AMERICAN JOURNAL OF MEDICINE

Reveille JD,
Soft-tissue rheumatism: diagnosis and treatment.
Am J Med (1997 Jan 27) 102(1A):23S-29S
ISSN: 0002-9343

Abstract:
Soft tissue rheumatism is one of the most common and most misunderstood categories of disorders facing the primary care physician. Among the more common types are subacromial bursitis, epicondylitis, trochanteric bursitis, anserine bursitis, and fibromyalgia. The keys to the diagnosis of soft-tissue rheumatism are the history and, more importantly, the physical examination. Extensive laboratory testing and radiographs are not as helpful in evaluating patients with these complaints. Treatment consists of nonsteroidal anti-inflammatory drugs (NSAIDs) and nonnarcotic analgesics. Especially in patients with localized disorders, intralesional injections of corticosteroids are particularly effective and safe and should be part of the armamentarium of the primary care practitioner. Fibromyalgia is a particularly challenging form of nonarticular rheumatism. The clinical presentation is rather characteristic, with the patient typically being a woman 30-60 years of age who presents with diffuse somatic pain. Patients often give a history of sleep disturbance, may be depressed, and show characteristic tender areas, or trigger points. Laboratory findings are normal. Management includes reassurance, correction of the underlying sleep disturbance with low doses of a tricyclic antidepressant, treatment with muscle relaxants and nonnarcotic analgesics or NSAIDs, and an exercise program with a strong aerobic component.

Institutional address:
Division of Rheumatology/Immunogenetics
University of Texas-Houston Health Sciences Center 77030
USA.

ANNALS OF THE RHEUMATIC DISEASES

Adami S Fossaluzza V Gatti D Fracassi E Braga V,
Bisphosphonate therapy of reflex sympathetic dystrophy syndrome.
Ann Rheum Dis (1997 Mar) 56(3):201-4
ISSN: 0003-4967

Abstract:
OBJECTIVE: The reflex sympathetic dystrophy syndrome (RSDS) is a painful limb disorder, for which a consistently effective treatment has not yet been identified. The disease is associated with increased bone resorption and patchy osteoporosis, which might benefit from treatment with bisphosphonates, powerful inhibitors of bone resorption. METHODS: Twenty patients with RSDS of foot and hand, were randomly assigned to blind administration of either alendronate intravenously (Istituto Gentili, Pisa, Italy) 7.5 mg dissolved in 250 ml saline solution or placebo saline infusions daily for three days. Two weeks later all patients had an identical treatment course with open labelled alendronate (7.5 mg/day for three days), independent from the results of the first blind treatment. RESULTS: In the patients treated with blind alendronate the diminution in spontaneous pain, tenderness, and swelling (circumference of the affected limb) and the improvement in motion were significantly different from baseline (p 0.001), from those observed within the first two weeks in the control group (p 0.01), and from week 2 to week 4 (p 0.01). In the patients given blind placebo infusions no relevant symptomatic changes were observed after the first two weeks of follow up, but they responded to the open alendronate therapy given afterwards. In 12 patients with RSDS of the hand the ultradistal bone mineral content (BMC) of the affected arm was considerably lower than that of the controlateral arm (mean (SD)) (426(82) mg/cm versus 688(49)). Six weeks after the beginning of the trial BMC rose by 77(12) mg/cm (p 0.001) in the affected arm, but it did not change in the controlateral. CONCLUSIONS: These results indicate that bisphosphonates should be considered for the treatment of RSDS, producing consistent and rapid remission of the disease.

Registry Numbers:
66376-36-1 (Alendronate)

Institutional address:
COC di Valeggio
University of Verona
Valeggio
Italy.

ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION

Mellick GA Mellick LB,
Reflex sympathetic dystrophy treated with gabapentin.
Arch Phys Med Rehabil (1997 Jan) 78(1):98-105
ISSN: 0003-9993

Abstract:
The use of the recently released anticonvulsant, gabapentin (Neurontin), in the treatment of severe and refractory reflex sympathetic dystrophy (RSD) pain in six patients ranging in age from 42 to 68 years is reported. Satisfactory pain relief obtained in all six patients suggests that this medication is an effective treatment for RSD pain. In addition to pain control, early evidence of disease reversal in these patients is suggested. Patient 6 is the first documented case of successful treatment and cure of the RSD pain syndrome using gabapentin alone. Specifically, reduced hyperpathia, allodynia, hyperalgesia, and early reversal of skin and soft tissue manifestations were noted. Gabapentin was chosen because it has properties similar to other anticonvulsant drugs and because previous studies have shown that it is well tolerated and appears to have a benign efficacy-to-toxicity ratio. It was considered an acceptable and compassionate therapeutic choice because previous medical and surgical approaches had been ineffective for these patients, who represent the first case series documenting the use of gabapentin for pain management. Presently, the mechanism of pain relief in these patients is unknown. In this article, the pathophysiology of RSD is discussed, and a mechanism by which gabapentin provides pain relief is proposed. In view of encouraging results in these and other RSD patients, further scientific investigation is needed to delineate the role of gabapentin in the treatment of reflex sympathetic dystrophy.

Registry Numbers:
60142-96-3 (gabapentin)

Institutional address:
American Pain Specialists Inc.
Elyria
OH 44035
USA.

