Clinical Rheumatology

, Volume 25, Issue 5, pp 687–693

Treatment of complex regional pain syndrome type I of the hand with a series of intravenous regional sympathetic blocks with guanethidine and lidocaine

  • Kosmas I. Paraskevas
  • Alexandra A. Michaloglou
  • Despina D. Briana
  • Maria Samara
Original Article

Abstract

The aim of this study was to evaluate the efficacy of guanethidine and lidocaine in the treatment of complex regional pain syndrome (CRPS) type I of the hand. Seventeen patients, aged between 33 and 72 years, suffering from CRPS type I of the hand received two series of intravenous regional sympathetic block (Bier's block) sessions with guanethidine and lidocaine according to the following therapeutic protocol: (1) 5 sessions (once every second day) composed of intravenous regional administration of 15 mg guanethidine and 1 mg lidocaine/kg body weight each and (2) 20 sessions (twice a week) composed of intravenous regional administration of 10 mg guanethidine and 1 mg lidocaine/kg body weight each. Complete disappearance of pain and return of the normal function and movement of the extremity were achieved. No side effects were observed. The above-described therapeutic protocol method resulted in excellent pain relief and full restoration of both function and range of movement of the affected extremity in 17 patients suffering from CRPS type I of the hand.

Keywords

Allodynia Bier's block Complex regional pain syndrome type I Hyperalgesia Intravenous regional guanethidine administration 

