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Old 06-29-2007, 06:48 PM
InHisHands InHisHands is offline
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InHisHands InHisHands is offline
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It was too long to put the summary and references in the above post so here they are:
Quote:
SUMMARY

Causalgia is an unusual and most fascinating painful disorder that follows partial injury to nerves. It is usually seen during wartime, but it is also seen in civilian patients subjected to high- velocity injury to peripheral nerves. It has so many peculiar characteristics specific to it that it deserves to have the name causalgia exclusively. One of the most important features of the condition is that sympathetic interruption promptly relieves the burning pain, allodynia, and hyperpathia. If sympathetic interruption is done early, it cures the condition.

A number of other conditions that I have included under the generic name of reflex sympathetic dystrophy have symptoms that are similar to those of causalgia, though less severe, and on the basis of their responses to sympathetic blockade it is probable that the underlying mechanisms are also the same. Reflex sympathetic dystrophy is clinically more important than causalgia because it occurs more frequently and can be cured if recognized and properly treated.

Careful review and assessment of various hypotheses that have been proposed about the mechanisms of causalgia and RSD reveal that, notwithstanding the vast amount of neurophysiologic and neuropathologic evidence acquired since Mitchell and Létiévant, we are still far from thoroughly understanding the mechanisms of these disorders. Moreover, we have not advanced much conceptually, because most authorities believe that causalgia is due to mechanisms that involve dysfunction of various parts of the peripheral and central nervous system as originally proposed by Mitchell and Létiévant. The available data suggest that: (a) the sympathetic nervous system plays a critical role in producing spontaneous pain; (b) persistent sensitization of WDR neurons in the dorsal horn of the neuraxis occurs as a result of the initial massive input from nociceptive afferents that occurs at the time of injury; © low-threshold mechanoreceptive afferents activated by light tactile stimulation can provoke increased excitation of the WDR neurons and thus produce allodynia; (d) the large-diameter low-threshold mechanoreceptor afferents can be activated by sympathetic efferent activity; and (e) in some cases the endings of polymodal nociceptors are sensitized.



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FIG. 11-5. Hands of a patient in the acute phase of reflex sympathetic dystrophy that developed 10 days after accidental injury that produced linear fracture of the scaphoid and lunate bones of the wrist. The left hand was edematous and red. The patient experienced moderately severe burning aching pain, which was promptly relieved with cervicothoracic sympathetic block. A series of four such treatments, done every other day, eliminated the edema and the skin changes as well as the pain.

FIG. 11-6. Hands of a patient with stage 2 reflex sympathetic dystrophy that developed after severe laceration of the volar surface of the left wrist caused by a swing saw. Within a few hours of the accident the wound was cleansed, cut tendons and nerves were repaired, and the wound was closed. Several days later the patient began to experience a diffuse burning pain and increased sensitivity of the thenar eminence in the palm, which became progressively worse. A. Two months after injury. Note trophic changes similar to those of the patient in Figure 11-3. Treatment consisted of a series of cervicothoracic sympathetic blocks and physical therapy. B. More than a year after injury. Treatment produced relief of burning pain, but some trophic changes remained.

FIG. 11-7. Photographs of the hands of a patient (MB) who developed reflex sympathetic dystrophy following pressure necrosis of the left forearm. This patient accidentally took an overdose of a muscle relaxant for spasticity of the lower extremities that was due to spinal cord injury. Soon after taking the relaxant she fell to the floor with her left arm underneath her body and a cigarette lighter beneath the arm. She remained in this position for 24 hours, when she was discovered by a relative. Soon afterwards she began to experience a diffuse burning pain and weakness of the hand and forearm, which were treated conservatively with analgesics and physical therapy for several months. A. Photograph taken some three months after the accident. Although the lesion gradually healed, the pain, weakness and trophic changes became progressively worse. When seen in consultation nearly 6 months after the accident she presented with grade 3 RSD. A series of diagnostic cervicothoracic sympathetic blocks was carried out with partial pain relief, after which sympathectomy was advised, but because of severe congenital malformation of the cervicothoracic portion of the spinal column and because of her poor physical condition it was decided to carry out chemical sympathectomy. After this procedure the pain gradually, albeit slowly, became less but never disappeared, and the contractions and osteoporosis remained (B, C) despite intensive therapy (see Fig. 11-8).

Fig. 11-8. Roentgenograms of the hands of MB. A. Moderate degree of osteoporosis in the left hand 3 months after injury. B. More severe and more diffuse osteoporosis of the left hand and a normal right hand, 15 months after injury.

Fig. 11-9. Diagram of the physiologic model developed by Roberts. A. Immediate response to trauma. Action potentials in C nociceptors propagate through the dorsal root ganglia (DRG) to the spinal cord, where they activate and sensitize wide-dynamic-range (WDR) neurons whose axons are sent to higher centers. B. The WDR neurons remain sensitized and now respond to activity in large- diameter A-mechanoreceptors, which are activated by light touch. This state produces allodynia. C.The same sensitized WDR neurons respond again to A-mechanoreceptor activity, but this activity is initiated by sympathetic efferent actions on the sensory receptors in absence of cutaneous stimulation. This phase represents sympathetically maintained pain. Modified from Roberts, W.J.: An hypothesis on the physiological basis for causalgia and related pain. Pain, 24:297, 1986.

Fig. 11-10. Model proposed by Nathan. A. Lesion of a peripheral nerve produces an abnormal state in the dorsal horn, first in the segments of entrance of the damaged nerve and subsequently in adjacent segments, making the peripheral nerves adjacent to the one that was injured also develop an abnormal state. B. Spread of abnormal state from a lesion in the dorsal horn or other parts of the neuraxis to neighboring regions and out along afferent nerves that end in the affected posterior horn. Compare with Figure 8-4. From Nathan, P.W.: Involvement of the sympathetic nervous system and pain. In Pain and Society. Edited by H.W. Kosterlitz and L.Y. Terenius. Weinheim, Verlag Chemie, 1980.
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