RSD/CRPS
Sympathetic or other regional pain syndromes are poorly understood and challenging to treat. Initially called Causalgia, at the time of the Civil War, and later renamed Reflex Sympathetic Dystrophy or RSD, and now known as Complex Regional Pain Syndrome, or CRPS, this pathologic complex remains a syndrome rather than a distinct disease entity. In fact it was renamed for that reason and for the fact that its pathophysiology remains largely unelucidated. Two types are generally recognized, Type 1 where no identifiable nerve injury is present and Type 2 where a distinct nerve insult is idevtifiable. Diagnoses must be based on exam, history, symptoms and resposnse to therapy, as commonly utilized diagnostic tests are, for the most part, useless except for rare patients. EMG and electrodiagnostic tests are negative with the exception of the QNS test in certain intstances, thermography may be usefull but is nonspecific and not generally validated, Bone Scans are almost always negative except in the most advanced cases when treatment is even less likely to be effective. The hallmark of the syndrome presentation is that symptoms are very much out of proportion to the nature of the injury and often to that of it's initial physical manifestations. Besides pain nd altered local function, patients have sleep pathogy which is distinct from a purely pain mediated sleep distirbance, and memory issues are common. Thius highlights thatn the patholgy has systemic components. The treating physician must really look very closely for telltale subtle changes of local skin temperature, sweating, color, tone, signs of edema, hair growth and restrictions of movement and for abnormal sensations to touch or temperature change. In general, the longer the symptoms have been present, the less likely an acceptablle outcome is to be expected. In some cases an insignificant injury such as a paper cut, or a period of immobiliztion due to casting, has triggered the syndrome pathophysiology. The longer and more severe the affected area is isolated, guarded and underutilized, the worse the expected outcome. Hence treatment with interevntional, physical therapeutic, and medical management can be crucial to optimize patient outcome. Patients treted at our centers have had generally good outcomes in terms of pain and function. Importantly, it is obvious that many Migraine and Cluster headache patients have sympathetic mediated pathologies involved in their headache syndromes, and have benefitted form our proprietary treatment options.