References

  1. 1.
    Doury P (1988) Algodystrophy. Reflex sympathetic dystrophy syndrome. Clin Rheumatol 7:173–180CrossRefPubMedGoogle Scholar
  2. 2.
    Kozin F (1994) Reflex sympathetic dystrophy syndrome. Curr Opin Rheumatol 6:210–216PubMedCrossRefGoogle Scholar
  3. 3.
    Veldman PH, Reynen HM, Arntz IE, Goris RJ (1993) Signs and symptoms of reflex sympathetic dystrophy: prospective study of 829 patients. Lancet 342:1012–1016CrossRefPubMedGoogle Scholar
  4. 4.
    Merskey H, Bogduk N (1994) Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms, 2nd edn. IASP, Seattle, pp 40–43Google Scholar
  5. 5.
    Teasell RW, Potter P, Moulin D (1994) Reflex sympathetic dystrophy involving three limbs: a case study. Arch Phys Med Rehabil 75:1008–1010PubMedGoogle Scholar
  6. 6.
    Schiffenbauer J, Fagien M (1993) Reflex sympathetic dystrophy involving multiple extremities. J Rheumatol 1993; 20:165–169PubMedGoogle Scholar
  7. 7.
    Price DD, Bush FM, Long S, Harkins SW (1994) A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales. Pain 56:217–226CrossRefPubMedGoogle Scholar
  8. 8.
    Bier A (1908) Über einen neuen Weg Lokalanesthesie an der Gliedmassen zu erzeugen. Arch Klin Chir 96:1007–1016Google Scholar
  9. 9.
    Stanton-Hicks M, Baron R, Boas R, Gordh T, Harden N, Hendler N, Koltzenburg M, Raj P, Wilder R (1998) Complex regional pain syndromes: guidelines for therapy. Clin J Pain 14:155–166CrossRefPubMedGoogle Scholar
  10. 10.
    Soucacos PN, Diznitsas LA, Beris AE, Xenakis TA, Malizos KN (1997) Reflex sympathetic dystrophy of the upper extremity. Clinical features and response to multimodal management. Hand Clin 13:339–354PubMedGoogle Scholar
  11. 11.
    Oerlemans HM, Oostendorp RA, de Boo T, Goris RJ (1999) Pain and reduced mobility in complex regional pain syndrome I: outcome of a prospective randomised controlled clinical trial of adjuvant physical therapy versus occupational therapy. Pain 83:77–83CrossRefPubMedGoogle Scholar
  12. 12.
    Oerlemans HM, Oostendorp RA, de Boo T, van der Laan L, Severens JL, Goris JA (2000) Adjuvant physical therapy versus occupational therapy in patients with reflex sympathetic dystrophy/complex regional pain syndrome type I. Arch Phys Med Rehabil 81:49–56CrossRefPubMedGoogle Scholar
  13. 13.
    Bounameaux HM, Hellemans H, Verhaeghe R (1984) Ketanserin in chronic sympathetic dystrophy. An acute controlled trial. Clin Rheumatol 3:556–557CrossRefPubMedGoogle Scholar
  14. 14.
    Hanna MH, Peat SJ (1989) Ketanserin in reflex sympathetic dystrophy. A double-blind placebo controlled cross-over trial. Pain 38:145–150CrossRefPubMedGoogle Scholar
  15. 15.
    Kettler RE, Abram SE (1988) Intravenous regional droperidol in the management of reflex sympathetic dystrophy: a double-blind, placebo-controlled, crossover study. Anesthesiology 69:933–936PubMedCrossRefGoogle Scholar
  16. 16.
    Verdugo RJ, Ochoa JL (1994) Sympathetically maintained pain. I. Phentolamine block questions the concept. Neurology 44:1003–1010PubMedGoogle Scholar
  17. 17.
    Schurmann M, Gradl G, Wizgal I, Tutic M, Moser C, Azad S, Beyer A (2001) Clinical and physiologic evaluation of stellate ganglion blockade for complex regional pain syndrome type I. Clin J Pain 17:94–100CrossRefPubMedGoogle Scholar
  18. 18.
    Rauck RL, Eisenach JC, Jackson K, Young LD, Southern J (1993) Epidural clonidine treatment for refractory reflex sympathetic dystrophy. Anesthesiology 79:1163–1169PubMedCrossRefGoogle Scholar
  19. 19.
    Reuben SS, Sklar J (2002) Intravenous regional anesthesia with clonidine in the management of complex regional pain syndrome of the knee. J Clin Anesth 14:87–91CrossRefPubMedGoogle Scholar
  20. 20.
    AbuRahma AF, Robinson PA, Powell M, Bastug D, Boland JP (1994) Sympathectomy for reflex sympathetic dystrophy: factors affecting outcome. Ann Vasc Surg 8:372–379CrossRefPubMedGoogle Scholar
