At the risk of prolonging this encounter, I just want to respond to the one narrow point upon which Vic has invited my comment, and that is his assertion of Dr. Schwartzman's "unethical" conduct in promoting remedies which he knew or should have known were not as effective as he claimed.

Vic starts with reference to an unspecified article in which Dr. Schwartzman suggested that surgical sympathectomies gave "permanent" remission (which it is asserted was artificially defined as two years) of symptoms. I have tried to find this assertion, but going through a number of articles by Dr. Schwartzman that are posted on the RSDSA Medical Articles Archive page [http://www.rsds.org/2/library/articl...ve/index.html], it's not there. Now, obviously Dr. Schwartzman has written a lot more than these articles, but if you look at them, none of them are truly leading the clarion call for sympathectomies in the absence of the then available medical data, as has been suggested. Check these out:

1. "Reflex Sympathetic Dystrophy, A Review," Schwartzman RJ, McLellan TL., Archives of Neurology 1987; 44: 555-561

2. "The movement disorder of reflex sympathetic dystrophy," Schwartzman RJ, Kerrigan J., Neurology 1990; 40: 57-61.

3. "Reflex Sympathetic Dystrophy, Occurrence of Inflammatory Skin Lesions in Patients With Stages II and III Disease," Webster GF, Schwartzman RJ, Jacoby, RA, Knobler RL, Uitto JJ, Archives of Dermatology 1991; 127: 1541-1544 and

4. "New Treatments for Reflex Sympathetic Dystrophy," Schwartzman RJ, The New England Journal of Medicine 2000: 654-655.

Yes, if you go back to his 1987 article with McClellan, "Reflex Sympathetic Dystrophy," he says, at page 558 that, "[f]or patients with severe or long-standing disease, sympathectomy should be performed early if there is any response to a paravertebral ganglion block." And in his 1990 piece with Kerrigan, "The movement disorder of reflex sympathetic dystrophy," there is the following at page 60, "[s]ympathectomy in an extremity that has been successfully blocked gives the best long term result." But these writings cannot be taken wholly out of context.

Indeed, I think I have found the article Vic may have had in mind. See, "Long-term outcome following sympathectomy for complex regional pain syndrome type 1 (RSD)," Schwartzman RJ, Liu JE, Smullens SN, Hyslop T, Tahmoush AJ, J Neurol Sci. 1997 Sep 10; 150(2): 149-52 (retrospective study of 29 patients with CRPS1 (RSD) who were initially examined between 1983 and 1993, and had either transthoracic (lower third of stellate ganglia to T3) or lumbar (L2-L4) sympathectomy; patients were followed from 24 to 108 months after surgery; patients with unsuccessful surgical outcomes had significantly longer duration of symptoms before surgery (median, 36 months) than those with successful outcomes (median, 16 months); all seven patients (100%) who had sympathectomy within 12 months of injury, nine of 13 patients (69.2%) who had sympathectomy within 24 months of injury, and only four of nine patients (44.4%) who had sympathectomy after 24 months of injury obtained permanent (greater than 24 months) symptom relief; patient age, sex, occupation, site of injury, type of injury, presence of trophic changes, and duration of follow-up were not significantly related (P>0.05) to surgical outcome).

But once again, that article has to be seen against the backdrop of the time in which it was written. See, e.g., "Sympathectomy for reflex sympathetic dystrophy: factors affecting outcome," AbuRahma AF, Robinson PA, Powell M, Bastug D, Boland JP, Annals Vasc. Surg. 1994 Jul; 8(4): 372-9 (study included 12-year experience with chemical sympathetic blocks and surgical sympathectomies for causalgic pain of reflex sympathetic dystrophy (RSD) with emphasis on factors affecting clinical outcome; medical records of patients undergoing sympathectomies for causalgic pain were analyzed; patients were classified according to Drucker et al. as stage I, II, or III; results of chemical and surgical sympathectomies were analyzed using both univariate and multivariate methods; 21 patients had lumbar and seven had cervicodorsal sympathectomies for RSD; mean duration between initial injury and chemical sympathetic block was 10 months with a mean of 11.4 months to surgical sympathectomy; patients with stage II presentations were significantly more likely to have satisfactory early (92%) and late (79%) outcomes than stage III patients; patients with an excellent response to chemical sympathetic block were more likely to have satisfactory early and late surgical outcomes; multivariate analyses demonstrated that the most important independent factor in determining early and late satisfactory outcomes of sympathectomy was the time between injury and sympathectomy).

But by the time you get to his 2000 editorial in The New England Journal of Medicine, any reference in his writings to sympathectomies appears to have ended. Yet in much of the rest of the medical world, they were still the rage. Indeed, here's a discussion I downloaded today from the site maintained by the UCLA Dept. of Neurosurgery, in which they have the following (and quaint) discussion of the treatment of "causalgia":

How is causalgia diagnosed?

