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Thermal Imaging As A Tool In Pain
Management - An
11 Year Study.
Part II: Clinical Applications
Hooshang Hooshmand, Masood Hashmi, Eric
Neurological Associates Pain Management
Center, Vero Beach, Florida, USA
ITI is a
neurophysiological tool providing diagnostic and therapeutic information
in patients suffering from neuropathic pain with neurovascular
involvement. This information cannot be obtained from anatomical tests (e.g.,MRI
Thermal Processor (Bales Scientific, Walnut Creek, CA)(762 patients) and
Agema Cameras (Flir)(2,503 patients) were used for this study of 3,265
successive patients. A review of our experience with Infrared thermal
imaging (ITI) and its role in pain management was conducted, and compared
with the recent medical literature. The study was limited to the role of
ITI in the management of complex chronic pain syndrome.
ITI is helpful in
proper localization of hyperthermic foci due to iatrogenic permanent
damage to thermosensory nerves, such as seen after repetitive sympathetic
ganglion blocks; or due to sympathectomy or prolotherapy. As the result,
the physician stays out of harms way by not causing further permanent
damage. In addition, ITI identifies the spread of CRPS, pointing to the
need for treatment of such spread. It helps differentiate migraine from
neuropathic occipital neuralgia - two diseases requiring to contrasting
ITI has not been
proven useful in evaluation of cervical and lumbar radiculopathies,
stroke, and transient ischemic attacks. ITI can differentiate cervicogenic
headaches from migraine - each requiring opposite forms of treatment. ITI
is a useful prognosticator for diabetic foot pain, sparing some patients
from amputation. ITI can spare patients from unnecessary carpal tunnel,
spinal disc, and TMJ surgeries by identifying the original source of
neuropathic pain. If ITI shows diffuse hyperthermia in the extremity
already treated with repeated sympathetic ganglion blocks (virtual
sympathectomy), such patients should be spared from undergoing further
ganglion blocks. The hypothermic extremity after sympathectomy proves the
futility of this and other ablative treatments such as chemical
sympathectomy, or neurolytic blocks.
- CRPS, Headache, Sympathectomy ,Thermography.
Infrarothermographie als Hilfsmittel im Schmerzmangement-in 11
Jahres Studie, 2.Teil:Der klinische Einsatz der
liefert als neurophysiologische Untersuchungsmethode diagnostische
und therapeutische Informationen über Patienten, die an
neuropathischem Schmerz mit neurovaskulärer Begleitsymptomatik
leiden. Diese Information kann durch keinen anatomischen Test (z.B.NMRI,
Ct) zur Verfügung gestellt werden.
Ein Bales Scientific Thermal
Processor (Bales Scientific, Walnut Creek, CA)(762 Patienten) und
Agema (Flir)Kameras (2,503 Patienten) wurden in dieser Untersuchung
an 3265 aufeionander folgenden Patienten verendet. Ein Überblick
über unsere Erfahrungen mit der Infrarrotthermographie wird gegeben
und der rezenten medizinischen Literatur zu diesem Thema gegenüber
gestellt. Die Untersuchung wurde auf die Bedeutung der
Infrarotthermographie im Management von Schmerzpatienten
beschränkt.Die Infrarotthermographie hilft in der Entdeckung
hyperthermer Zonen, die durch wiederholte iatrogene Schädigung der
thermosensiblen Nervenfasern entstehen und die bei wiederholten
Sympathikusblockaden, Sympathektomie oder therapeutischer
Gewebe-Sklerosierung vorkommen.Durch solche Veränderungen gewarnt,
international 11 / 3 (2001)
kann der Arzt
weitere Schädigungen vereiden. Die Infrarotthermographie kann die
weitere Ausbreitung Schädigungen vermeiden. Die
Infrarotthermographie kann die weitere Ausbreitung eines komplexen
chronischen Schmerzsyndroms (CRPS) anzeigen und auf eine notwendige
Therapie dieser Ausbreitung hinweisen. Die Infrarot-Technik kann
auch für die Differenzierung zwischen Migräne und
neuropathischerOkzipitalneuralgie hilfreich sein, zumal diese
Krankheitsbilder völlig unterschiedliche Behandlungen benötigen.
