Georg Gradl

Assessment of peripheral sympathetic nervous function for diagnosing early post-traumatic complex regional pain syndrome type I

Clinical diagnosis of complex regional pain syndrome type I (CRPS I) in post-traumatic patients is often delayed since the clinical appearance of this disease resembles normal post-traumatic states to a certain extent (pain, edema, loss of function). The purpose of this study was to assess the incidence of specific clinical features in CRPS I patients and normal post-traumatic patients and to evaluate the diagnostic value of a bedside test that measures the sympathetic nervous function. Fifty patients with post-traumatic CRPS I of the upper limb and 50 patients 8 weeks after distal radius fracture with an undisturbed course of disease were subjected to a detailed clinical examination. Pain was assessed using the VAS (visual analog scale), skin temperature measured with an infrared camera and grip-strength with a pneumatic manometer. In CRPS I patients, motor disturbances defined as an impaired active range of motion of the hand, were most frequent (96%, fracture patients: 40%), followed by edema (88%, fracture patients: 80%) and spontaneous pain (VAS 4.0 +/- 2.3, fracture patients: VAS 1.3 +/- 0.6). Systematic temperature differences (>1 degree C) between the affected and unaffected limbs were seen in only 42% of CRPS I patients and in 34% of the fracture patients. Further sensory, sudomotor or trophic changes of the hands were rare. As expected, there were significant differences in the quantity of edema, motor disturbances and sensory disturbances between CRPS I patients and normal fracture patients. However, normal fracture patients still suffered from several of the evaluated symptoms 8 weeks after trauma, which makes an early clinical diagnosis of the complication more difficult. Using a newly developed bedside test, the peripheral sympathetic nervous function was assessed in both groups of patients and in 50 age-matched healthy controls. The decrease in skin blood flow following sympathetic provocation maneuvers, detected by laser Doppler flowmetry, was quantified as sympathetic reactivity. In the affected hands of CRPS I patients, as well as in the contralateral hands, the sympathetic reactivity was obliterated or diminished in contrast to the age-matched controls and normal fracture patients. A multivariate analysis did not reveal any correlation between sympathetic function and the severity of any clinical symptom. Sympathetic reactivity seems to be an independent variable in CRPS I and the test presented may facilitate the difficult clinical diagnosis of this disease.

Imaging in early posttraumatic complex regional pain syndrome. A comparison of diagnostic methods

ObjectivesThe complex regional pain syndrome type I (CRPS I) still is difficult to diagnose in posttraumatic patients. As CRPS I is a clinical diagnosis the characteristic symptoms have to be differentiated from normal posttraumatic states. Several diagnostic procedures are applied to facilitate an early diagnosis, although their value for diagnosing posttraumatic CRPS I is unclear. MethodsOne hundred fifty-eight consecutive patients with distal radial fracture were followed up for 16 weeks after trauma. To assess the diagnostic value of the commonly applied methods a detailed clinical examination was carried out 2, 8, and 16 weeks after trauma in conjunction with bilateral thermography, plain radiographs of the hand skeleton, three phase bone scans (TPBSs), and contrast-enhanced magnetic resonance imaging (MRI). All imaging procedures were assessed blinded. ResultsAt the end of the observation period 18 patients (11%) were clinically identified as having CRPS I and 13 patients (8%) revealed an incomplete clinical picture which were defined as CRPS borderline cases. The sensitivity of all diagnostic procedures used was poor and decreased between the first and the last examinations (thermography: 45% to 29%; TPBS: 19% to 14%; MRI: 43% to 13%; bilateral radiographs: 36%). In contrast a high specificity was observed in the TPBS and MRI at the eighth and sixteenth-week examinations (TPBS: 96%, 100%; MRI: 78%, 98%) and for bilateral radiographs 8 weeks after trauma (94%). The thermography presented a fair specificity that improved from the second to the sixteenth week (50% to 89%). DiscussionThe poor sensitivity of all tested procedures combined with a reasonable specificity produced a low positive predictive value (17% to 60%) and a moderate negative predictive value (79% to 86%). These results suggest, that those procedures cannot be used as screening tests. Imaging methods are not able to reliably differentiate between normal posttraumatic changes and changes due to CRPS I. Clinical findings remain the gold standard for the diagnosis of CRPS I and the procedures described above may serve as additional tools to establish the diagnosis in doubtful cases.

