Reflex Sympathetic Dystrophy (Current Management of Pain Book 7)

The diagnosis of cancer inspires fear, in part because of the high mortality rate associated with most malignancies, and in part because of the perception that cancer is a painful disease. Recently compiled statistics tend to support patients'fears. Pain is a major symptom in 70% of patients with advanced cancer [1]. Half of all patients undergoing anticancer therapy experience pain [2]. It has been estimated by members of the World Health Organization that 3. 5 million people worldwide suffer from cancer pain. One study of the severity of cancer pain estimates that pain is moderate to severe in 50% of cancer pain patients, very severe or excruciating in 30% [3]. An analysis of several reports of patients in developed countries estimates that 50-80% of patients had inadequate relief [2]. In underdeveloped countries, adequacy of treatment may be far lower because of lack of availability of medical facilities and legal constraints on the use of potent narcotics. The picture need not be this bleak. The reality is that, for most patients, cancer pain is relatively easy to control with simple, inexpensive measures. Several studies have indicated that cancer pain can be well controlled with oral morphine in over 90% of patients [4,5]. Long-acting orally effective opiate preparations such as time­ release morphine, methadone, and levorphanol allow patients to sleep comfortably through the night. When the oral route is impossible, narcotics can be administered rectally or by intravenous or subcutaneous infusion. Painful disorders following injury ofperipheral nerves; bones and othersoft tissueshaveoccurredfrom theearliesttimesofhuman existence. Ambroise ParewascalledupontotreatthepersistentpainexperiencedbyKing Charles IXwhich wascausedbyalancetwound. Thepainwaspersistent, diffuseand associatedwithcontractureofmuscles. Thekingcouldneitherflexnorextend hisarmforamonth untilthepainfmally disappeared WeirMitchell, G.R. Moorehouse, andW. W. Keeneproducedamonumental treatisein 1864titled"GunshotWoundsandOtherInjuriesofNerves, "which containedan account ofsymptoms and signs ofperipheral nerve injuries as observed in Unionist Soldiers. After 1864, however, little mention ofthis condition wasmade during peacetimeuntil a spateofarticlesappearedagain afterWorldWarOneandTwo. With the formation ofsocieties such as International Association for the Study of Pain, renewed interest has been shown in understanding the mechanismsandmanagementofpainsyndromes. Paincausedbysympathetic disordershasalwayscaughtthefancyofclinicians, andyetconfusionexistsas tothe etiologyandpropertreatmentofreflexsympathetic dystrophy. Many new names have been proposed for these syndromes; recent ones include sympatheticallyornonsympatheticallymaintained pain. Taxonomy ofThe International Association for the Study ofPain lists causalgia and reflex sympathetic syndromes as two distinct entities. All clinicians seem to feel that pain relieved by a diagnostic sympathetic block should be labeled as causalgia or reflex sympathetic dystrophy. Similarly, numerous therapeuticmodalitieshavebeenproposed. Theyallcenteraround sympathetic denervation of some sort, pharmacologically, chemically, or surgically. Inspiteofagreatadvanceinourunderstandingofpainmechanism in the last quarter century, we are no closer to improving the outcome of patientswithsevere reflexsympatheticdystrophy. Etiologyand incidenceis xvi Serieseditorforeword still unclear. Diagnosis is made late and treatment is not standardized Clinicians whotreatcausalgiaandreflexsympatheticdystrophyhavedifferent treatmentsbasedupon their background and experience, ratherthan on the mechanism ofthesyndrome itself. ThetimeisopportunenowtogathersomeunbiasedthoughtsonRSDand clem- the air. Our editors, in particular Michael Stanton-Hicks, needto be congratulatedfor organizing a timely symposium onthesubject and inviting international expertsto discuss the pathophysiology and treatmentofRSD. Whatfollowsinthismonograph isaclear, concisepresentationanddiscussion ofnomenclature, etiology, incidence, mechanism, treatment, and outcome of RSD Front Matter....Pages i-xviii Front Matter....Pages xix-xix Reflex Sympathetic Dystrophy: Clinical Features....Pages 1-8 Reflex Sympathetic Dystrophy: Incidence and Epidemiology....Pages 9-15 Chronic Pain Mechanisms....Pages 17-24 Sympathetically Maintained Pain Principles of Diagnosis and Therapy....Pages 25-28 Psychosomatic Aspects of Reflex Sympathetic Dystrophy....Pages 29-36 Back Matter....Pages 37-38 Front Matter....Pages 39-39 Pathobiology of Reflex Sympathetic Dystrophy: Some General Considerations....Pages 41-54 Spinal Hyperexcitability in Sympathetically Maintained Pain....Pages 55-60 Neuropharmacological Aspects of Reflex Sympathetic Dystrophy....Pages 61-69 Clinical and Neurophysiological Observations Relating to Pathophysiological Mechanisms in Reflex Sympathetic Dystrophy....Pages 71-80 Mechanisms and Role of Peripheral Blood Flow Dysregulation in Pain Sensation and Edema in Reflex Sympathetic Dystrophy....Pages 81-95 Back Matter....Pages 97-98 Front Matter....Pages 99-99 Sympathetic Nerve Blocks: Their role in sympathetic pain....Pages 