Infrarorthermographie ist wenig brauchbar in der Beurteilung von
zervikalen oder lumbalen Radikulopathien, von Schlaganfall oder
transitorischen ischämischen Attacken. Man kann aber mit ihrer Hilfe
cervikogenen Kopschmerz von der Migräne unterscheiden. Die
Infrarotthermographie hat prognostische Bedeutung bei Fussschmerzen
von Diabetikern,und hat so manchen Patienten eine Amputation erspart.
Ebenso können auf Grund von Infrarotbildern nicht notwendige
Operationen wegen eines Karpaltunnelsyndroms, einer Bandscheibe oder
chirurgische Eingriffe im Kieferbereich vermieden werden, da die
Ursache eine neuropathischen Schmerzgeschehens eindeutig gefunden
werden kann. Wenn die Infrarotthermographieeine diffuse Hyperthermie
bei Patienten nach wiederholten Sympathikusblockaden zeigt, sind
weitere Blockaden nicht mehr angezeigt. Eine hypotherme Extremität
nach Sympathektomie beweist die Entbehrlich keit dieser und anderer
destruierender Behandlungen wie z.B. die chemische Sympathektomie
- CRPS, Kopfschmerze, Sympathektomie ,Thermographie
THE ROLE OF
ITI IN SELECTION OF NERVE BLOCKS
indispensable information which guides the physician to stay out of harms
way, and to prevent iatrogenic trauma. One example is the role of ITI in
selection of proper nerve block modality. Traditionally, the nerve block
of choice in CRPS has been stellate ganglion nerve blocks. After more than
a dozen stellate, or lumbar ganglion nerve blocks, the repetitive needle
insertion traumatizes the ganglion enough to result in permanent
hyperthermia in the extremity ("Virtual Sympathectomy") (1). In such
patients, ITI of the extremity shows permanent hyperthermia in face of no
pain relief. Kozin, in his review of 500 patients treated with sympathetic
ganglion blocks, reported "the majority of patients have transient or no
significant pain relief" (2). Another meta-analysis of retrospective and
prospective randomized controlled trials of 1144 patients revealed the
local anaesthetic sympathetic blockade was as ineffective as placebo in
treatment of CRPS(3).
identified the "virtual sympathectomy" phenomenon, and spared the patients
from further damage by canceling the procedure (1) (Table 1). Repetitive
ganglion nerve blocks are routinely applied for diagnosis (4) and
treatment of neuropathic pain such as complex regional pain syndrome
(CRPS). However, Hogan et al (5), have reported only 27% of stellate
ganglion block achieved the goal of ipsilateral warming to exceed the
contralateral skin temperature. This 27% success is not worth the
traumatic complications of ganglion blockade. Moreover, they noted (5)
that cervical paratracheal blocks frequently failed to produce evidence of
sympathetic interruption to the arm. The sympathetic ganglion blockade
done in peripheral occlusive vascular disease or CRPS maybe potentially
dangerous and harmful1 (1,2,3,6).
sympathectomy results in partial hyperthermia, with compensatory
contralateral extremity hypothermia, this result in the spread of pain in
the contralateral extremity. Out of desperation, sympathectomy has been
applied for treatment of causalgia since 1916 (7). The literature review
of sympathectomy literature for treatment of CRPS shows high rates of
failure. Welch et al (8) showed 13% successful results of sympathectomy in
8.4 years of long term follow-up. In contrast, Jebara and Saade, on their
short -term sympathectomy follow-up of 26-60 days among teenage soldiers
showed very good results (9). Obviously, ablation surgery provides
temporary palliative relief. The rest of the literature review shows
random follow-ups and results (10). The high percentage group has been
wartime soldiers which have been diagnosed early , undergone surgery
within a few days , and sent home to be lost to follow-up (10-31).
