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European Journal of Trauma and Emergency Surgery

, Volume 37, Issue 6, pp 597–604 | Cite as

Endoscopic thoracic sympathectomy for posttraumatic complex regional pain syndrome

  • K. DemeyEmail author
  • S. Nijs
  • W. Coosemans
  • H. Decaluwé
  • G. Decker
  • P. De Leyn
  • D. Van Raemdonck
  • A. Sermon
  • P. Broos
  • T. Lerut
  • P. Nafteux
Original Article

Abstract

Introduction

Posttraumatic complex regional pain syndrome (CRPS) has a strongly negative impact on rehabilitation and activities of daily living. Treatment is most often unrewarding.

Aim

To analyze the efficacy of endoscopic thoracic sympathectomy (ETS) in reducing pain and disability associated with CRPS prospectively.

Patient and methods

Over a 5-year period, 12 patients (7 females and 5 males; median age 46.5 [range 34–60 years]) with posttraumatic CRPS underwent unilateral ETS. The median duration of CRPS symptoms before ETS was 3.8 months (range 1.2–19.9). The sympathetic chain was resected from the 2nd to the 5th rib, and the nerve of Kuntz was severed. Median postoperative 16 months (range 12–40). Pain was assessed, at rest (passive) and during movement (active), using a visual analogue scale (VAS) from 0 to 10.

Results

One patient (8%) suffered a hydrothorax and 3 patients (25%) complained of contralateral compensatory hyperhydrosis. At 1 month (n = 12), 2 months (n = 7), 6 months (n = 12), and 1 year (n = 12) after ETS, there was a significant decrease in passive and active VAS (P < 0.05). Ten out of the 12 patients (83%) needed fewer analgesics after surgery, and eight (67%) did not need analgesics at all. The median sleep duration improved significantly from a preoperative value of 2 h (range 1–7) to a postoperative value of 6.25 h (range 3.5–8) (P < 0.001). Overall, patient satisfaction was 83%.

Conclusion

ETS is effective at decreasing pain and improving quality of life, and should therefore be considered in the treatment of CRPS.

Keywords

Complex regional pain syndrome Reflex sympathetic dystrophy Sudeck’s dystrophy Endoscopic thoracic sympathectomy 

Notes

Acknowledgments

The authors wish to thank Johnny Moons for the statistical analysis and technical support.

Conflict of interest

The authors state that there is no ethical problem or conflict of interest.