101-112 Intravenous Regional Sympathetic Blocks....Pages 113-124 Reflex Sympathetic Dystrophy-Neurosurgical Approaches....Pages 125-134 Peripheral Nerve Stimulator Implant for Treatment of RSD....Pages 135-141 Psychologic Support of the Patient with Reflex Sympathetic Dystrophy....Pages 143-150 Reflex Sympathetic Dystrophy Non-Invasive Methods of Treatment....Pages 151-164 Multi-disciplinary Management of Reflex Sympathetic Dystrophy....Pages 165-172 Back Matter....Pages 173-173 Front Matter....Pages 175-175 Three-Phase Bone Scanning in Reflex Sympathetic Dystrophy....Pages 177-185 An Investigation of the Role of Clonidine in the Treatment of Reflex Sympathetic Dystrophy....Pages 187-196 Back Matter....Pages 197-197 Back Matter....Pages 199-210 One of the most exciting developments in medicine in this century has been the discovery of opioid receptors and their pharmacology. The breadth of know- edge derived from such discovery has truly changed the practice of medicine today. The acceptance by the clinicians of the research data obtained by the basic scientist on spinal opioids is truly amazing. The clinical sequelae of the discovery of opioid receptors has been the development of the technique of intraspinal administration of opioids. In the last decade much has been written about indications, effects, and side effects of intraspinal opioids. The technique has become commonplace for cancer and postoperative pain. However, no standards of care and management of patients with spinally administered opioids have been developed. We need these standards to be developed and universally followed. The monograph was conceived to update clinicians on the applied pharma­ cology of spinal opioids. We were fortunate to have Drs. N. Rawal and D. Coombs agree to edit this monograph. They have been able to assemble world-renowned experts as contributing authors. It is our hope that the con­ tents of this book will be stimulating, informative, and useful to the reader. PREFACE Much has been written about the subject of spinal opioid analgesia, includ­ ing several notable reviews. We were stimulated to assemble this particular volume in this important series on pain management initiated by Dr. Raj for a number of reasons. The pain center/clinic is in the stage of transition. It has come a long way since chronic pain was a nonexistent entity and patients with difficult pain problems did not receive well-deserved attention or were lost in the busy practices of vari­ ous specialty clinics. Thirty-five years ahead of the rest of us, John]. Bonica was the first physician who had a clear vision of a pain center's potential. Twenty years later, in response to loud public demands for relief of chronic pain, this idea was put into practice by a number of others on a somewhat larger scale. A team of specialists from various disciplines, trained in the management of chronic pain, now offer approaches ranging from simple outpatient care to inpatient hospital­ ization for comprehensive care including drug detoxification, behavior modi­ fication, and total rehabilitation of these patients. Hospitals have entered this arena with renewed enthusiasm. The pain center/clinic is now an established, ac­ cepted, and expanding method of providing care for chronic pain patients. The chapters in this book are based on examples of multidisciplinary projects that deal comprehensively with management of chronic pain. Aimed primarily at the pain center/clinic in the university hospital setting, this book ranges from his­ torical perspectives to current pain centers with their less orthodox methods of re­ lieving chronic pain to the future of algology as a specialty. Chronic and persistent pain, which is a problem for the individual who suffers and the society that has to deal with it, has become increasingly appreciated. Over the last three decades, several books and journals have been specifically devoted to the topic of pain, especially chronic and persistent pain. It has been increasingly recognized that chronic and persistent pain, unlike acute pain, involves significant psychosocial factors and requires treatment strategies that deal with these issues. All measurements and factors that affect improvement seem to be in the psychosocial area rather than the medical/ biological/physical areas. Psychosocial conveys the importance of the environmental and interpersonal factors of the patient's functioning. The writing of this book has brought together some of the leading researchers and clinicians in the area of managing the patient with chronic pain. The authors express their opinions based on experience and review of the literature available to date. Each of the chapters focuses on an important element of the assessment and/or treatment intervention utilized for the individual with chronic pain. The concluding chapter summarizes the status of the assessment and treatment strategies for those patients. COMMENTSFUTURE PERSPECTIVES: EXPERIMENTAL NEUROBIOLOGICAL RESEARCH IN REFLEX SYMPATHETIC DYSTROPHY AND ITS INTERACTION WITH CLINICAL RESEARCH; PROPOSED DEFINITION OF REFLEX SYMPATHETIC DYSTROPHY Edited By Michael Stanton-hicks. Includes Bibliographical References And Index.