Realizing that children and teenagers (such as soldiers), show a strong
plasticity and healing power as compared to adults (32,33), and realizing
that early diagnosis and treatment is more successful (34,35),
Table 1. The influence
of treatment on CRPS stages during 2 years or longer follow-up in
824 patients. Amputation or sympathectomy deteriorate the disease
from stage I to stage III.
Characteristics of treatment
Stage I ****
number of patients
of Amputation *
patients had more than one treatment modality which change the
Sympathectomy; rotator cuff; thoracic out syndrome;
compression neuropathy; exploration; etc.
Stage I = Dysfunction; Stage II= Dystrophy; Stage III=
According to the type of treatment stage III may reverse to
stage I and vice-versa.
Table 1A. Surgical and
Note high percentage of
stage III in the surgical group
Non - Surgical
the beneficial, albeit temporary, results of wartime sympathectomy. In
contrast, the sympathectomy done in stage III CRPS* has been
reported to show zero percent relief (36). Usually, by the time the
physician resorts to the sympathectomy procedure, the patient is in
advanced stages of the disease. In such late stages, the nervous system
has lost its plasticity and cannot respond properly to surgical
sympathectomy(37,38). More over, the disease spreads (1,37,39-44) to other
parts of the body; hence a regional sympathectomy will not be of any
benefit to the patient.
Outcome: ITI showed failure of sympathectomy to relieve the vascular
dysfunction. Thermal imaging done in patients who underwent surgical or
chemical sympathectomy showed a high percentage of surgical
ARTICULAR FACET BLOCKS
facet joint blocks and prolotherapy (injection of sclerotic agents to
ligament surrounding the joints) act as new sources of trauma and pain
originating from the injured vertebral facet joint. In contrast, spinal
epidural and paravertebral blocks do not cause chemical (sclerotic) damage
due to injection of hypertonic glucose or phenol as in the case with
prolotherapy. These blocks should not be mistaken for articular facet
injections. The facet injections should be avoided to prevent harmful
facet joint damage.
Stages of CRPS
Dysfunction: with thermal changes, neuroinflammation,
neurovascular instability, neuropathic pain, vasomotor and flexion
II: Dystrophy: hair, nail, and skin trophic changes; bouts of
hair loss, alopecia, skin rash, spontaneous subcutaneous bleeding,
ulcerative lesions, edema, and entrapment neuropathy.
III: Atrophy: as well as fluctuating vital signs, visceral
neuroinflammation, chest pain, neurovascular instability.
According to Cheema (47), paravertebral nerve block provides effective
pain relief for both sympathetically maintained pain and sympathetically
independent pain. This is in contrast to articular facet (zygoapophyseal)
blocks which are fraught with painful joint injuries (due to needle
traumatizing the joint). Bogduk et al (48) have reported only 40% pain
relief from radiofrequency treatment of the facet joints. The same applies
to prolotherapy which is done by injection of sclerosing agents (such as
phenol) into the ligaments surrounding articular facet joints.
Neurophysiologic tests for neuropathic pain and somatic pain.
Nerve Fiber Type
efferent spino-thalamic nerves
cannot study the thermo-receptor or vasomotor function
Neuro-muscular and myelinated somatic nerve study
Thermal Imaging (ITI)
vascular and C-thermo-receptors
old and new pathologies indiscrim-inately
body regional study
Evoked Potential (LEP)
myelinated C- fibres;
peripheral and central neuropathic pain
ganglionic sympathetic efferent C-fibres
on sympathetic efferents
Invasive, time taking, and painful
Quantitative Sensory Test (QST)
thermo-receptors vs spino-thalamic tactile nerves
test for thermoreceptors vs tactile somatosensory nerves
a limited area
Sensitive study of C- thermoreceptors vs somatic fibres
Quantitative Sudomotor Axon Reflex Test (QSART)
Parasympathetic; cholinergic, sudomotor nerves
a limited area. It cannot study the thermal function
Evoked Potential (SSEP)
Somatosensory nerve fibres
Identifies sensory nerve tracks
Triphasic Bone Scan (SBS)
Informative in early stages
diagnostic in 25-55% of patients
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Thirty-six patients had undergone Prolotherapy before they
were referred to our Clinic. ITI showed focal hyperthermia in the area of
Prolotherapy. None had effective long-term relief from this prolotherapy.