References

  1. 1.
    Mitchell SW. Injuries of the nerves and their consequences. Lippincott, Philadelphia, 1872.Google Scholar
  2. 2.
    Singh B, Moodley J, Shaik AS, Robbs JV. Sympathectomy for complex regional pain syndrome. J Vasc Surg. 2003;37:508–11.PubMedCrossRefGoogle Scholar
  3. 3.
    Bandyk DF, Johnson BL, Kirkpatrick AF, Novotney ML, Back MR, Schmacht DC. Surgical sympathectomy for reflex sympathetic dystrophy syndromes. J Vasc Surg. 2002;35:269–77.PubMedCrossRefGoogle Scholar
  4. 4.
    Albazaz R, Wong YT, Homer-Vanniasinkam S. Complex regional pain syndrome: a review. Ann Vasc Surg. 2008;22:297–306.PubMedCrossRefGoogle Scholar
  5. 5.
    Sudeck P. Über die acute (reflektorische) Knochenartropahie nach Entzündungen und Verletzungen in den Extremitäten und ihre klinischen Erscheinungen. Fortschr Röntgenstr. 1901;5:227–93.Google Scholar
  6. 6.
    de Mos M, de Bruijn AG, Huygen FJ, Dieleman JP, Stricker BH, Sturkenboom MC. The incidence of complex regional pain syndrome: a population-based study. Pain. 2007;129:12–20.PubMedCrossRefGoogle Scholar
  7. 7.
    de Mos M, Sturkenboom MC, Huygen FJ. Current understandings on complex regional pain syndrome. Pain Pract. 2009;9:86–99.PubMedCrossRefGoogle Scholar
  8. 8.
    Sandroni P, Benrud-Larson LM, McClelland RL, Low PA. Complex regional pain syndrome type I: incidence and prevalence in Olmsted county, a population-based study. Pain. 2003;103:199–207.PubMedCrossRefGoogle Scholar
  9. 9.
    Merkskey H, Bogduk N. Classification of chronic pain: description of chronic pain syndromes and definitions of pain terms, 2nd edn. Seattle: IASP Press, 1994.Google Scholar
  10. 10.
    Bruehl S, Harden RN, Galer BS, Saltz S, Backonja M, Stanton-Hicks M. Complex regional pain syndrome: are there distinct subtypes and sequential stages of the syndrome? Pain. 2002;95:119–24.PubMedCrossRefGoogle Scholar
  11. 11.
    Veldman PH, Reynen HM, Arntz IE, Goris RJ. Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet. 1993;342:1012–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Birklein F. Complex regional pain syndrome. J Neurol. 2005;252:131–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Galer BS, Henderson J, Perander J, Jensen MP. Course of symptoms and quality of life measurement in complex regional pain syndrome: a pilot survey. J Pain Symptom Manag. 2000;20:286–92.CrossRefGoogle Scholar
  14. 14.
    Cepeda, Carr DB, Lau J. Local anesthetic sympathetic blockade for complex regional pain syndrome. Cochrane Database Syst Rev. 2005;19:CD004598.Google Scholar
  15. 15.
    Raja SN, Grabow TS. Complex regional pain syndrome I (reflex sympathetic dystrophy). Anesthesiology. 2002;96:1254–60.PubMedCrossRefGoogle Scholar
  16. 16.
    Schott GD. Interrupting the sympathetic outflow in causalgia and reflex sympathetic dystrophy. BMJ. 1998;316:792–3.PubMedCrossRefGoogle Scholar
  17. 17.
    Johnson JP, Obasi C, Hahn MS, Glatleider P. Endoscopic thoracic sympathectomy. J Neurosurg. 1999;91:90–7.PubMedGoogle Scholar
  18. 18.
    Rizzo M, Balderson SS, Harpole DH, Levin LS. Thoracoscopic sympathectomy in the management of vasomotor disturbances and complex regional pain syndrome of the hand. Orthopedics. 2004;27:49–52.PubMedGoogle Scholar
  19. 19.
    Claes G. Indications for endoscopic thoracic sympathectomy. Clin Auton Res. 2003;13(suppl 1):I16–9.PubMedGoogle Scholar
  20. 20.
    Bonjer HJ, Hamming JF, du Bois NAJJ, van Urk H. Advantages of limited thoracoscopic sympathectomy. Surg Endosc. 1996;10:721–3.PubMedGoogle Scholar
  21. 21.
    Hashmonai M, Kopelman D, Schein M. Thoracoscopic versus open supraclavicular upper dorsal sympathectomy: a prospective randomised trial. Eur J Surg Suppl. 1994;572:13–6.PubMedGoogle Scholar
  22. 22.
    Bosco Vieira DJ, Kux P, Duarte DF. Endoscopic thoracic sympathicotomy for the treatment of complex regional pain syndrome. Clin Auton Res. 2003;13(suppl 1):I58–62.Google Scholar
  23. 23.
    Rocco G. Endoscopic VATS sympathectomy: the uniportal technique. Multimedia Manual Cardiothorac Surg. 2004. doi: 10.1510/MMCTS.2004.000323.
  24. 24.
    Chung IH, Oh CS, Koh KS, Kim HJ, Paik HC, Lee DY. Anatomic variations of the T2 nerve root (including the nerve of Kuntz) and their implications for sympathectomy. J Thorac Cardiovasc Surg. 2002;123:498–501.PubMedCrossRefGoogle Scholar
  25. 25.
    Marhold F, Izay B, Zacherl J, Tschabitscher M, Neumayer C. Thoracoscopic and anatomic landmarks of Kuntz’s nerve: implications for sympathetic surgery. Ann Thorac Surg. 2008;86:1653–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Ramsaroop L, Partab P, Singh B, Satyapal KS. Thoracic origin of a sympathetic supply to the upper limb: the “nerve of Kuntz” revisited. J Anat. 2001;199:675–82.Google Scholar
  27. 27.
    Singh B, Ramsaroop L, Partab P, Moodley J, Satyapal KS. Anatomical variations of the second thoracic ganglion. Surg Radiol Anat. 2005;27:119–22.PubMedCrossRefGoogle Scholar
  28. 28.
    Krasna MJ. Thoracoscopic sympathectomy: a standardized approach to therapy for hyperhidrosis. Ann Thorac Surg. 2008;85:S764–7.PubMedCrossRefGoogle Scholar
  29. 29.
    AbuRahma AF, Robinson PA, Powell M, Bastug D, Boland JP. Sympathectomy for reflex sympathetic dystrophy: factors affecting outcome. Ann Vasc Surg. 1994;8:372–9.PubMedCrossRefGoogle Scholar
  30. 30.
    Ahn SS, Ro KM. Thoracoscopic sympathectomy. Ann Vasc Surg. 1998;12:509–14.PubMedCrossRefGoogle Scholar
  31. 31.
    Pather N, Singh B, Partab P, Ramsaroop L, Satyapal KS. The anatomical rationale for an upper limb sympathetic blockade: preliminary report. Surg Radiol Anat. 2004;26:178–81.PubMedCrossRefGoogle Scholar
  32. 32.
    Geertzen JH, Dijkstra PU, Groothoff JW, ten Duis HJ, Eisma WH. Reflex sympathetic dystrophy of the upper extremity—a 5.5-year follow-up. Part II. Social life events, general health and changes in occupation. Acta Orthop Scand Suppl. 1998;279:19–23.Google Scholar
  33. 33.
    Stanton-Hicks MD, Burton AW, Bruehl SP, Carr DB, Harden RN, Hassenbusch SJ, Lubenow TR, Oakley JC, Racz GB, Raj PP, Rauck RL, Rezai AR. An updated interdisciplinary clinical pathway for CRPS: report of an expert panel. Pain Pract. 2002;2:1–16.PubMedCrossRefGoogle Scholar

Copyright information

© Urban & Vogel 2011

Authors and Affiliations

  • K. Demey
    • 1
    Email author
  • S. Nijs
    • 3
  • W. Coosemans
    • 2
  • H. Decaluwé
    • 2
  • G. Decker
    • 2
  • P. De Leyn
    • 2
  • D. Van Raemdonck
    • 2
  • A. Sermon
    • 3
  • P. Broos
    • 3
  • T. Lerut
    • 2
  • P. Nafteux
    • 2
  1. 1.Department of General SurgeryUniversity Hospitals LeuvenLeuvenBelgium
  2. 2.Department of Thoracic SurgeryUniversity Hospitals LeuvenLeuvenBelgium
  3. 3.Department of TraumatologyUniversity Hospitals LeuvenLeuvenBelgium

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