RSD Puzzle #078

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 #78
Dangerous RSD Treatments
(The Fads That Cause Failure of RSD Treatment)

Question:

"What are the reasons for failure of treatment of RSD"? - To put it another way, What are the dangerous forms for treatment of RSD?

1. "RSD burns itself out and goes away after a few years." This is a big lie! It only goes away if the patient has had multidisciplinary treatments. The doctor is not intentionally lying. But after a few years of no effective treatment the patient goes to another doctor, does not see the original doctor and then the original doctor concludes that the patient must have been cured, because the patient did not return.

2. Instructing the patient to be confined to a wheelchair because he or she in pain.

3. Clonidine patch applied to the area of lesion in the extremity rather than the area of referred pain in cervical or lumbar spine region. (See #16 below)

4. Only one or two trigger point injections for frozen shoulder.

5. Bier Block needle insertion in the area of flared up RSD.

6. Treatment with ice.

7. Hot and cold challenge treatment.

8. Only 10mg or 25mg tricyclic anti-depressant per day for treatment of pain.

9. Repetitive Sympathetic nerve blocks after extremity becomes warm and has undergone virtual sympathectomy with nerve blocks.

10. Monotherapy with nerve block, or opioid medication.

11. Indiscriminate use of Neurontin. Neurontin is exclusively effective for burning type of pain, so if the patient has dull ache or electric shock type of pain then Neurontin won't work.

12.Small doses of anticonvulsant such as 100mg-300 mg of Neurontin or 1-2 Tegretol a day.
Two principles should be followed: First of all,the dosage should be enough anticonvulsant to manage the burning pain (Neurontin), or the stabbing electric shock pain (Tegretol). Secondly, generic anticonvulsants are useless (according to the American Academy of Neurology)

13. Instructing the patient to bathe while wearing the clonidine patch.

14. Mistaking paravertebral nerve blocks for articular facet injections.

15. Mistaking diagnostic sympathetic nerve block with simple Marcaine injection as a therapeutic block.

16. Treatment of high blood pressure with newer anti-hypertensives rather than the alpha blockers. When the patient is treated with alpha blockers such as Dibenzyline, Hytrin, or Clonidine, not only is the hypertension managed, but also the patient receives systemic sympathetic block. It is true that RSD is a dysfunction of the sympathetic system, but in different parts of the body the dysfunction is different. At the area of the nerve damage at the apex of the sympathetic nerve injury, there is focal hyperthermia pointing to an ephaptic nerve damage paralysis of the sympathetic function. In earlier stages of the disease, this area is surrounded by vasoconstriction and SMP (sympathetically mediated pain) pointing to the compensatory hyperactivity of the sympathetic system. The wide dynamic range (WDR) at the spinal cord level as well as the stimulation of the sympathetic system through the paravertebral sympathetic ganglia causes regional and remote sympathetic stimulation. Treatment with alpha blockers helps ameliorate this condition. The opposite is also true. The application of Clonidine patch over the area of sympathetic nerve damage (the vortex of the sympathetic paralysis and heat emission) only aggravate the condition. On the other hand, the application of the Clonidine patch over the referred pain area in the involved paravertebral region relieves the sympathetic dysfunction.

17. Trigger point injections and nerve blocks in the nerve damaged area while paravertebral nerve blocks and trigger point injections are helpful when applied to the paravertebral nerves in the regional referred pain area of the spine, the same trigger point injections or nerve blocks when applied to the area of nerve damage aggravate the RSD. One example is BIER blocks. BIER blocks are very effective unless the intravenous injection is done in the involved area of the extremity. If the patient has had an injury to the dorsal aspect of the foot resulting in RSD, insertion of an IV needle in this area flares up the condition and adds insult to injury, In this situation, The BIER block does not relieve the patient's pain, but aggravates the disease.

18. Reading too much into the Phentolamine block result. In the late stages of RSD, the SMP changes to SMP and SIP or purely SIP (sympathetic independent pain). This may be due to the therapeutic trauma such as multiple nerve blocks or surgical procedures (surgery for carpal tunnel syndrome, tarsal tunnel syndrome, or thoracic outlet syndrome), or simply long-standing vasoconstriction of the region of CRPS (Chronic regional pain syndrome) causing long standing hypoxia involving somatic as well as sympathetic nerves. The end result is that frequently after several months or a few years, the CRPS pain is not sympathetically mediated anymore. Even in early stages of the disease, the hyperpathia is mainly transmitted through the thermal receptors (SMP) whereas allodynia is transmitted to the mechanoreceptors (a-delta fibers resulting in mechanoallodynia in contrast to small c-thermal receptor fibers). So, sooner or later the mechanoallodynia becomes the main feature of the illness and the SMP changes to SIP. Treatments such as application of ice, immobilization of the extremity, excessive use of narcotics such as MS Contin, Duragesic, or Methadone, which cause a reduction of the mobility of the extremity, result in secondary aggravation of the mechanoallodynia. This is also aggravated by stimulation of the so-called sleeping nociceptors secondary to immobilization. In such patients, SIP is the general rule of thumb rather than being an exception. In patients receiving large doses of narcotics, there is a tendency for edema of the lower extremities, attacks of inflammation secondary to stimulation of the sleeping nociceptors. This inflammation is manifested by spontaneous bruises, neurodermatitis, along with painful edema of the extremity.

19. Amputation

20. Chemical sympathectomy

21. Cingulotomy

22. Neuroectomy

23. Cryosurgery

24. Alcohol nerve block

25. Phenol nerve block

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.