Clinical and physiologic evaluation of stellate ganglion blockade for complex regional pain syndrome type I

Objective: The efficacy of peripheral sympathetic interruption after stellate ganglion blockade was assessed by a sympathetic function test. Results were compared with clinical signs such as temperature changes, pain reduction, and the development of Horner syndrome to evaluate the correlation with clinical investigations. Design: Stellate ganglion blockade with local anesthetics was carried out via an anterior paratracheal approach in 33 patients suffering from complex regional pain syndrome type I. Patients were examined before and after the procedure. For assessment of sympathetic nervous function, the vasoconstrictor response to sympathetic stimuli was assessed using laser Doppler flowmetry. Clinical parameters like surface temperature changes (thermography), pain relief (visual analogue scale), and Horner syndrome were monitored. Results: Twenty-three (70%) of 33 patients developed an increase in temperature difference between the treated hand and the contralateral hand of more than 1.5°C after the procedure, which is a clinical sign of sympathicolysis. In 48% (n = 11) of these patients, the sympathetic function test showed an undisturbed sympathetic nervous function. In 10 patients, no significant increase in temperature difference was observed. Although these patients presented with a normal sympathetic vasoconstrictor response, 4 felt pain relief of more than 50%, suggesting a placebo effect. Only 7 patients with pain relief revealed both clinical sympathicolysis and extinguished sympathetic nervous function and qualified for sympathetically maintained pain. Conclusions: Clinical investigation is not reliable in the assessment of stellate ganglion blockade. Proof of sympathetically maintained pain based on pain relief after stellate ganglion blockade is not conclusive.

Assessment of the Peripheral Microcirculation Using Computer-Assisted Venous Congestion Plethysmography in Post-Traumatic Complex Regional Pain Syndrome Type I

In complex regional pain syndrome type I (CRPS-I), edema of the affected limb is a common finding. Therefore, the changes in macro- and microcirculatory parameters were investigated to elucidate the underlying pathophysiology. Twenty-four patients with post-traumatic CRPS-I and 25 gender- and age-matched healthy subjects were examined by means of an advanced computer-assisted venous congestion strain-gauge plethysmograph. The recording of the volume response of the forearm to a stepwise inflation of an occlusion cuff placed at the upper arm enabled the calculation of the arterial blood flow into the arm (Q_a), the vascular compliance (C), the peripheral venous pressure (P_v), the isovolumetric venous pressure (P_vi; = hydrostatic pressure needed to achieve net fluid filtration) and the capillary filtration capacity (CFC) – an index of microvascular permeability. The study revealed no difference in any of the parameters between the right and left hand of healthy subjects. In CRPS-I patients, however Q_a, P_v, P_vi and CFC were significantly (p < 0.01/0.001) elevated in the affected arm (Q_a 11.2 ± 7.0 ml min^–1 100 ml^–1, P_v 20.2 ± 8.1 mm Hg, P_vi 24.7 ± 4.2 mm Hg, CFC 0.0058 ± 0.0015 ml min^–1 100 ml^–1 mm Hg^–1) compared to the unaffected arm (Q_a 4.2 ± 2.4 ml min^–1 100 ml^–1, P_v 10.0 ± 5.1 mm Hg, P_vi 13.2 ± 3.7 mm Hg, CFC 0.0038 ± 0.0005 ml min^–1 100 ml^–1 mm Hg^–1) and the values obtained in healthy controls (Q_a 5.1 ± 1.3 ml min^–1 100 ml^–1, P_v 10.4 ± 4.3 mm Hg, P_vi 15.7 ± 3.3 mm Hg, CFC 0.0048 ± 0.0012 ml min^–1 100 ml^–1 mm Hg^–1). Whereas the values in the unaffected arm of CRPS-I patients revealed no difference in Q_a, P_v and P_vi but a lower CFC (p < 0.01) compared to those from healthy controls. These results suggest profound changes in both macro- and microvascular perfusion in the affected arm of CRPS-I patients. The high CFC contributes to the edema formation, and combined with the elevated P_vi, they are in agreement with the hypothesis of an inflammatory origin of CRPS.

Sympathetic dysfunction as a temporary phenomenon in acute posttraumatic CRPS I.

