Reflex sympathetic dystrophy (RSD)

is a difficult and often frustrating problem which is poorly understood and lacks a precise objective definition. Briefly described, it is a painful condition which most often develops following trauma. The expected immediate physical response to a painful injury appears to be exaggerated and prolonged in patients with RSD. Local effects of the sympathetic nervous system (variably affecting circulation, bone density, sweating and soft tissue thickness) produce a variety of clinical presentations, which may range from subtle to grotesque. Recovery is unpredictable and may span years or be incomplete. Reflex sympathetic dystrophy may be staged using variety of systems:

RSD Category

I Immediate - beginning within first 48 hours of event

II Early - beginning 1 to 12 weeks from the initial event

III Late - after 3 months, or with late trophic changes

Betcher's Classification

1. Pain, Edema, Vasomotor changes

2. 1 + Pain aggravated by motion

3. 2+ Trophic changes

Prognosis is best for patients who have had early diagnosis and treatment, and who have shown definite progress early on in their treatment course. In some cases, treatment is recommended on a presumptive basis, so as to avoid missing the window of opportunity for cure. The process may be quite disabling, and the overall outcome is worse in patients who deal with their problem in a passive mode. Permanent disability may occur in the form of stiffness, joint contractures, disuse patterns of use, and chronic pain syndrome. Treatment options include therapy, medications, sympathetic block techniques, and care of local problems which are suspected of providing a local persistently painful triggering focus of disease. The mainstay of treatments is nonsurgical and ongoing RSD may be a contraindication to surgery itself.

If surgery is required on an extremity with either a prior or ongoing problem with RSD, the following steps may help prevent the surgery from worsening the effects of RSD:

Before surgery:

* Preauthorize and schedule postoperative therapy.

* Preoperative demonstration that stress loading and desensitization techniques are able to be performed by the patient.

* Consent to proceed with postoperative stellate blocks if needed.

* Stop smoking.

During surgery:

* Treat all painful or nerve - related problems.

* Use systemic soluble and long acting corticosteroids.

* Use brachial plexus or stellate block anesthesia.