JOURNAL OF BONE AND JOINT SURGERY. AMERICAN VOLUME

Cobb TK Morrey BF,
Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients.
J Bone Joint Surg Am (1997 Jun) 79(6):826-32
ISSN: 0021-9355

Abstract:
We retrospectively reviewed the results of primary total elbow arthroplasty for the treatment of an acute fracture of the distal aspect of the humerus in twenty consecutive patients (twenty-one elbows) who had a mean age of seventy-two years (range, forty-eight to ninety-two years) at the time of the injury. The patients were managed between November 1982 and October 1992. The presence of rheumatoid arthritis in nine patients (ten elbows) influenced the choice of treatment. The mean interval between the injury and the total elbow arthroplasty was seven days (range, one to twenty-five days). The mean duration of postoperative hospitalization was seven days (range, four to thirteen days). The mean duration of follow-up was 3.3 years (range, three months to 10.5 years). All patients were followed for a minimum of two years or until the time of death; the duration of follow-up was less than two years for three patients who died. None of the patients were lost to follow-up. Twenty implants were intact at the latest follow-up examination. One patient had a revision total elbow arthroplasty twenty months after the index procedure because of a fracture of the ulnar component sustained in a fall on the outstretched arm. On the basis of the Mayo elbow performance score, fifteen elbows had an excellent result and five had a good result; there were inadequate data for one elbow. There were no fair or poor results. The mean arc of flexion was 25 to 130 degrees. There was no evidence of loosening on the radiographs. Postoperative complications included fracture of the ulnar component in one patient, ulnar neurapraxia in three, and reflex sympathetic dystrophy in one. The results suggest that total elbow arthroplasty can be an alternative form of treatment of a severely comminuted fracture of the distal aspect of the humerus in older patients even in the presence of rheumatoid arthritis. This procedure is not an alternative to osteosynthesis in younger patients.

Institutional address:
Mayo Clinic
Rochester
Minnesota 55905
USA.

NEW ENGLAND JOURNAL OF MEDICINE

Shah N Weinstein A,
Reflex sympathetic dystrophy syndrome following air-bag inflation [letter]
N Engl J Med (1997 Aug 21) 337(8):574
ISSN: 0028-4793

Abstract:
[No Abstract Available]

NEUROLOGY

Galer BS Jensen MP,
Development and preliminary validation of a pain measure specific to neuropathic pain: the Neuropathic Pain Scale.
Neurology (1997 Feb) 48(2):332-8
ISSN: 0028-3878

Abstract:
Neuropathic pain syndromes are commonly seen in clinical practice and are frequently used as pain models in testing new therapies. However, no pain scale exists with the primary purpose to measure pain in neuropathic syndromes. This paper describes the development and preliminary validation of the Neuropathic Pain Scale (NPS), which is designed to assess distinct pain qualities associated with neuropathic pain. Results support the discriminant and predictive validity of the NPS items. Moreover, the NPS items appear to be sensitive to treatments known to impact neuropathic pain. These findings provide support for the further development of the NPS.

Institutional address:
Department of Neurology
University of Washington School of Medicine
Seattle
USA.

POSTGRADUATE MEDICINE

Lopez RF,
Reflex sympathetic dystrophy. Timely diagnosis and treatment can prevent severe contractures.
Postgrad Med (1997 Apr) 101(4):185-90
ISSN: 0032-5481

Abstract:
Reflex sympathetic dystrophy is a clinical syndrome consisting of persistent burning pain and varying degrees of vasomotor and trophic changes in an extremity after trauma. Although several mechanisms have been proposed, none have been universally accepted. Historically, treatment has involved sympathetic blockade or sympathectomy to prevent the proposed sympathetic hyperactivity. However, only a limited number of controlled studies have been conducted, and results have been controversial. The cornerstone of treatment is physical therapy to prevent the severe contractures that can result.

Institutional address:
Hidden Valley Family Medicine
Draper
UT 84020
USA.

RADIOLOGY

Gangi A Dietemann JL Gasser B Mortazavi R Brunner P Mourou MY Dosch JC Durckel J Marescaux J Roy C,
Interstitial laser photocoagulation of osteoid osteomas with use of CT guidance.
Radiology (1997 Jun) 203(3):843-8
ISSN: 0033-8419

Abstract:
PURPOSE: To evaluate interstitial laser photocoagulation (a minimally invasive percutaneous technique of thermal destruction of deep-seated tumors, with low-power laser energy) in local destruction of osteoid osteoma, with computed tomographic (CT) guidance. MATERIALS AND METHODS: Fifteen patients (age range, 8-48 years) with presumed osteoid osteoma were treated with CT-guided interstitial laser photocoagulation of the nidus. A high-power semiconductor diode laser (805 nm) with a 400-microm optical fiber was used. The fiber was introduced into the nidus through an 18-gauge needle. Around the fiber tip, well-defined coagulative necroses from 5 to 9 mm (energy delivery, 400-1,000 J) were obtained. RESULTS: Fourteen patients had complete pain relief, which was apparent within 24 hours in eight patients. One patient had recurrence of pain after 6 weeks. The remaining nidus was treated a second time, with complete relief. Treatment was unsuccessful in one patient, and surgical excision was performed. Daily activities were not restricted after the intervention. All patients were followed up for more than 1 year, with no sign of recurrence. The only notable complication was a mild reflex sympathetic dystrophy of the wrist in one patient. Sclerosis of the nidus was observed 4-6 months after the procedure. CONCLUSION: Percutaneous interstitial laser photocoagulation of osteoid osteoma seems to be a promising, simple, precise, and minimally invasive alternative to traditional surgical and percutaneous ablations.

Institutional address:
Department of Radiology
University Hospital of Strasbourg
France.

AMERICAN JOURNAL OF OTOLARYNGOLOGY

Kiroglu MM Sarpel T Ozberk P Soylu L Cetik F Aydogan LB,
Reflex sympathetic dystrophy following neck dissections.
Am J Otolaryngol (1997 Mar-Apr) 18(2):103-6
ISSN: 0196-0709

Abstract:
PURPOSE: Reflex sympathetic dystrophy (RSD), which is a disorder that occurs after injury or surgery on the extremities, has not been reported as a complication of neck dissections until now. A group patients with head and neck cancer have been examined to determine the incidence of RSD in neck dissections. PATIENTS AND METHODS: Forty- six patients with head and neck cancer, who had undergone neck dissections together with the removal of the primary tumor, were evaluated for RSD on their routine controls. RESULT AND CONCLUSION: The presentation of RSD in two patients who were treated with radical neck dissection is probably a result of sympathetic hyperactivity that is secondary to surgical trauma.

