RSD Puzzle #079

RSD PUZZLE #79
ATTACKS OF STABBING AND ELECTRIC SHOCK PAIN IN RSD PATIENTS

The type of pain, described above by a patient is the classic "Causalgic pain". The word Causalgia was first coined by Doctor S.W. Mitchell, the first physician who reported the existence of RSD. This type of pain is caused by practically and electric shock short between adjacent damaged nerve fibers.

The normal nerve fibers are insulated with a fatty sheath called "myelin". If an injury (usually minor, occasionally due to sharp objects, or even bullets) causes damage to the adjacent nerve fibers, the insulating sheath is damaged resulting in the electrical current in the nerve fiber (which works as an electrical wire conducting messages) to spread to the adjacent damaged nerve fibers and to irritate the adjacent nerve fibers. Eventually, the cumulative effect of the multiple areas of nerve damage and irritation results in a sudden electrical discharge strong enough to stimulate an electric shock type of pain sensation. At times, it is so severe that the arrival of such an electric shock to the spinal cord causes an extremely transient shock to the nerves that are responsible for the posture and balance, and as a result, the patient has a tendency to either completely or partially fall to the ground.

This symptom, like any other symptom of RSD, becomes more severe and more prominent due to aggravation of the disease by inflammation and edema. The falling attacks are seen in late (3rd and 4th) stages of RSD.

This electric shock type of pain is usually seen in causalgia which is also called CRPS II.

The treatment of choice for this condition is an anticonvulsant called Tegretol. Unfortunately, because of the cost problems, the pharmacist dispenses the generic form called Carbamazepine. Unless the physician specifies "no generic" the patient ends up with treatment with the generic Carbamazepine. This is a rare situation where the generic does not at all work the same as the brand name Tegretol.

In patients suffering from epilepsy, it has been a well known fact for decades that Tegretol is an excellent anticonvulsant, but the generic form Carbamazepine is not even half as effective.

Due to the above mentioned facts, other anticonvulsants have been tried for treatment of causalgic, electric shock pain. These have consisted of Dilantin, which is only partially effective, and, recently, Neurontin (Gabapentin).

Unfortunately, there has been a tendency for overuse and disuse for Neurontin (Gabapentin). There is no sense and no proof that Neurontin (Gabapentin) can do any good with a patient with CRPS I (disuse RSD). It is mainly and anticonvulsant and unless the patient has the above described type of pain, the Neurontin doesn't do much for the continuous sharp, burning pain.

Even though Gabapentin (Neurontin) has a beneficial psychotropic effect (makes the patient feel better), Tegretol has even a stronger psychotropic beneficial effect.

If the patient cannot tolerate any of the above medications, then treatment with Klonopin of even Valporic Acid should be considered.

In addition to the above mentioned anticonvulsants, the patient should also be treated with an effective antidepressant with least side effect. In this regard, Amitriptyline (Elavil) should be avoided because it has a tendency to cause inactivity, fatigue, obesity, and disturbance of pulse and blood pressure. The SSRI antidepressants such as Prozac and Paxil are effective analgesic type of antidepressants, but one in five patients treated with these SSRI antidepressants develop sexual difficulties in the form of lack of desire and poor potency. Antidepressants such as Effexor which have a tendency for stimulating the patient due to dopamine re-uptake inhibition should also be avoided.

After review of the above list of antidepressants, one is left with two antidepressants with the least side effects and best results for RSD patients, i.e. Trazodone and Desipramine.

H. Hooshmand, M.D.

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