied, the success rate in the first 6 months is as high as 85%. After two years, the success rate drops to 70 to 80%. After five years, the successful treatment of RSD drops to less than 10%.

There are certain factors that accelerate the course of the disease and the disease can go into stages three and four in the matter of a few weeks or months. One is the case of causalgia secondary to intravenous needle insertion or secondary to amputation when the patient develops an accelerated course of deterioration of RSD.

The other factor is operations such as neurectomies, cryosurgery (surgery with ice cold equipment), sympathectomy, unnecessary operations for the so-called diagnoses of carpal tunnel syndrome, tarsal tunnel syndrome, etc., and the use of spinal stimulators in the late stages of RSD. Obviously, treatment with ice or ice and heat challenge as well as resorting to assistive devices such as braces, wheelchairs, and especially the use of casts, accelerates the disease and push the patient farther down to the 100% failure.

One important factor in poor prognosis in late stages of the disease is that the patient has had some partial treatment earlier in the course of the disease such as nerve blocks which change the nature of the illness and the patient does not develop the full-blown picture of stage two or stage three. The patient stays in stage one due to the partial beneficial effect of the treatment and suddenly jumps into stage four with the complications mentioned above. As the patient stays in stage one, the doctors doubt the diagnosis of RSD on the peculiar logic that if the patient has had RSD for years she shouldn't be looking so good.

By the time the RSD is over 4 to 5 years old and has not responded properly to treatment and by the time such a patient continues to deteriorate on her rapidly downhill course, the only thing that can help the patient is an infusion pump. This is in the form of Morphine or Morphine and Baclofen combination, or Morphine and Clonidine combination. In our series of over 80 patients followed for more than 3 years who were 100% failure, the infusion pump has had a success rate of 80%. However, the success rate of the infusion pump in the future is going to be far lower because the doctors who apply infusion pumps do not understand the principle of not adding other narcotics to the treatment of the patient who is already on the infusion pump. When the patient is given other narcotics along with the infusion pump, the disease becomes much worse and the patient develops a lot of inflammation, arthritis and rapidly deteriorates. I personally do not insert the infusion pump. It is usually done by an anesthesiologist or a neurosurgeon but I make certain that my patient who is on the infusion pump does not take any other narcotics and does not go over the safe limit of daily dosage of Morphine administration in the pump.

There is no quick, fixed and easy method of treatment for the late stages of RSD. Unfortunately, one of the criteria for RSD is the disturbance of limbic system (emotional part of the brain), and the patient easily becomes convinced that the best thing they can do is to find any surgeon who is willing to operate on them and to resort to a wheelchair and addicting medications.

At any stage of the disease and regardless of how far gone the disease is, the patient can be helped as long as they are willing to change their medication and eating habits, and is also willing to stay active, and avoid surgical procedures be it with a radio frequency knife or a gamma knife or other types of surgical procedures.

H. Hooshmand, M.D.

1. Poplawski ZJ, Wiley AM, Murray JF: Post traumatic dystrophy of the extremities. J Bone Joint Surg [Am] 1983; 65:642-55

2. Hooshmand H.: Chronic pain: Reflex sympathetic dystrophy. Prevention and management Boca Raton, FL, CRC Press, 1993.

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