Reflex sympathetic dystrophysyndrome (RSDS) is a clinical syndrome characterized by severe pain with autonomic dysfunction in the extremities following trauma. The nature of the pain is burning and unbearable. Autonomic disturbances include pain hypersensitivity to touch, sweating or dryness of the skin, hot and cold skin due to vasodilatory and motor disturbances, and later muscle atrophy and osteoporosis. The lesions progress slowly, and the course of the disease often exceeds the expected healing time. The effect of various treatments is often poor for a long period of time, which makes the patient prone to anxiety and depression. We admitted 19 patients with RSD of the accumulated distal limb from 1985 to 2012 and tried various treatments, which are now reported as follows.
1. Clinical data.
1.1 General data: 19 cases in this group, all with a history of surgery or trauma, 12 males and 7 females. Age 18-56 years old, average 31.3 years old; injury site, ankle 4 cases, calf 7 cases, hand 3 cases, forearm 5 cases; injury mechanism crush injury 8 cases, fall injury 2 cases, car accident injury 3 cases, cutting injury 6 cases. 17 cases of 19 cases were treated conservatively, 2 cases were treated surgically. The shortest time between injury and diagnosis of RSD was 19 days, and the longest was 1 year, including 2 cases of early misdiagnosis.
1.2 Diagnostic basis: The diagnosis was mainly based on clinical manifestations and signs, according to the six diagnostic criteria proposed by Genant et al.
① Excessive prolonged pain and tenderness in the limb, which is not consistent with the degree of injury;
② soft tissue swelling, thinning and shiny skin;
(iii) Decreased motor function, which affects the patient’s daily life and movement;
④Nutritional skin changes, hairy skin or muscle atrophy;
⑤ vasomotor instability, increased or decreased skin temperature, excessive sweating or dryness;
⑥Typical X-ray reveals patchy osteoporosis. There are also some patients who have psychological problems such as anxiety or depression because of the symptoms themselves. At least 4 of the above 7 items are diagnostic criteria.
1.3 Treatment.
1.3.1 Oral non-steroidal anti-inflammatory drugs: for patients with severe and prolonged pain. This includes oral ibuprofen extended-release capsules Celecoxib and other commonly used drugs.
1.3.2 Application of neurotrophic drugs: intramuscular injection of Micropôle, one once a day, changed to one once a week after one week of continuous use, and changed to oral mecobalamin capsules for maintenance after one month.
1.3.3 Application of glucocorticoids: high-dose short-course shock therapy with prednisone 60-80 mg/d orally four times, gradually reducing the dose after 2 weeks and stopping it after 3-4 weeks. In some patients, a small dose of prednisone 5-10mg/d is required for long-term application to control symptoms. Especially for those patients who are treated with nerve block but the effect is short-lived.
1.3.4 Topical herbal fumigation: fumigation with Haidongpi soup or external fumigation with blood-vitalizing soup twice a day for 40 minutes each time.
1.3.5 Manipulative massage: slow pushing and moistening with the palm of the hand along the skin in one direction.
1.3.6 Nerve block: local nerve block at the painful point or the affected limb, including 2% lidocaine, trimethoprim suspension, and Micropol. The drug includes 2% lidocaine, trimethoprim suspension, and miconazole. The treatment should be given once every 2-5 days according to the condition, and 3 times a course.
1.3.7 Physiotherapy: Heat therapy, acupuncture, transcutaneous electrical nerve stimulation, etc. in the physiotherapy department.
1.3.8 Surgical treatment: including surgical investigation of the nerve or its branch damage, repair of the outer membrane of the nerve, or sympathetic ganglion block, etc.
1.3.9 Psychological treatment: patients with psychological problems such as anxiety or depression were given psychological comfort to help them build up confidence that they could be cured, while anti-anxiety drugs (such as Valium and Doxepin) were given depending on the symptoms.
1.4 Results.
1.4.1 Observation indexes.
①Change in pain level;
②The degree of self-care of life;
③The degree of need for oral analgesic drugs;
④Psychological health degree. The effect grouping after treatment: complete control: the pain disappeared or was significantly reduced, did not affect sleep at all, life was completely self-care, did not take analgesic drugs, optimism; partial control: the pain was reduced, basically did not affect sleep, still had a certain impact on the quality of life, no longer need to use or occasionally use analgesic drugs, psychological health; treatment failure: various symptoms did not ease, or further aggravated, seriously affected Quality of life, the need for long-term use of analgesic drugs, psychological depression aggravated, the patient is extremely painful or even suicide relief.
1.4.2 In this group of 19 patients, after active comprehensive treatment and several years of follow-up, 9 cases were completely controlled, 8 cases were partially controlled, and 2 cases were ineffective. One case, a 44-year-old female, died by suicide after one year of poor treatment for the onset of the disease in the lower extremities.
2. Discussion.
RSDS is a syndrome of severe pain in the limbs with autonomic dysfunction, and the disease commonly occurs after traumatic factors such as fractures, skin breaks, ligament injuries and surgery. Trauma is therefore often the main cause of the disease, with a very low incidence. This disease is very easy to be missed and misdiagnosed, so we should be ideologically alert to this disease, and its diagnosis mainly relies on the history of trauma and clinical symptoms and signs. For example, the six diagnostic criteria proposed by Genant et al. However, in practice, clinicians often do not pay enough attention to the disease or do not know enough about the disease leading to misdiagnosis and mistreatment of the disease, which affects the whole process of diagnosis and treatment of the disease. The disease is neglected due to clinical rarity and misdiagnosed due to lack of awareness, which can easily lead to “turning a blind eye” to the disease in clinical work. In addition, the slow development of the disease, the length of the disease varies, and the patients are mostly scattered in outpatient clinics, which makes the diagnosis and treatment of the disease more difficult. In our treatment cases, there have been cases of suicide due to the disease, which is regrettable.
The pathogenesis of the disease is not fully understood. It is generally believed that RSDS is an excessive response of the limb to the injury, and there are various theories, for which there are various treatment modalities, mainly conservative treatment and occasionally surgery, but there is no special treatment, so we will not go into the details here. However, it is worth paying attention to the fact that although RSDS is not an incurable disease, it has a greater impact on the quality of life and psychology of patients, because there is no special treatment, the course of treatment is long, coupled with the delay in clinical diagnosis and the long duration of pain, patients often have psychological disorders. Therefore, the patient’s confidence in healing is a factor that cannot be ignored, and should be detected early in clinical work for early diagnosis and early treatment to help patients establish confidence in overcoming the disease and adhere to treatment. In conclusion, we medical personnel in the diagnosis and treatment of RSDS need to constantly pay attention to, practice, summarize, and improve ourselves, to reduce misdiagnosis and mistreatment as much as possible. We strive for early diagnosis and treatment, combining Chinese and Western medicine, conservative and surgery, and perfecting the physiological-psychological-social treatment model to reduce the pain caused by RSDS for patients as much as possible.