Institutional address:
Department of Otolaryngology
University of Cukurova School of Medicine
Balcali
Turkey.

ANAESTHESIA AND INTENSIVE CARE

Walker SM Cousins MJ,
Complex regional pain syndromes: including "reflex sympathetic dystrophy" and "causalgia".
Anaesth Intensive Care (1997 Apr) 25(2):113-25
ISSN: 0310-057X

Abstract:
"Reflex sympathetic dystrophy" and "causalgia" are now classified by the International Association for the Study of Pain as Complex Regional Pain Syndromes I and II. Sympathetically maintained pain is a frequent but variable component of these syndromes, as the sympathetic and somatosensory pathways are no longer functionally distinct. Pain is the cardinal feature of CRPS, but the constellation of symptoms and signs may also include sensory changes, autonomic dysfunction, trophic changes, motor impairment and psychological changes. Diagnosis is based on the clinical picture, with additional information regarding the presence of sympathetically maintained pain or autonomic dysfunction being provided by carefully performed and interpreted supplemental tests. Clinical experience supports early intervention with sympatholytic procedures (pharmacological or nerve block techniques), but further scientific data is required to confirm the appropriate timing and relative efficacy of different procedures. Patients with recurrent or refractory symptoms are best managed in a multi-disciplinary pain clinic as more invasive and intensive treatment will be required to minimize ongoing pain and disability.

Institutional address:
University of Sydney
Pain Management and Research Centre
Royal North Shore Hospital
N.S.W.

CLINICAL AND EXPERIMENTAL RHEUMATOLOGY

Bhatnagar A Chakraborty K Mehndiratta MM Jena A Soni NL Mondal A,
Cervical mass lesion presenting as reflex sympathetic dystrophy of the hand.
Clin Exp Rheumatol (1997 Jan-Feb) 15(1):101-4
ISSN: 0392-856X

Abstract:
A case with multiple small joint swelling and skin dystrophic changes in the right hand was initially treated as seronegative non-specific arthritis. Later, a triple phase bone scan indicated reflex sympathetic dystrophy (RSD) and the primary lesion was shown on MRI scan to be a cervical cord mass with associated sub-acute haematoma. The case underscores the need to consider RSD in the differential diagnosis of such conditions and the importance of a detailed neurological examination in RSD with no local causative factor.

Institutional address:
Department of Nuclear Medicine
INMAS
Delhi
India.

CLINICAL JOURNAL OF PAIN

Gulevich SJ Conwell TD Lane J Lockwood B Schwettmann RS Rosenberg N Goldman LB,
Stress infrared telethermography is useful in the diagnosis of complex regional pain syndrome, type I (formerly reflex sympathetic dystrophy).
Clin J Pain (1997 Mar) 13(1):50-9
ISSN: 0749-8047

Abstract:
OBJECTIVE: To assess the sensitivity, specificity, and predictive value (PV) of stress infrared telethermography (IRT) in the complex regional pain syndrome, type I (CRPS-I). METHODS: One hundred eighty- five consecutive patients (47 men, 138 women) with 205 pairs of chronically painful limbs (upper, lower, or both) were examined by pain specialists in neurology, physiatry, and anesthesia, who then reached a consensus diagnosis. A clinical diagnosis of CRPS-I required at least two of the following observations: burning pain, vasomotor changes, diaphoresis, trophic changes, allodynia. Patients with only one criterion were classified as possible CRPS-I; those with none were judged not to have CRPS-I. Patients and 24 asymptomatic control subjects underwent stress IRT, which was considered positive for CRPS-I if it showed three of the following: quantitative thermal emission of or = 1.00 degree C, abnormal distal thermal gradient patterns, presence of a "thermal marker," and abnormal response to functional cold water autonomic stress testing. RESULTS: By clinical criteria, CRPS-I was diagnosed in 73 pairs of limbs; not CRPS-I was diagnosed in 70; and 62 pairs had possible CRPS- I. Excluding possible CRPS-I cases, there were 5 false-negative stress IRTs (sensitivity 93%) and 7 false-positive results (specificity 89%). Based on estimated 50% prior probability for our population, the positive PV is 90% and the negative PV 94%. None of the control subjects exhibited thermographic evidence of CRPS-I. CONCLUSION: Stress IRT is a sensitive and specific indicator of CRPS- I.

Institutional address:
Colorado Neurological Institute
Center for Spine and Orthopedic Rehabilitation
Englewood
USA.

CLINICAL NEUROLOGY AND NEUROSURGERY

Muizelaar JP Kleyer M Hertogs IA DeLange DC,
Complex regional pain syndrome (reflex sympathetic dystrophy and causalgia): management with the calcium channel blocker nifedipine and/or the alpha-sympathetic blocker phenoxybenzamine in 59 patients.
Clin Neurol Neurosurg (1997 Feb) 99(1):26-30
ISSN: 0303-8467

Abstract:
Complex Regional Pain Syndrome (CRPS) is the new name for entities formerly known mostly as Reflex Sympathetic Dystrophy and Causalgia. Treatment of CRPS with either the calcium channel blocker nifedipine or the alpha-sympathetic blocker phenoxybenzamine was assessed in 59 patients, 12 with early stages of CRPS, 47 with chronic stage CRPS. In the early stage CRPS patients, 3 of 5 were cured with nifedipine and 8 of 9 (2 of whom had earlier received nifedipine) with phenoxybenzamine, for a cure rate of 92% (11 out of 12). In the chronic stage CRPS patients, 10 of 30 were cured with nifedipine; phenoxybenzamine cured 7 of 17 patients when administered as a first choice and another 2 of 7 patients who received nifedipine earlier, for a total late stage success rate of 40% (19 out of 47). The most common side effects necessitating discontinuing the drug were headaches for nifedipine and orthostatic dizziness, nausea and diarrhoea for phenoxybenzamine. All male patients on phenoxybenzamine experienced impotence, but this did not lead to discontinuing this agent and immediately disappeared after stopping the drug. These results once again stress the importance of early recognition of CRPS, and treatment with either of these drugs could be considered as a first choice for early CRPS, especially because in this series this treatment was not combined with physical therapy making it very cost- effective. In the chronic stage of CRPS, treatment with these drugs was much less successful (40%), even though it was always combined with physical therapy, but it can still be considered, either as a first choice or when other types of treatment have failed.