ObjectiveSympathetic testing was carried out in patients in the acute phase of “complex regional pain syndrome type I” (CRPS I) shortly after trauma to the upper limb. Repeated measurements were used to detect changes in peripheral sympathetic function during the course of the disease.Material and methodsIn a busy trauma center, 10 consecutive patients who developed CRPS I following trauma or surgery of the upper limb were diagnosed according to the 1999 modified IASP diagnostic criteria for CRPS I. Clinical signs and symptoms and bilateral hand temperature (infrared thermometry) were recorded. Vasoconstrictor response to sympathetic provocation (inspiratory gasp, contralateral cooling) at the tip of the middle finger of both hands was measured employing laser Doppler flowmetry (LDF). Sympathetic reaction was quantified by the magnitude of blood flow decrease after provocation (SRF parameter).ResultsThe diagnosis CRPS I could be established 63 days (46–72 days) post-injury. The mean follow-up time after diagnosis was 83±15 days. Pain measured by a visual analog scale (VAS 0–10) showed an average of 5.0±2.0 at the time of diagnosis and decreased to 1.7±1.9 at the last examination. Edema and active range of motion improved substantially during the follow-up period. On the ipsilateral hand marked sympathetic dysfunction was seen early after the onset of CRPS I (mean SRF parameter: 0.14±0.01), slowly returning to normal sympathetic reaction three months after the onset of symptoms (mean SRF parameter: 0.42±0.21). Diminished sympathetic function was seen even on the contralateral hand.ConclusionsSympathetic dysfunction is regularly seen at the onset of CRPS I and normalizes during the course of the disease. This temporary phenomenon suggests a posttraumatic sympathetic deficit playing a decisive role in the genesis of CRPS I.

Early Diagnosis in Post-traumatic Complex Regional Pain Syndrome

Since prospective studies confirmed an incidence of >10% of complex regional pain syndrome complication in patients after distal radial fracture, early diagnosis is important. Therapy should be commenced immediately with a systematic approach to avoid chronicity of the disease. Despite this, epidemiological studies revealed an extreme delay in effective treatment among complex regional pain syndrome patients, who were repeatedly referred to different physicians and often treated inadequately before being referred to specialized pain clinics. In post-traumatic patients, the clinical examination still is preferred to establish the diagnosis of complex regional pain syndrome. First, possible differential diagnoses must be excluded. Next the clinical criteria of the consensus definition should be checked and documented, if possible with the help of verifying procedures. Imaging methods could be applied; however, they are not useful for early diagnosis since sensitivity is low and the consequences of trauma may interfere with potential complex regional pain syndrome findings. In questionable cases repeated examinations after short periods detect the presence of complex regional pain syndrome in orthopedic patients, particularly if symptoms are progressive or an expected improvement does not occur.

Metastatic lesions of the humerus treated with the isoelastic diaphysis prosthesis.

Between January 1, 1987, and December 31, 1997, an isoelastic polyacetal resin prosthesis was used in 50 patients with metastatic bone disease to reconstruct pathologic or impending fractures of the humeral diaphysis. Fifty-seven operations were performed, including seven revision surgeries. The patients were assessed before and after surgery for limb function and quality of life using a modified Karnofsky scale. The mean survival time was 440 days. Ninety-one percent of the operations resulted in restoration or improvement of quality of life. Limb function was good or excellent in more than 80% of the patients after surgery. Breaking of the implant (n = 3), loosening of the implant (n = 2), periprosthetic fracture (n = 1), hematoma (n = 2), infection (n = 1), and one radial nerve paralysis were the main complications. In the cases of implant failure, the prosthesis broke at the site of a locking screw that was inserted across the prosthetic shaft in the cementless implantation technique. This kind of complication could be avoided by using bone cement for implantation or additional plate osteosynthesis between the prosthesis and humeral shaft. The isoelastic diaphyseal prosthesis offers a promising method of treating patients with metastatic lesions of the humeral shaft.