  21. 21.
    Olcott C 4th, Eltherington LG, Wilcosky BR, Shoor PM, Zimmerman JJ, Fogarty TJ (1991) Reflex sympathetic dystrophy—the surgeon's role in management. J Vasc Surg 14:488–492CrossRefPubMedGoogle Scholar
  22. 22.
    Bandyk DF, Johnson BL, Kirkpatrick AF, Novotney ML, Back MR, Schmacht DC (2002) Surgical sympathectomy for reflex sympathetic dystrophy syndromes. J Vasc Surg 35:269–277CrossRefPubMedGoogle Scholar
  23. 23.
    Adami S, Fossaluzza V, Gatti D, Fracassi E, Braga V (1997) Biphosphonate therapy on reflex sympathetic dystrophy syndrome. Ann Rheum Dis 56:201–204PubMedCrossRefGoogle Scholar
  24. 24.
    Manicourt DH, Brasseur JP, Boutsen Y, Depreseux G, Devogelaer JP (2004) Role of alendronate in therapy for posttraumatic complex regional pain syndrome type I of the lower extremity. Arthritis Rheum 50:3690–3697CrossRefPubMedGoogle Scholar
  25. 25.
    Varenna M, Zucchi F, Ghiringelli D, Binelli L, Bevilacqua M, Bettica P, Sinigaglia L (2000) Intravenous clodronate in the treatment of reflex sympathetic dystrophy syndrome. A randomized, double blind, placebo controlled study. J Rheumatol 27:1477–1483PubMedGoogle Scholar
  26. 26.
    Cortet B, Flipo RM, Coquerelle P, Duquesnoy B, Delcambre B (1997) Treatment of severe, recalcitrant reflex sympathetic dystrophy: assessment of efficacy and safety of the second generation bisphosphonate pamidronate. Clin Rheumatol 16:51–56CrossRefPubMedGoogle Scholar
  27. 27.
    Robinson JN, Sandom J, Chapman PT (2004) Efficacy of pamidronate in complex regional pain syndrome type I. Pain Med 5:276–280CrossRefPubMedGoogle Scholar
  28. 28.
    Kubalek I, Fain O, Paries J, Kettaneh A, Thomas M (2001) Treatment of reflex sympathetic dystrophy with pamidronate: 29 cases. Rheumatology (Oxford) 40:1394–1397CrossRefGoogle Scholar
  29. 29.
    Gobelet C, Waldburger M, Meier JL (1992) The effect of adding calcitonin to physical treatment on reflex sympathetic dystrophy. Pain 48:171–175CrossRefPubMedGoogle Scholar
  30. 30.
    Hamamci N, Dursun N, Ural C, Cakci A (1996) Calcitonin treatment in reflex sympathetic dystrophy: a preliminary study. Br J Clin Pract 50:373–375PubMedGoogle Scholar
  31. 31.
    Bickerstaff DR, Kanis JA (1991) The use of nasal calcitonin in the treatment of post-traumatic algodystrophy. Br J Rheumatol 30:291–294PubMedCrossRefGoogle Scholar
  32. 32.
    Christensen K, Jensen EM, Noer I (1982) The reflex dystrophy syndrome response to treatment with systemic corticosteroids. Acta Chir Scand 148:653–655PubMedGoogle Scholar
  33. 33.
    Tountas AA, Noguchi A (1991) Treatment of posttraumatic reflex sympathetic dystrophy syndrome (RSDS) with intravenous blocks of a mixture of corticosteroid and lidocaine: a retrospective review of 17 consecutive cases. J Orthop Trauma 5:412–419PubMedCrossRefGoogle Scholar
  34. 34.
    Papadopoulos GS, Xenakis TA, Arnaoutoglou E, Tefa L, Kitsoulis PB (2001) The treatment of reflex sympathetic dystrophy in a 9-year-old boy with long standing symptoms. Minerva Anestesiol 67:659–663PubMedGoogle Scholar
  35. 35.
    Zyluk A (1998) Results of the treatment of posttraumatic reflex sympathetic dystrophy of the upper extremity with regional intravenous blocks of methylprednisolone and lidocaine. Acta Orthop Belg 64:452–456PubMedGoogle Scholar
  36. 36.
    Korpan MI, Dezu Y, Schneider B, Leitha T, Fialka-Moser V (1999) Acupuncture in the treatment of posttraumatic pain syndrome. Acta Orthop Belg 65:197–201PubMedGoogle Scholar
  37. 37.
    Fialka V, Resch KL, Ritter-Dietrich D, Alacamlioglu Y, Chen O, Leitha T, Kluger R, Ernst E (1993) Acupuncture for reflex sympathetic dystrophy. Arch Intern Med 153:661–665CrossRefPubMedGoogle Scholar
  38. 38.
    Wu WH, Bandilla E, Ciccone DS, Yang J, Cheng SC, Carner N, Wu Y, Shen R (1999) Effects of qigong on late-stage complex regional pain syndrome. Altern Ther Health Med 5:45–54PubMedGoogle Scholar