Registry Numbers:
21829-25-4 (Nifedipine)
59-96-1 (Phenoxybenzamine)

Institutional address:
Department of Neurosurgery
University of California
Davis
Sacramento 95817
USA.

CLINICAL RHEUMATOLOGY

Cortet B Flipo RM Coquerelle P Duquesnoy B Delcambre B,
Treatment of severe, recalcitrant reflex sympathetic dystrophy: assessment of efficacy and safety of the second generation bisphosphonate pamidronate.
Clin Rheumatol (1997 Jan) 16(1):51-6
ISSN: 0770-3198

Abstract:
The objective of the study was to assess the efficacy and the safety of pamidronate (APD) in recalcitrant reflex sympathetic dystrophy (RSD). Ten women and 13 men with a mean (+/-standard deviation, SD) age of 44 +/- 11 years were included. The involved sites were: the ankle (n = 10), the foot (n = 7), the hand (n = 3), the hip (n = 2), the knee (n = 2) and the shoulder (n = 1). Some patients had more than one site involved. Mean (+/-SD) duration of the disease was 15 +/- 13 months. RSD was in pseudo-inflammatory phase in 16 patients and in ischaemic phase in 7 patients. RSD was post-traumatic in 17 cases; 11 patients have been previously treated unsuccessfully by sympathetic blockades. APD was administered intravenously (perfusion) to a dose of 1 mg/kg/day during 3, 2 or one day. Fourteen patients received APD during 3 consecutive days whereas 7 patients have been treated during 2 consecutive days and 2 patients only during 1 day mainly due to adverse events. Efficacy was assessed by a decrease of pain = visual analogic scale (VAS, 0-100 mm) and verbal scale (PVS, range 0-3). Moreover, the patient and the observer have estimated the efficacy of the treatment on a verbal scale (EVS, range 0-3). Measurements of these parameters were performed immediately before the treatment and 7, 30, 60 and 90 days later. The maximum duration after treatment was 9 months. A significant decrease of VAS and PVS were observed between D0 and D30 (p = 0.0002 and p = 0.0002 respectively), D0 and D60 (p = 0.0004, p = 0.0004 respectively), and D0 and D90 (p = 0.00003, p = 0.0001 respectively). A significant increase of EVS was only observed between D0 and D90 (p = 0.03). Adverse events were noted in 14 patients: transient fever (n = 6), venous inflammation (n = 2), transient symptomless hypocalcaemia (n = 3), nausea (n = 1), lymphopenia (n = 1), transient hypertension (n = 1). These results suggest an efficacy of APD in recalcitrant RSD. Double-blind placebo controlled studies are required to back up these preliminary results.

Registry Numbers:
40391-99-9 (amidronate)

Institutional address:
Department of Rheumatology
University of Lille
CH & U Lille
France.

DENTAL CLINICS OF NORTH AMERICA

Merrill RL,
Orofacial pain mechanisms and their clinical application.
Dent Clin North Am (1997 Apr) 41(2):167-88
ISSN: 0011-8532

Abstract:
This article has discussed the peripheral and central mechanisms of the various orofacial pain conditions, including musculoskeletal disorders, neurogenic inflammation, and neuropathic pain. To make an accurate diagnosis of orofacial pain and render treatment, all organ systems need to be considered and evaluated. Central sensitization was discussed as it relates to musculoskeletal disorders and neuropathic pain. It has been suggested that treatment of these disorders be problem oriented, addressing both peripheral and central mechanisms if present. Musculoskeletal disorders are characterized by pain that is provokable with function and manipulation. Neurovascular pain is episodic with pain-free periods between attacks. The pain is not related to or provoked by jaw function. Neuropathic pain is more continuous and may be aggravated by light touch. Neuropathy with peripheral involvement responds variably to local anesthetics but may need to be treated with topical or local agents as well as centrally acting agents. Neuropathic pain that does not respond to topical or local agents is more profoundly centralized. These conditions need to be treated with centrally acting agents. In addition, if there is no response to medications, sympathetic involvement needs to be ruled out with sympathetic ganglion blockade.

Institutional address:
Department of Orofacial Pain
University of California
Los Angeles Dental School
USA.

EUROPEAN RADIOLOGY

Grampp S Steiner E Imhof H,
Radiological diagnosis of osteoporosis.
Eur Radiol (1997) 7 Suppl 2:S11-9
ISSN: 0938-7994

Abstract:
[No Abstract Available]

Institutional address:
Department of Osteoradiology
University of Vienna-AKH
Austria.

FOOT AND ANKLE INTERNATIONAL

Rand N Mosheiff R Liebergall M,
Nonunion of a fracture of the lateral malleolus: a case report and review of the literature.
Foot Ankle Int (1997 Jan) 18(1):50-2
ISSN: 1071-1007

Abstract:
Nonunion of a fracture of the lateral malleolus is a rare condition. We present a case of established nonunion of a fracture of the lateral malleolus confirmed and treated surgically, using debridement and internal fixation with autologous bone graft. At 5-year follow- up, the fracture was united but the patient still showed clinical signs of reflex sympathetic dystrophy. Male gender, supination fractures, Weber type C fractures, and primary internal fixation are cited as possible risk factors. Prognosis is variable.

Institutional address:
Department of Orthopedics and Rehabilitation
Vanderbilt University School of Medicine
Nashville
Tennessee 37232-2550
USA.