EXTREMITY NEEDLE INSERTION
In the area of
original nerve damage, the hyperthermia points to damage and paralysis of
vasoconstrictive function of sympathetic system (1). The hyperthermia area
surrounded by hypothermia usually points to the apex of damaged
thermosensory nerve resulting in heat leakage, as well as accumulation of
substance P (49-51), and nitric oxide(52,53). This is an important
therapeutic clue to help avoiding further trauma. Traumatic procedures
such as surgical exploration, nerve blocks, botulinum toxin injection,
capsaicin, or EMG needle insertion should not be applied to the damaged
hyperthermic area in the extremity which may lead to further damage and
aggravation of the condition (54-56).
If at all possible,
amputation should be avoided (57). All 11 painful amputee patients in our
series (Table 1) who were referred to us after they had undergone
amputation showed marked deterioration post-op. The surgical stump was the
source of multiple neuromas with severe causalgic and ephaptic (11) CRPS
II type of intractable pain. Amputation changed the CRPS from type I to
type II by forming innumerable neuromas and nerve impingements in the
surgical stump. Amputation should be avoided by all means due to its side
effects of aggravation of pain and tendency for spread of CRPS. Dielissen
et al (58) reported the results of amputation in 28 RSD patients who had
undergone 34 amputations in 31 limbs. Only 2 of 28 patients reported
partial pain relief. In 26 of 28 patients, stump involvement with RSD made
it impossible to wear a prosthesis (57). ITI can identify the proper level
of the extremity undergoing amputation (59). This spares the patient from
losing any excess tissue in the amputee stump (59).
ITI provided information that prevented amputation in 5 of 6 patients
referred to us for evaluation and for consideration of amputation. Of the
5 patients, 4 showed enough warmth and intact circulation to prevent
amputation. The 5th patient was found to suffer from diabetic
neuropathy with multiple pathologic right foot fractures aggravated by 2
years of non-weight bearing. Under proper analgesia, the patient was
instructed to start weight bearing. After 3 months, the fractures healed
enough to avoid the necessity for amputation.
NECK AND BACK PAIN
The 1970's and
1980's literature reflects confusing reports on diagnostic value of ITI in
cervical and lumbar radiculopathies, back pain, disc herniation, and
sciatica (54,56,60-66). More recent literature has reported that ITI has
no consistent diagnostic value for the neck and back injuries (67-71). One
reason may be the inconsistent delta-T measured by liquid crystal contact
thermography (72) making it difficult to arrive at accurate "normal"
In the present
study, the ITI done in patients suffering from failed spine, neck or back
pain, and pain in the extremities revealed conflicting
results - especially when compared with the thermal imaging tests done on
the same patients in other laboratories. The confusion has its roots in
technical limitations, and improper clinical applications of the
test(67,68). Harper (73) and Chafetz (74) have successively reported 56%
and 40% abnormal ITI of spine in the "normal" controls. In our daily
lives, the spine undergoes minor injuries. Such preexisting minor injuries
may show persistent minor abnormalities on ITI, contaminating the control
studies. Lack of a consistent control standard handicaps the value of ITI
in diagnosis of spine pathology. There have been repeated attempts to
compare the physiological test of ITI with anatomical tests such as MRI
and CT (75). This is an illogical comparison. ITI cannot be expected to
diagnose disc herniation because disc bulging and herniation cannot be
clearly represented on ITI. Conversely, MRI cannot be expected to identify
micro neurosensory pathology.