The initial step in diagnosis is a thorough history and physical examination. Physical examination is difficult to perform secondary to pain. The diagnostic procedure of choice is proof of complete or partial relief with a sympathetic block.

How is causalgia treated?

Medical therapy is usually ineffective.

Sympathetic block: 18-25% of patients have satisfactory long-lasting relief after a series of sympathetic blocks. Temporary regional blockade can be achieved by local anesthetic (e.g. lidocaine) injection of the stellate ganglion, the lumbar ganglia, or the celiac plexus. These procedures lead to sympathetic denervation of the head, neck and upper extremity, the lower extremity, and the abdominal region, respectively.

Surgical sympathectomy: Relieves pain in >90% of patients. Techniques used include anterior thoracic, thoracic endoscopy, percutaneous radiofrequency and supraclavicular. Sympathectomy has been reported to provide complete relief in over 80% and significant relief in 95% of patients with causalgia. Similar results have been obtained with reflex sympathetic dystrophy. The risk of significant complication is approximately 5%. These include a pneumothorax, intercostal neuralgia, spinal cord injury, and Horner's syndrome. [http://neurosurgery.ucla.edu/Diagnos...PainDis_1.html]

Vic's next assertion is that Dr. Schwartzman is on record as telling patients that ketamine works virtually 100% of the time. I was his patient and he certainly never told me that. In fact, in the CNN story, it says that ketamine works in approximately 50% of the cases. Who really takes issue with that? See, also, "Tackling depression with ketamine," NewScientist.com 20 January 2007 [free text available at http://www.lca-uk.org/lcaforum/viewt...7005e9e459b17]

Schwartzman's methods are not for the faint-hearted. He gives RSD sufferers doses of ketamine high enough to put them in a coma for five days, accompanied by anti-anxiety medications to reduce the nightmare of the k-hole. But for many, the results are worth it. In 14 cases out of 41, according to Schwartzman, patients were completely cured. "We haven't cured the original injury," he says, "but we have cured the RSD or kept it in remission. The RSD pain is gone."

"No one ever cured it before," he adds. "In 40 years, I have never seen anything like it. These are people who were disabled and in horrible pain. Most were completely incapacitated. They go back to work, back to school, and are doing everything they used to do. Most are on no medications at all. I have taken morphine pumps out of people. You turn off the pain and reset the whole system."

“In 40 years, I have never seen anything like it."

Vic also suggests, with respect to the principle study on the use of ketamine, to which I had previously made reference - "Subanesthetic Ketamine Infusion Therapy: A Retrospective Analysis of a Novel Therapeutic Approach to Complex Regional Pain Syndrome," Correll GE, Maleki J, Gracely EJ, Muir JJ and Harbut RE, Pain Medicine 2004; 5:263-275 (in patients who underwent a second course of ketamine infusion, results indicated that 58% of the patients had relief for at least 1 year and that almost a third of the patients remained pain free beyond 3 years) - as follows:

. . . I read the study Mike wrote about, and I noticed that patients who had RSD less than six months had the really long periods of remission. Amazingly long.

Those patients who had been diagnosed more than three years previous showed more ambiguous results: mainly because someone forgot to do follow-ups on them.

This assertion is simply not borne out by a close reading of the study. (Also available on the RSDSA Medical Articles Archive page.) If you look at Table 1 on pp. 266-67 of the study, of the 8 out of 33 subjects for which there was an incomplete follow up, only 2 of those 8 had a CRPS history of greater than 8 months! What the study said, at pp. 270-271, is as follows:

In five patients the condition was fairly acute and of less than 1 month in duration. Nevertheless, it did appear to the physicians evaluating these patients that they indeed had early CRPS, as opposed to acute posttraumatic nociceptive pain. The patients were offered this alternative treatment and they recovered. We recognize that, in those five, patients the CRPS symptoms might have improved spontaneously.

It is impressive to note that the treatment has the potential of eliminating even the pain of those patients who have been suffering from the condition for several years, and not just more recently developed cases. In the case of Patient 25, CRPS was present for more than 20 years until it was completely suppressed with the ketamine infusion. This also points out the dynamic nature of the pain processing system and its long-lasting responsiveness to what appears to be neuromodulation therapy.

Finally, it should be borne in mind that the man has by no means reached the limit of his endurance with his work on ketamine, but remains in the forefront of work looking at the immunological aspects of this disease. See, e.g., "Changes in Cerebrospinal Fluid Levels of Pro-inflammatory Cytokines in CRPS," Alexander GM, van Rijn MA, van Hilten JJ, Perreault MJ, Schwartzman RJ, Pain 2005;116: 213-219, also available on the RSDSA Medical Articles Archive page.

I know I've covered a lot of ground and I appreciate the reader's patience. I've just tried, as best I could, to disabuse anyone of a notion that a guy who has probably done more - over the course of his long career - for the good of RSD patients than any other living individual is somehow a fraud and a huckster. And with that, I am done.

Mike