INSTRUCTIONAL COURSE LECTURES

Lindenfeld TN Bach BR Jr Wojtys EM,
Reflex sympathetic dystrophy and pain dysfunction in the lower extremity.
Instr Course Lect (1997) 46:261-8
ISSN: 0065-6895

Abstract:
[No Abstract Available]

Institutional address:
Cincinnati Sportsmedicine and Orthopaedic Center
Ohio
USA.

Bach BR Jr Wojtys EM Lindenfeld TN,
Reflex sympathetic dystrophy, patella infera contracture syndrome, and loss of motion following anterior cruciate ligament surgery.
Instr Course Lect (1997) 46:251-60
ISSN: 0065-6895

Abstract:
[No Abstract Available]

Institutional address:
Department of Orthopaedic Surgery
Rush Medical College
Rush Presbyterian-St. Luke's Medical Center
Chicago
Illinois
USA.

INTERNATIONAL ORTHOPAEDICS

Rodriguez-Merchan EC,
Subtalar dislocations. A study of 19 cases [letter]
Int Orthop (1997) 21(2):142
ISSN: 0341-2695

Abstract:
[No Abstract Available]

JOURNAL OF THE AMERICAN OSTEOPATHIC ASSOCIATION

Nelson KE,
Osteopathic medical considerations of reflex sympathetic dystrophy.
J Am Osteopath Assoc (1997 May) 97(5):286-9
ISSN: 0098-6151

Abstract:
Review of current medical literature reveals little understanding of the physiology underlying the complex signs and symptoms that accompany reflex sympathetic dystrophy (RSD). The author surveyed the osteopathic medical literature and found a significant body of research documenting the physiology of somatic dysfunction. The manifestations of upper thoracic somatic dysfunction are strikingly similar to those of RSD and may offer insight into its heretofore unexplained physiology of this disorder.

Institutional address:
Division of Osteopathic Manipulative Medicine
Chicago College of Osteopathic Medicine
Downers Grove
IL 60515
USA.

JOURNAL OF HAND SURGERY. BRITISH VOLUME

Field J Atkins RM,
Algodystrophy is an early complication of Colles' fracture. What are the implications?
J Hand Surg [Br] (1997 Apr) 22(2):178-82
ISSN: 0266-7681

Abstract:
One hundred patients who had sustained a Colles' fracture were observed for features of algodystrophy at 1, 5, 9 and 12 weeks following injury. The diagnosis of algodystrophy was possible as soon as 1 week after fracture. Early diagnosis has important clinical implications: the aetiological factors may become apparent and different treatment modalities be identified; furthermore, early treatment can be started, limiting the morbidity of the condition. It is proposed that patients with features of algodystrophy require physiotherapy after a Colles' fracture. Those without features may not.

Institutional address:
University Department of Orthopaedics
Bristol Royal Infirmary
UK.

Ide J Yamaga M Kitamura T Takagi K,
Quantitative evaluation of sympathetic nervous system dysfunction in patients with reflex sympathetic dystrophy.
J Hand Surg [Br] (1997 Feb) 22(1):102-6
ISSN: 0266-7681

Abstract:
The sympathetic nervous system function in 20 patients with reflex sympathetic dystrophy (RSD) of one upper extremity was examined by a non-invasive laser Doppler method to assess fingertip blood flow and vasoconstrictor response to deep inspiration. We observed an increased blood flow but an unchanged vasoconstrictor response in the affected hand in stage 1 of the disorder, but in stage 2 there was a decreased blood flow and a stronger vasoconstriction following an inspiratory gasp. Skin blood flow and vasoconstrictor response returned to normal following successful treatment of the condition. These results suggest that in RSD patients the sympathetic nervous system function is altered and is different in the various stages. The objective method used in our study may be of value in the diagnosis and management of RSD.

Institutional address:
Department of Orthopaedic Surgery
Kumamoto University School of Medicine
Japan.

Field J Gardner FV,
Psychological distress associated with algodystrophy.
J Hand Surg [Br] (1997 Feb) 22(1):100-1
ISSN: 0266-7681

Abstract:
We have carried out a prospective study of the level of psychological distress in patients with Colles' fractures. Those who developed algodystrophy did not show increased distress before the onset of the condition.

Institutional address:
Bristol Royal Infirmary
UK.

JOURNAL OF HAND THERAPY

Hardy MA Hardy SG,
Reflex sympathetic dystrophy: the clinician's perspective.
J Hand Ther (1997 Apr-Jun) 10(2):137-50
ISSN: 0894-1130

Abstract:
Theories on the etiology of reflex sympathetic dystrophy (RSD) are reviewed and presented in three categories: peripheral, spinal, and supraspinal. The peripheral pathophysiology involves a prolonged inflammatory, response to injury due to the axon reflex with release of vasoactive neuropeptides and sensitized nociceptors. The spinal component of RSD genesis involves nociceptive spinal cord neurons with lowered thresholds due to chronic pain input. These sensitized spinal neurons respond in turn by signaling pain reflexes through the sympathetic system. A physical-emotional diathesis may predispose individuals to respond to stress through autonomic arousal. Autonomic arousal, coupled with injury, signals the supraspinal influence on this syndrome. Since the puzzle of RSD remains to be solved, measurement and treatment strategies are suggested to provide intervention at each level. Measurement techniques should include a battery of static tests and stress tests. Static tests are used to quantify a physiological parameter at one point in time. Stress tests access physiological response to various neuro-vaso-motor challenges. A "hands off" treatment regime is presented that includes pain control, methods to reset sensory thresholds, vasomotor challenges, and an active motion program.

Institutional address:
Department of Physical Therapy
University of Mississippi Medical Center
Jackson
USA.

