Reflex sympathetic dystrophy

1. Characterized by persistent, severe pain; pain has a burning quality and frequently radiates beyond the territory of the injured nerve; skin in area of pain is very sensitive to touch (hyperesthesia)
2. Area involved will typically undergo trophic changes with the skin becoming moist and warm or cool and eventually shiny and smooth; atrophy and osteoporosis of the bone may also occur
3. Stages of RSD
   1. I – acute onset of pain; beginning of bone mineralization
   2. II – begins a month after the injury; dystrophic stage; decrease in steady burning pain but increase in allodynia (painless stimuli perceived as painful)
4. Pain thought to be maintained by sympathetic system since sympathectomy usually resolves their pain
5. Treatment:
   1. temporary regional sympathetic block of the stellate ganglion, lumbar ganglia or celiac plexus
   2. upper thoracic ganglionectomy – resection of the second thoracic ganglion results in nearly complete sympathetic denervation of the upper extremity and is considered a satisfactory sympatholyis for the treatment of hyperhydrosis and causalgia
      1. may be resected through a dorsal approach; removal of transverse process of T3 with the medial portion of the third rib giving adequate access to the T2 ganglion; rami communicantes are divided and the ganglion removed
   3. splanchnicectomy – used for treatment of pancreatic disease and visceral pain; T9-12 ganglia are resected
   4. lumbar sympathectomy – used for lower extremity pain; can be treated by abolishing the first and second lumbar root ganglia
6. outcome: sympathectomy provides relief in 80-95% of people