Neurological Associates

Pain Management Center

Vero Beach, Florida

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RSD PUZZLE #71
VENIPUNCTURE RSD

An example of a small nerve damage to the sympathetic system causing RSD, and one of the most severe types causalgia (CRPS-II), is due to selective nerve damage to the wall of blood vessel. This disease (which fortunately is rare) is called "Venipuncture RSD". It is caused by the needle-used to draw blood from the vein-accidentally injuring the small nerve fibers (sympathetic nerve fibers) surrounding these blood vessels [1,2]. It happens one in several million cases of venipuncture (IV needle injury) causing severe causalgic pain. This is one of the most severe and most painful forms of RSD, yet the only damage is in the form of damage done to the small nerves in the wall of the blood vessel. This may be the reason for the misconception that in some cases complex regional pain syndrome (RSD) there is no nerve damage. There has to be some sort of nerve damage to cause such severe pain and CRPS. The nerve damage is microscopic and can not be appreciated by standard tests. As is the case with practically all the other cases of RSD, EMG and nerve conduction times are normal. EMG and nerve conduction times become abnormal in RSD only due to disc complications (inflammation causing entrapment neuropathy) but the rest of RSD patients show no abnormality on EMG and nerve conduction times studies because the EMG and NCV study motor function rather than sympathetic function. Triphasic bone scan is nonspecific. As is the case with the other RSD patients, bone scan is abnormal in no more than half the cases [3].
  
In Venipuncture RSD, the sympathetic nerves in a very small area of the blood vessel have been injured causing causalgia without involvement of any other non-sympathetic nerves. This is in contrast to the more severe injuries (i.e., fracture of the extremity), where the somatic nerve stimulation overshadows the sympathetic nerve damage. Venipuncture RSD has a rapidly deteriorating course and a very poor prognosis. The prognosis is very poor in contrast to the case where the injury has caused fracture and damages to the non-sympathetic nerves as well. In the experience of Doctor Horowitz [1,2], only one out of eleven patients showed a significant improvement. In our study of seven patients, only three patients have shown partial improvement. Such a low percentage of improvement is seen only in RSD patients who have ended up having amputation, or in patients who have gone undiagnosed and improperly treated for years. The Venipuncture RSD example is used as a model to contrast the CRPS type of pain as opposed to the usual, run of the mill acute somatic (non-sympathetic) pain seen in more major traumatic cases. Even in Venipuncture RSD, the therapeutic success rate improves if the proper diagnosis and proper treatment are applied in the course (the above example of 3 out of 7 versus 1 out of 11 partial improvement).


H. Hooshmand, M.D.

References:

1. Horowitz SH: Peripheral nerve injury and causalgia secondary to routine venipuncture. Neurology 1994; 44: 962-964.

2. Horowitz SH: Iatrogenic causalgia classification, clinical findings, and legal ramifications. Arch Neurol 1984; 41:821-824.

Hooshmand, H., Hashmi, M., Phillips, E.M.: Venipuncture Complex Regional Pain Syndrome  Type II.  American Journal of Pain Management.  Vol 11: no 4: 112-124, October 2001.

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Copyright © 1997-2006 H. Hooshmand, M.D. No part of this publication may be reproduced, transmitted, stored in a retrieval system other than this specific media, transcribed, or translated into any language without the expressed written permission from the author; H. Hooshmand, M.D. and Eric Phillips and CMNE. This material 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.

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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.

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This page was last updated on 3/11/2000.