JOURNAL OF HEPATOLOGY

Voigt MD Trey G Levitt NS Raine R Lombard CJ Robson SC Gordon G Kirsch RE,
Autonomic neuropathy in extra-hepatic portal vein thrombosis: evidence for impaired autonomic reflex arc.
J Hepatol (1997 Mar) 26(3):634-41
ISSN: 0168-8278

Abstract:
BACKGROUND/AIMS: Autonomic dysfunction is common in cirrhosis, and may be associated with increased mortality and hyperdynamic circulatory changes. Our aim was to investigate whether autonomic disturbances occur in extrahepatic portal vein thrombosis and their correlation with hemodynamic abnormalities. PATIENTS AND METHODS: Heart rate variation in response to standing, deep breathing, and Valsalva maneuver, and blood pressure response to sustained handgrip and to standing, were studied in 16 subjects with portal vein thrombosis (10 males, 30.8+/-2.8 years: mean+/-SE), 12 with cirrhosis (7 males, 52+/-2.3 years), and 10 healthy controls (7 males, 30.8+/- 3.0 years). Supine resting, and 10- and 30-min standing epinephrine and norepinephrine levels were measured and results correlated with cardiac output. RESULTS: Autonomic dysfunction occurred in 62% of portal vein thrombosis and 75% of cirrhosis subjects, but in no controls (p 0.02). Similarly, postural hypotension occurred in portal vein thrombosis (-10.25+/-0.65 mmHg, p=0.003) and cirrhosis (-7.42+/- 0.82 mmHg, p=0.007) but not in controls. All groups had similar baseline epinephrine and norepinephrine concentrations. Epinephrine increased significantly in controls (45%, p 0.01 and 49%, p 0.02) after 10 of 30 min standing but not in the portal vein thrombosis or the cirrhotic group, and norepinephrine increased after 10 and 30 min standing in cirrhotics (128%, p 0.004 and 130%, p 0.008) and controls (129%, p 0.002 and 116%, p 0.004), but not portal vein thrombosis (34.5% and 39%, NS vs baseline). Portal vein thrombosis and cirrhosis groups had increased cardiac output (4441+/-509 and 3262+/-292) vs controls (1763+/-212 ml/min/m2, p 0.002), but there was no correlation with autonomic neuropathy or with catecholamine levels. CONCLUSIONS: Autonomic dysfunction and impaired catecholamine response to orthostatic stress occur commonly in portal vein thrombosis and suggest an impairment of the autonomic reflex arc, but changes do not correlate with hemodynamic abnormalities.

Registry Numbers:
EC 3.4.23.15 (Renin)
11128-99-7 (Angiotensin II)

Institutional address:
Department of Medicine
University of Cape Town
South Africa.

JOURNAL OF RHEUMATOLOGY

Lovy MR Goodman R,
Dual energy X-ray absorptiometry in reflex sympathetic dystrophy [letter; comment]
J Rheumatol (1997 Apr) 24(4):812-4
ISSN: 0315-162X

Abstract:
[No Abstract Available] Comment on: J Rheumatol 1996 Sep;23(9):1557-9

JOURNAL OF SPINAL DISORDERS

Thalgott JS Sasso RC Cotler HB Aebi M LaRocca SH,
Adult spondylolisthesis treated with posterolateral lumbar fusion and pedicular instrumentation with AO DC plates.
J Spinal Disord (1997 Jun) 10(3):204-8
ISSN: 0895-0385

Abstract:
Attainment of successful lumbar fusion in adults with spondylolisthesis has historically been unpredictable. Recent results and conclusions have been conflicting regarding the role of instrumentation in improving the fusion rate and clinical outcome in this patient population. In a retrospective multicenter clinical study, we assessed the outcome of 42 adults with spondylolisthesis who underwent posterolateral lumbar fusion by using pedicular instrumentation with AO DC plates. No attempt was made to reduce slippage. Follow-up clinical outcome was obtained from a patient questionnaire administered and assessed by an independent reviewer. Fusion status was assessed by anteroposterior, lateral, and oblique radiographs at the most recent follow-up examination. Spondylolisthesis was classified as degenerative in 21 patients and isthmic in 21 patients. Solid fusion was achieved in 32 (76%) patients; pseudoarthrosis occurred in two (5%) patients; the fusion mass was indeterminate in eight (19%) patients. Clinical outcome parameters rated 73% excellent to good and 27% fair to poor. Complications included four infections and two screw breakages. Poor results correlated strongly with cigarette smoking and multiple previous surgeries. In this study, fusion rate and clinical outcome were consistent with previous reports of adult spondylolisthesis. Rates of successful fusion varied according to the type of spondylolisthesis.

Institutional address:
Department of Orthopaedic Surgery
University of Nevada
Las Vegas
USA.

MEDICAL HYPOTHESES

Silber TJ,
Eating disorders and reflex sympathetic dystrophy syndrome: is there a common pathway?
Med Hypotheses (1997 Mar) 48(3):197-200
ISSN: 0306-9877

Abstract:
The comorbidity of eating disorders and reflex sympathetic dystrophy syndrome in the same patients raises the possibility of a common pathway for both conditions. Reflex sympathetic dystrophy syndrome may be manifesting itself in those individuals who have sympathetic overdrive. Microtrauma, often induced by compulsive exercise, and depression may be contributory factors. It is recommended that: patients with eating disorders who develop pain in an extremity should be investigated for possible reflex sympathetic dystrophy syndrome; patients with reflex sympathetic dystrophy syndrome should be discouraged from dieting, and eating disorders should be suspected if they begin to lose weight or are already malnourished.

Institutional address:
Department of Adolescent and Young Adult Medicine
George Washington University School of Medicine and Health Sciences
Washington
DC
USA.

MOVEMENT DISORDERS

Feinstein A,
Abnormal movements in a patient with reflex sympathetic dystrophy [letter]
Mov Disord (1997 May) 12(3):470-1
ISSN: 0885-3185

Abstract:
[No Abstract Available]

Kurlan R Brin MF Fahn S,
Movement disorder in reflex sympathetic dystrophy: a case proven to be psychogenic by surveillance video monitoring [see comments]
Mov Disord (1997 Mar) 12(2):243-5
ISSN: 0885-3185

Abstract:
[No Abstract Available] Comment
Mov Disord 1997 May;12(3):470-1

Institutional address:
Department of Neurology
Dentistry
New York
USA.