In the present study, the ITI done in patients suffering from failed
spine, neck or back pain, and pain in the extremities
revealed conflicting results - especially when compared with the thermal
imaging tests done on the same patients in other laboratories. The
confusion has its roots in technical limitations, and improper clinical
applications of the test (67,68).
international 11 / 3 (2001)
REGIONAL PAIN SYNDROME (CRPS, RSD)
ITI can facilitate
early diagnosis of Complex Regional Pain Syndrome (CRPS) (76), and can
achieve a higher recovery rate among CRPS patients (10,11,34,77) by virtue
of early diagnosis of the disease. CRPS cannot be accurately diagnosed by
a single test. CRPS is a clinical diagnosis when the following four
principles are met:
hyperpathic, or causalgic pain;
disturbance, flexor spasm, or tremor;
3. Inflammation at
some point in the course of the disease; and
4. Limbic system
dysfunction in form of insomnia, agitation, depression, and poor memory
Tests such as ITI
are mainly helpful to obtain information regarding the nature and extent
of the disease, and to guide the clinician in proper management of pain
(11). ITI has the advantage of providing a comprehensive picture of the
entire body temperature (79). In acute stage, the epicenter of the damaged
area is usually hyperthermic (11,80). After a few weeks, the hyperthermic
area shrinks. In some cases (80) the hyperthermia persists due to
permanent damage to sympathetic nerve fibers (1). This is a harbinger of
poor prognosis. The hypothermic area surrounding the hyperthermic
epicenter of the damaged nerve reflects up-regulation and supersensitivity
of sensory nerves to norepinephrine (81-84).
In chronic stages
(85), the disease is manifested by a dysfunctional rather than an
up-regulated sympathetic system (11,86-90). The neurovascular instability
contributes to confusion and misunderstanding of ITI changes in CRPS. For
example, spread of vasoconstriction to other extremities maybe mistaken
for other diseases such as Raynaud’s Phenomenon (90). The ITI, like any
other test, cannot be expected to show 100% diagnostic sensitivity. Even
with the cold water stress ITI testing (76,89), it is sensitive in 93 % of
the patients, specific in 89 %, positive predictive value (PPV) of 90%,
and negative predictive value (NPV) of 94% (76). Recently, Herrick et al
(90), have found cold stress ITI useful to diagnose patients suffering
from fracture who are at risk for CRPS.
TESTS IN CRPS
Lee and Weeks (91),
in their meta-analysis of scintigraphic bone scan (SBS) (91)showed this
test to be positive in no more than 55% of CRPS patients (71,91). EMG and
NCV (92,93), or CT and MRI cannot be expected to detect the microscopic
perivascular nerve dysfunction in CRPS. Even if a coincidental disc
bulging is seen on MRI, surgical procedure in the inflamed region is apt
to severely aggravate the CRPS (94-97). Quantitative sudomotor axon reflex
test (QSART) (98) (Table 3) studies the post- ganglionic cholinergic
sudomotor function of the sympathetic system (94,95,99,100),not the
thermoregulatory function. Laser evoked potential (LEP) (Table 3) is a
sensitive test for the study of capillary circulation (44,101-103). It
studies a small area of the body thereby limiting its overall extent of
information. Quantitative thermal sensory evoked response test (QST)
(44,104,105) (Table 3) is sensitive and useful in studying the functions
of c-thermoreceptors and A-beta mechanoreceptors in CRPS (104). This test
identifies the threshold of somatic (spinothalamic)cold or heat touch
sensation - versus neuropathic (sympathetic) cold or heat pain sensation.
TEMPERATURE CHANGES IN CRPS
difference between the two extremities (delta-T)
should not normally exceed more than 0.4 -0.6º
C (54,56). In early stages of CRPS, the ITI shows more than 0.50º
C difference. In later stages, the temperature
difference gradually disappears. The delta T between the two extremities
is not statistically significant in CRPS patients. In contrast, comparing
the same CRPS patients with non-CRPS group, the CRPS extremities were
significantly colder than the control group (106). The cut off line to
discriminate the patient from the control group was 0.61º
C for accurate predictability of CRPS diagnosis (106). The equalization of
function is due to symmetrical representation of autonomic changes at
hypothalamic and spinal cord levels (107). Other pathologic changes such
as asymmetrical foci of hyperthermia identify the site of the injury.