Computergestützte Venenverschlußplethysmographie-Untersuchungen zur Pathophysiologie des Posttraumatischen Complex Regional Pain Syndrome Type I (CRPS I) — ist das CRPS I ein ‘local inflammatory response syndrome’

Das ‚Complex Regional Pain Syndrome Typ l ‘(CRPS 1), besser bekannt als M. Sudeck ist eine haufige Komplikation nach Traumen im Bereich der Extremitaten. Klinisch imponiert die Erkrankung u.a. mit autonomen Storungen. Hierzu zahlen ein distal generalisiertes Odem und eine veranderte Durchblutung der betroffenen Extremitat. Die Ursachen hierfur wurden bislang kontrovers diskutiert. Eine bislang nicht uberprufte Hypothese gemas der ein reflektorisch erhohter Venolentonus an einem Ungleichgewicht der Starling Krafte verantwortlich ist und zu einer erhohten peripheren Filtration und Odembildung fuhrt, soll im Rahmen der Studie untersucht werden. Material und Methode: Prospektiv wurde bei 21 posttraumatischen Patienten mit klinisch eindeutigem CRPS und generalisierter Odembildung an der oberen Extremitat eine computergestutzte Venenverschlusplethysmographie durchgefuhrt. Dabei konnten die Mikrozirkulations-parameter Pvi (isovolumetrischer venoser Druck = Kapillardruck), Kf (Filtrationskoeffizient = Gefaspermeabilitat), Qa (arterieller Blutfluss) valide bestimmt werden. Als Kontrollgruppe wurden 20 gesunde Probanden gegenubergestellt. Ergebnisse: In der Gruppe der CRPS I Patienten fand sich ein durchschnittlicher Pvi von 25,1 ± 3,9 mmHg der betroffenen Seite gegenuber 15,9 ± 3,4 mmHg der nicht betroffenen Seite. Dieser Unterschied ist mit p < 0,001 signifikant. Bei gesunden Probanden fand sich ein uber beide Unterarme gemittelter Wert von 18,1 ± 2,4 mmHg (links 18,7, rechts 17,5 mmHg). Die kapillare Permeabilitat Kf war von erkrankter Seite zur Gegenseite signifikant (p < 0,001) erhoht mit 6,02 ± 1,83 (ml*min-1* 100 ml-1mrnHg-1*10-3), zu 3,96 ± 1,03. Bei gesunden Personen fand sich ein gemittelter Wert von 3,94 ± 1,09. Ebenso konnten fur den arteriellen Blutflus deutliche Seitenunterschiede gemessen werden. In der Kontrollgruppe fand sich ein durchschnittlicher Flus von 5,1 ± 1,4 (ml/min/100 ml Gewebe) und ein Spitzenflus von 11,5 ± 4,1. Demgegenuber zeigten die CRPS I Patienten an der betroffenen Extremitat einen durchschnittlichen Flus von 10,2 ± 6,2 und einen Spitzenflus von 19,4 ± 8,5 (kontralateral: durchschnittlich 3,2 ±1,1 und Spitzenflus 8,4 dz 2,8). Die intraindividuellen als auch die interindividuellen Unterschiede waren ebenfalls statistisch signifikant (p<0,01). Zusammenfassungg: Als Ursache fur das generalisierte Odem kann bei im Seitenvergleich deutlich vergroserter Kapillarpermeabilitat nicht eine alleinige Erhohung des postkapillaren Druckes angenommen werden. Hoher arterieller Blutfluss, hoher kapillarer Druck und ein ‘capillary leakage’ spricht eher fur ein im aktuellen Schrifttum haufiger postuliertes lokales Entzundungsgeschehen bei der Pathophysiologie des CRPS.

Clinical and physiologic evaluation of stellate ganglion blockade for complex regional pain syndrome type I. (Ludwig‐Maximilians‐University, Munich, Germany) Clin J Pain. 2001;17:94–100.

Stellate ganglion blockade with local anesthetics was carried out via an anterior paratracheal approach in 33 patients suffering from complex regional pain syndrome type I. Twenty-three (70%) of the 33 patients developed an increased in temperature difference between the treated hand and the contralateral hand of more than 1.5°C after the procedure, which is a clinical sign of sympathicolysis. In 48% of these patients, the sympathetic function test showed an undisturbed sympathetic nervous function. In 10 patients, no significant increase in temperature difference was observed. Only 7 patients with pain relief revealed both clinical sympathicolysis and extinguished sympathetic nerve function and qualified for sympathetically maintained pain. Conclude that clinical investigation is not reliable in the assessment of stellate ganglion blockade. Proof of sympathetically maintained pain based on pain relief after stellate ganglion blockade is not conclusive.