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RSD PUZZLE #76
Deformed Hands And Extremities In RSD
The medical files of 495 RSD patients were divided into two categories:
Category A. Patients with no extremity deformity.
Category B. Patients with extremity deformity.
The following parameters were studied:
1. Duration of the illness before the deformity started.
2. Risk factors:
2A. Application of ice for longer than 2 weeks versus shorter than 2 weeks.
2B. Surgery for entrapment syndromes (carpal tunnel, tarsal tunnel, ulnar
nerve transposition, and resection for thoracic outlet syndrome)
2C. Use of assistive devices such as cast, brace, or wheel-chair
2D. Little or no physical therapy
3. Risk factors consists of surgical treatments in the form of:
3A. Spinal cord stimulator (SCS)
3B. Amputation
3C. Chemical sympathectomy
4. Surgery for neuroma exploration
5. Rotator cuff surgery
6. Single versus multiple operations in the injured area
CRPS I (RSD) VERSUS CRPS II (CAUSALGIA)
RESULTS
1. Time duration. The patients with deformity had an average lag of 22.3 months delay
between the onset of the disease and the first diagnosis of RSD. This was in contrast with
the no-deformity patients who had a lag of 14.5 months between the onset and diagnosis.
2. Treatment with ice or heat and cold challenge, 2 weeks or more. The patients with
deformity were treated with ice or hot and cold challenge for an average of 4.6 months
versus the patients with no deformity for an average of 3.1 months. In both groups, the
hypothermia therapy was usually discontinued due to the persistent protestation of the
patient against ice treatment because of aggravation of pain.
2B. Entrapment surgery. The surgery for carpal tunnel syndrome, tarsal tunnel syndrome,
thoracic outlet syndrome, rib resection, and ulnar nerve transposition was performed in
38% of the patients with deformity versus 14.5% of the patients without deformity.
2C. Assistive devices. In this category, the use of assistive devices after the
development of deformity was excluded from comparison. This was done because of the fact
that the patients suffering from deformities were in more need of assistive devices than
the ones with no deformity. After excluding such patients, the use of assistive devices
showed no statistical significance between the two groups.
3A. The use of spinal stimulators. The non-traumatic spinal stimulator procedures showed
no statistically significant higher rate of deformity. On the other hand, of the 44
patients who had received spinal stimulator treatment, 3 patients had traumatic
complications of temporary or permanent paralysis of the lower extremities which required
assistive devices.
Of the 42 patients who received spinal stimulator treatment, followed for more than 2
years, the majority of the patients lost any beneficial pain relief from the spinal
stimulators after as early as 7 days and as long as 13 months duration.
3B. Infusion pump: Infusion pump done on 96 patients proved to be no risk for development
of deformity. If anything, the patients who received Baclofen in the pump, had a
significant relief of spasticity and reduction of deformity.
3C. Sympathectomy: This group was divided to standard sympathectomy, and chemical
sympathectomy. The post-sympathectomy deformity developed within a few months after the
surgery. Of the 62 patients who had undergone standard or chemical sympathectomy, 14
developed post-surgical extremity deformity.
4. "Neuroma" exploration: This was usually done over the foot and ankle area by
podiatrists. This group consisted of 42 "neuroma" explorations, and 18 ended up
with deformity post-operatively.
Interestingly, of the 42 "neuroma" explorations, only 3 patients were in
possession of the pathologic microscopic biopsy sample. None of the three biopsies showed
neuroma.
5. Rotator cuff surgery: Fifty-eight patients had undergone "rotator cuff
surgery" procedure. Only 1 patient had the pre-operative MRI diagnosis of rotator
cuff tear. 14 others had MRI which was either negative or showed inflammatory changes over
the shoulder region. In this group, the frozen shoulder and the flexion deformity of the
arm and forearm became aggravated and more disabling post-operatively in 29 patients.
Of the rotator cuff tear surgical patients, only 3 had direct injury to the shoulder. The
rest had no history of direct injury to the shoulder. These consisted of patients who
suffered from hand, wrist, forearm, or elbow injuries and a small number (5) patients had
the onset of the disease after heart attack or stroke. There was not even one patient in
the no-deformity group who had already undergone "rotator cuff surgery"
procedure.
6. CRPS I (RSD) versus CRPS II (Causalgia) categories: There was no statistical difference
between the two categories in regard to the incidence of complication of limb deformity.
However, the causalgic group developed the limb deformity earlier in the course of the
illness. The average lag time between trauma and the development of the deformity in CRPS
II (causalgia) group was 7 months.
CONCLUSION
The risk factors contributing to the development of limb deformity consist of surgical
procedures, exploratory operative procedures (such as looking for neuroma or looking for
entrapment neuropathy), immobilization with cast or wheelchair, and prolonged use of
cryotherapy (application of ice).
The deformity evolved earlier in the CRPS II (Causalgic) group than in the CRPS I (RSD)
group.
H. Hooshmand, M.D.
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