These hyperthermic foci are usually a sign of damage to the nerve fibres
causing hyperthermic ephaptic (in contrast to synaptic)(108) electrical
discharges between the adjacent sensory nerve fibres. Frequently, the
injured side may show a hyperthermic focus, compensated by the
contralateral normal side undergoing moderate hypothermia(109).
ITI FINDINGS IN CRPS
approximately 1/3 of CRPS patients, the complex regional pain and
inflammation spreads to other extremities manifested on ITI test
(98,110-114).The spread through paravertebral chain of sympathetic ganglia
may be vertical, horizontal, or both (110,111,115,116).
ice application may result in chilblains (or perniosis) due to
inflammatory areas of hyperthermia secondary to long term frost bite type
of nerve damage by application of ice. The ITI helps diagnose this
condition to discontinue the destructive cryotherapy. Basbaum (117), and
others (118-121) have demonstrated lesions affecting large myelinated
axons secondary to ice exposure. These lesions are in the form of Valerian
degeneration and segmental demyelination (117,118,121). The cryotherapy
causes iatrogenic hypothermia with islands of permanent hyperthermia due
to frostbite nerve damage mentioned above.
ITI was helpful in identifying the areas of thermosensory nerve damage,
and as well as diagnosing the phenomenon of CRPS spread.
AND DIABETIC FOOT
In advanced stages
of diabetic neuropathy, the disease is complicated by neuroinflammatory
changes, fractures (Charcot’s foot), and by foot ulcers (122-125). The ITI
changes in these patients are the prototypical examples of nerve damage
causing irreversible hyperthermia in different degrees. Armstrong et al
(122) have utilized ITI as the predictor of early sign of deterioration of
ulcers and trophic fracture. They have used the high delta-T of 2º
C between the involved and contralateral extremities to initiate
In our studies, in all 11 diabetic foot patients hyperthermic foci were
observed. These 11 patients were referred to us for a second opinion
before amputation. None of these patient ended up with amputation. ITI
played a pivotal role in sparing these patients’ extremities. The
recognition of neuroinflammatory phenomenon (101) in these patients led us
to treat them with weight-bearing, mobilization, nerve blocks, I.V.
Mannitol, physical therapy, etc., sparing these patients from amputation
as well as relieving neuroinflammation and pain with nerve blocks and I.V.
Mannitol (100gm/500cc D5W treatment)(126,127).
ITI is useful in diagnosing Traumatic
lateral epicondylitis (128,129), or tennis elbow. The ITI showed a
focalized hyperthermia at the lateral epicondyle in 53 of 56 patients
(95%)(128). Similar finding of hyperthermia is also noted in tarsal tunnel
entrapment neuropathy. These areas of hyperthermia should not be
aggravated by needle insertion. Any trigger point injection or nerve block
should be performed proximal to the hyperthermic area. Injections aimed at
the foot, ankle, hand, or wrist causes further trauma and up-regulation of
the sympathetic system leading to a source of pain, and further thermal
Another frequently over-diagnosed and over- treated syndrome in
neuropathic pain is Thoracic Outlet Syndrome (TOS)(130). Due to the
inflammatory nature of neuropathic pain, especially in CRPS in upper
extremities, brachial plexitis is frequently mistaken for TOS and is
improperly managed by surgery. The surgical procedure becomes a new source
of neuropathetic pain, further deteriorating the condition (130,131). ITI
has been instrumental in identifying the nature of pathology in distal
portion of the extremity in form of ephaptic hyperthermia- pointing to the
original source of pathology rather than the secondary inflammation of
brachial plexitis. ITI spared such patients from surgery for TOS in 14 of
824 CRPS patients with presumptive diagnosis of TOS (37).
ITI can help
diagnose and differentiate cervicogenic headaches from migraine. The
cervicogenic headache shows areas of hyper - and hypothermia in the
distribution of posterior sensory nerve branches of C2 through C4 nerve
roots, and occipital nerves. Nerve blocks in these areas provide excellent
relief (11,37). On the other hand, radiofrequency damage to articular
facet (48,132,133), or rhizotomy (134) generates a new source of algogenic
pathology, hyperthermia and more severe pain. Stimulation of the
peripheral ends of the cut dorsal roots dilates cutaneus blood vessels
(135). The retrograde activation of cutaneous sensory nerves leads to
focal vascular changes causing neurogenic inflammation (136,137) due to
the release of pro-inflammatory chemicals (50-53,116,138-159).