NETHERLANDS JOURNAL OF MEDICINE

van Hengel P Nikken JJ de Jong GM Hesp WL van Bommel EF,
Mannitol-induced acute renal failure.
Neth J Med (1997 Jan) 50(1):21-4
ISSN: 0300-2977

Abstract:
Mannitol is widely used because of its osmotic diuretic action and its presumed antioxidant properties. In pre-existent renal dysfunction, however, mannitol may accumulate leading to potentially deleterious effects. We describe a 71-year-old woman with moderate chronic renal failure due to diabetic nephropathy who developed acute anuric renal failure after mannitol administration for post-traumatic reflex sympathetic dystrophy. After haemodialysis symptoms of acute renal failure rapidly disappeared with recovery of pre-existent renal function. Daily measurement of the osmolal gap as a simple and accurate way of monitoring patients receiving mannitol infusion is emphasized. A rapid increase in the osmolar gap should prompt adjustment of the dose or even discontinuation of mannitol, especially in the case of pre-existent risk factors.

Registry Numbers:
69-65-8 (Mannitol)

Institutional address:
Department of Internal Medicine
Drechtsteden Ziekenhuis
AK Dordrecht
Netherlands.

NEUROSURGERY

Kumar K Nath RK Toth C,
Spinal cord stimulation is effective in the management of reflex sympathetic dystrophy.
Neurosurgery (1997 Mar) 40(3):503-8; discussion 508-9
ISSN: 0148-396X

Abstract:
OBJECTIVE: The purpose of this study was to determine the efficacy of spinal cord stimulation (SCS) in patients with symptoms of reflex sympathetic dystrophy (RSD), a disabling clinical condition with significant consequences of morbidity and loss of productivity. METHODS: We have used epidural SCS for pain control during the past 15 years. An analysis of our records revealed 12 consecutive patients diagnosed as having RSD before undergoing SCS. Eight of the 12 patients had undergone previous ablative sympathectomy. The mean age of the nine men and three women was 38.2 years. All suffered extremity injuries from a variety of causes. RESULTS: All 12 patients experienced relief of pain after trial stimulation and had their systems permanently implanted. At an average of 41 months follow-up, all patients were using their stimulators regularly and only two were receiving adjunctive minor pain medication. The level of pain present pre- and postoperatively was determined by administering a modified McGill Pain Questionnaire and a visual analog scale to each patient. Eight patients reported excellent pain relief, and four patients described good results. Five minor complications occurred. CONCLUSION: SCS is an effective treatment for the pain of RSD, including recurrent pain after ablative sympathectomy. The low morbidity of this procedure and its efficacy in patients with refractory pain related to RSD suggest that SCS is superior to ablative sympathectomy in the management of RSD.

Institutional address:
Department of Surgery
University of Saskatchewan
Regina
Canada.

ORTHOPEDICS

Hood-White R Gainor J,
Reflex sympathetic dystrophy in an 8-year-old: successful treatment by physical therapy.
Orthopedics (1997 Jan) 20(1):73-4
ISSN: 0147-7447

Abstract:
[No Abstract Available]

Institutional address:
Santa Barbara Medical Foundation Clinic
Santa Barbara
Calif
USA.

PAIN

Birklein F Sittl R Spitzer A Claus D Neundorfer B Handwerker HO,
Sudomotor function in sympathetic reflex dystrophy.
Pain (1997 Jan) 69(1-2):49-54
ISSN: 0304-3959

Abstract:
Sudomotor functions were studied in 27 patients suffering from reflex sympathetic dystrophy (RSD) according to the criteria established by Bonica (18 women, 9 men; mean age 50 +/- 12.3 years; median duration of disease 8 weeks, range 2-468 weeks). To measure local sweating rates, two small chambers (5 cm2) were affixed to corresponding areas of hairy skin on the affected and unaffected limbs. Dry nitrogen gas was passed through the chambers (270 ml/min) and evaporation was recorded at both devices with hygrometers. Thermoregulatory sweating (TST) was induced by raising body temperature (intake of 0.5 1 hot tea and infra-red irradiation). Local sweating was also induced through an axon reflex (QSART) by transcutaneous iontophoretic application of carbachol (5 min, 1 mA). In addition, skin temperature was measured on the affected and unaffected side by infra-red thermography. Mean skin temperature was significantly higher on the affected side (P 0.003). In spite of the temperature differences, there was no difference in basal sweating on the affected and unaffected side. However, both methods of sudomotor stimulation lead to significantly greater sweating responses on the affected compared to the unaffected side (TST: P 0.05, QSART: P 0.004). Latency to onset of sweating was significantly shorter on the affected side under both test conditions (P 0.04 and P 0.003, respectively). Sweat responses were not correlated to absolute skin temperature but were probably related to the increased blood flow on the affected side. Our findings imply a differential disturbance of vasomotor and sudomotor mechanisms in affected skin. Whereas vasoconstrictor activity is apparently lowered, sudomotor output is either unaltered or may even be enhanced.

Institutional address:
Neurologische Klinik
Friedrich-Alexander-Universitat Erlangen
Germany.

Malleson P,
Reply to Veldman and Goris, PAIN, 64 (1996) 463-466 [letter]
Pain (1997 Jun) 71(2):207-8
ISSN: 0304-3959

Abstract:
[No Abstract Available]

REGIONAL ANESTHESIA

Wassef MR,
Phantom pain with probable reflex sympathetic dystrophy: efficacy of fentanyl infiltration of the stellate ganglion.
Reg Anesth (1997 May-Jun) 22(3):287-90
ISSN: 0146-521X

Abstract:
BACKGROUND AND OBJECTIVES: The stellate ganglion can alleviate phantom pain of the upper extremity, possibly because of the presence in it of enkephalin receptors, as has been suggested by experimental and clinical reports. A case is reported in which fentanyl, instead of local anesthetic, was used for stellate ganglion block. METHODS: A 49-year-old man, with a left below-elbow amputation, presented with probable symptoms of reflex sympathetic dystrophy, pain and temperature changes at the stump, and phantom hand symptoms the English-language literature revealed no reports of the use of fentanyl infiltration of the stellate ganglion was performed for management of this condition. RESULTS: Significant alleviation of pain and sensation of warmth at the stump and in the phantom hand was achieved. CONCLUSIONS: Fentanyl infiltration of the stellate ganglion proved to be successful in the management of the pain and temperature sensation changes in the stump and phantom upper extremity.

