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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?
Answer: Here are some reasons for failure of treatment:
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.
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