international 11 / 3 (2001)
This vasodilation and inflammation explains the hyperthermia in the area
of nerve injury. The trigeminal vascular sympathetic function is
influenced by many factors including, but not limited to, chemical changes
in the blood (160), craniovascular circulatory changes (161,162), and
stimulation of trigeminal nucleus by referred pain originating from the
posterior nerve branches of the C1 to C4 nerve roots (163).
Outcome: ITI helps identify the
craniocervical hyperthermic areas, and differentiate this headache from
migraine. Where as in migraine headaches thermal fluctuations are quite
unstable, in cervicogenic headaches the hyperthermia is present in the
occipital nerve region and the craniocervical junction (11). These two
types of headaches require two opposite forms of treatment. Sumatriptan
aggravates cervicogenic headaches; conversely nerve blocks do not usually
relieve the true migraine headaches.
term migraine has been relatively loosely applied to any type of
neurovascular headache, migraine or otherwise. This results in
contamination of studies done on this subject. The ITI has been reported
as having no value for evaluation of true, generic migraine headaches
(160,164) excluding cervicogenic, TMJ, and Trigeminal nerve injury
headaches. The migraine headaches cause craniofacial thermal fluctuations
which are unstable and change in different stages of the migraine attack
(115). Hypothermia over the ophthalmic branch of the trigeminal nerve has
been reported on ITI of migraine patients (160). It is seen mainly during
the acute attack as a transient phenomenon. Mathew et al (165), have
reported thermal symmetry in 78% of headache - free volunteers. However,
this symmetry can also be present in a high percentage of migrainous
patients as well.
More studies are needed regarding the role of ITI in true migraine.
ITI sheds more light
on the complex subject of temporomandibular dysfunction (TMD): In painful,
clicking type of TMD, McBeth et al, showed ITI to have a diagnostic
sensitivity of 87% (166). This was in contrast with normal controls
showing normal specificity of 86% (166). ITI and liquid crystal
thermographies were usually normal in between flare ups of trigeminal
neuralgia or trigeminovascular facial pains (167). During the symptomatic
attacks ITI showed hot or cold spots in over 80 % of patients (84,167).
The hot spots are more likely due to TMJ pathology (168,169) or facial
patients who had undergone TMJ surgery followed by persistence and spread
of neuropathic pain were referred to us for diagnosis and treatment in the
past six years. Two main factors - careful history taking and ITI - solved
the puzzle, and explained the reason for poor recovery.
The ITI revealed an abnormal sympathetic
dysfunction in the cervical (16 patients), lumbar (9 patients), and
thoracic spine regions (7 patients). Only one patient had shown no spinal
involvement - instead the patient was found to suffer from maxillary bone
osteonecrosis and abnormal thermal changes in the Trigeminal nerve
A properly performed
ITI, provides diagnostic therapeutic information not obtained by EMG, NCV,
CT, or MRI. This information is indispensable in helping to arrive at an
accurate diagnosis, and in identifying the pathologic areas. It helps the
physician to avoid further invasive blocks or surgical procedures.
Lack of such
information leads to misdiagnosis, and to labeling the patients for being
a malingerer, or as suffering from conversion reaction.
We are most grateful to Mr. Eric Phillips for his indispensable, and
extensive research and preparation of this report.
The authors have no fiduciary interest in any medical supplies, or any
medications discussed in this paper.
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(Manuscript received on 7.3.2000. revision accepted 20.4.2001)
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