Registry Numbers:
437-38-7 (Fentanyl)

Institutional address:
Department of Anesthesiology
Elmhurst Hospital Center
Mount Sinai School of Medicine
New York
New York
USA.

Heavner JE Calvillo O Racz GB,
Thermal grill illusion and complex regional pain syndrome type I (reflex sympathetic dystrophy).
Reg Anesth (1997 May-Jun) 22(3):257-9
ISSN: 0146-521X

Abstract:
BACKGROUND AND OBJECTIVES: In normal humans, placing a hand on a thermal grill containing warm elements separated by cool ones produces a burning sensation. In this case report, responses to a thermal grill in a patient with neuropathic pain were examined. METHODS: The responses of a 31-year-old woman with complex regional pain syndrome type I (reflex sympathetic dystrophy) to a thermal grill were evaluated before and after stellate ganglion block. RESULTS: The patient experienced a burning sensation when the unaffected hand was placed on the grill and could distinguish which element was warm and which was cool. An intolerable burning sensation caused the patient to quickly (within 4 seconds) withdraw the affected hand when it was placed on the grill. Touching cool elements with the affected hand produced an intense burning sensation (cold allodynia), whereas touching warm elements produced a pleasant warm sensation. Stellate ganglion block with phenol, local anesthetic, and steroid resulted in long-lasting absence of cold allodynia. CONCLUSION: The thermal grill may be a useful a tool to help understand the pathophysiology of complex regional pain syndrome type I.

Institutional address:
Department of Anesthesiology
Texas Tech University Health Sciences Center
Lubbock 79430
USA.

REVUE DU RHUMATISME. ENGLISH EDITION

Laroche M Redon-Dumolard A Mazieres B Bernard J,
An X-ray absorptiometry study of reflex sympathetic dystrophy syndrome.
Rev Rhum Engl Ed (1997 Feb) 64(2):106-11
ISSN: 0035-2659

Abstract:
X-ray absorptiometry (Lunar DPX) was performed before and after treatment to determine bone mineral content and density, as well as fat-free mass and body fat, in 28 males and 11 females with a mean age of 37 years who met Doury's criteria for reflex sympathetic dystrophy syndrome. Mean disease duration was eight months. Before treatment, as compared to the unaffected limb, bone mineral content was decreased by 8.8%, bone mineral density by 9.6%, and fat-free mass by 6.2%, whereas body fat was increased by 6%. These differences were largest in those patients with the longest disease durations. The severity of bone loss was not correlated with the outcome, the severity of roentgenographic lesions, or whether the patient was evaluated at the warm or cold stage of the disease process. Study parameters were unchanged after three months both in patients who were and were not improved. After nine to 12 months, increases in bone and fat-free mass were seen in those patients whose clinical manifestations had subsided.

Institutional address:
Rheumatology Department
Rangueil Teaching Hospital
Toulouse
France.

Bouvier M Colson F Noel E Tebib JG Felman C,
Two new case-reports of reflex sympathetic dystrophy syndrome in patients with osteogenesis imperfecta. Review of the literature [letter]
Rev Rhum Engl Ed (1997 Mar) 64(3):202-4
ISSN: 0035-2659

Abstract:
[No Abstract Available]

Laroche M Redon-Dumolard A Moulinier L Cantagrel A Mazieres B,
Phosphate excretion in reflex sympathetic dystrophy syndrome before and after a single infusion of pamidronate.
Rev Rhum Engl Ed (1997 Mar) 64(3):172-6
ISSN: 0035-2659

Abstract:
To clarify the relations between reflex sympathetic dystrophy syndrome and moderate phosphate diabetes, we prospectively determined urinary phosphate excretion parameters (clearance, renal tubular reabsorption of phosphate and threshold of tubular reabsorption of phosphate) in 37 patients with reflex sympathetic dystrophy syndrome before and after treatment with 60 mg of pamidronate (n = 23) and in 35 age- and sex-matched controls. Urinary phosphate excretion parameters were identical in cases and in controls. Fourteen of the 23 cases treated by pamidronate were improved after one to two months. Pamidronate had no effect on phosphate excretion. Four cases versus only one control had phosphate diabetes (X2 = 0.18). Three of the four cases with phosphate diabetes failed to respond to pamidronate therapy but improved under phosphate and 1,25-diOH vitamin D3 therapy.

Registry Numbers:
104982-03-8 (Osteocalcin)
32222-06-3 (Calcitriol)
40391-99-9 (amidronate)
60-27-5 (Creatinine)
7440-70-2 (Calcium)

Institutional address:
Rheumatology Department
Rangueil Teaching Hospital
Toulouse
France.

SKELETAL RADIOLOGY

Magnussen JS Chik K Karplus T Van der Wall H,
Ulnar distribution of reflex sympathetic dystrophy due to compression of the brachial plexus by a primary venous malformation.
Skeletal Radiol (1997 May) 26(5):303-5
ISSN: 0364-2348

Abstract:
An atypical variant of reflex sympathetic dystrophy (RSD) is presented in a 45 year old female with a vascular malformation of the right arm and chest wall. The mechanism was thought to be compression of the brachial plexus by the malformation. The unique scintigraphic features of this presentation of RSD in the ulnar arterial distribution are illustrated.

Institutional address:
Department of Nuclear Medicine
Concord Repatriation General Hospital
New South Wales
Australia.