  39. 39.
    Price DD, Long S, Wilsey B, Rafii A (1998) Analysis of peak magnitude and duration of analgesia produced by local anesthetics injected into sympathetic ganglia of complex regional pain syndrome patients. Clin J Pain 14:216–226CrossRefPubMedGoogle Scholar
  40. 40.
    Arias LM, Bartkowski R, Grossman KL, Schwartzman RJ, Tom CM (1989) Sufentanil stellate ganglion injection in the treatment of refractory reflex sympathetic dystrophy. Reg Anesth 14:90–92PubMedGoogle Scholar
  41. 41.
    Lin TC, Wong CS, Chen FC, Lin SY, Ho ST (1998) Long-term epidural ketamine, morphine and bupivacaine attenuate reflex sympathetic dystrophy neuralgia. Can J Anaesth 45:175–177PubMedGoogle Scholar
  42. 42.
    Kumar K, Nath RK, Toth C (1997) Spinal cord stimulation is effective in the management of reflex sympathetic dystrophy. Neurosurgery 40:503–508CrossRefPubMedGoogle Scholar
  43. 43.
    Forouzanfar T, Kemler MA, Weber WE, Kessels AG, van Kleef M (2004) Spinal cord stimulation in complex regional pain syndrome: cervical and lumbar devices are comparably effective. Br J Anaesth 92:348–353CrossRefPubMedGoogle Scholar
  44. 44.
    Kemler MA, De Vet HC, Barendse GA, Van Den Wildenberg FA, Van Kleef M (2004) The effect of spinal cord stimulation in patients with chronic reflex sympathetic dystrophy: two years' follow-up of the randomized controlled trial. Ann Neurol 55:13–18CrossRefPubMedGoogle Scholar
  45. 45.
    Kemler MA, Barendse GA, van Kleef M, Egbrink MG (2000) Pain relief in complex regional pain syndrome due to spinal cord stimulation does not depend on vasodilation. Anesthesiology 92:1653–1660CrossRefPubMedGoogle Scholar
  46. 46.
    Kemler MA, Barendse GA, Van Kleef M, Van Den Wildenberg FA, Weber WE (1999) Electrical spinal cord stimulation in reflex sympathetic dystrophy: retrospective analysis of 23 patients. J Neurosurg Spine 90:79–83CrossRefGoogle Scholar
  47. 47.
    Robaina FJ, Dominguez M, Diaz M, Rodriguez JL, de Vera JA (1989) Spinal cord stimulation for relief of chronic pain in vasospastic disorders of the upper limbs. Neurosurgery 24:63–67PubMedCrossRefGoogle Scholar
  48. 48.
    Barolat G, Schwartzman R, Woo R (1989) Epidural spinal cord stimulation in the management of reflex sympathetic dystrophy. Stereotact Funct Neurosurg 53:29–39PubMedCrossRefGoogle Scholar
  49. 49.
    Kemler MA, Reulen JP, Barendse GA, van Kleef M, de Vet HC, van den Wildenberg FA (2001) Impact of spinal cord stimulation on sensory characteristics in complex regional pain syndrome type I: a randomized trial. Anesthesiology 95:72–80CrossRefPubMedGoogle Scholar
  50. 50.
    Wallace MS, Ridgeway BM, Lebung AY, Gerayli A, Yaksh TL (2000) Concentration-effect relationship of intravenous lidocaine on the allodynia of complex regional pain syndrome types I and II. Anesthesiology 92:75–83CrossRefPubMedGoogle Scholar
  51. 51.
    Hord AH, Rooks MD, Stephens BO, Rogers HG, Fleming LL (1992) Intravenous regional bretylium and lidocaine for treatment of reflex sympathetic dystrophy: a randomized, double-blind study. Anesth Analg 74:818–821PubMedCrossRefGoogle Scholar
  52. 52.
    Linchitz RM, Raheb JC (1999) Subcutaneous infusion of lidocaine provides effective pain relief for CRPS patients. Clin J Pain 15:67–72CrossRefPubMedGoogle Scholar
  53. 53.
    van de Vusse AC, Stomp-van den Berg SG, Kessels AH, Weber WE (2004) Randomised controlled trial of gabapentin in complex regional pain syndrome type 1 [ISRCTN84121379]. BMC Neurol 4:13CrossRefPubMedGoogle Scholar
  54. 54.
    Mellick GA, Mellick LB (1997) Reflex sympathetic dystrophy treated with gabapentin. Arch Phys Med Rehabil 78:98–105CrossRefPubMedGoogle Scholar
  55. 55.
    Birklein F, Claus D, Riedl B, Neundorfer B, Handwerker HO (1997) Effects of cutaneous histamine application in patients with sympathetic reflex dystrophy. Muscle Nerve 20:1389–1395CrossRefPubMedGoogle Scholar
  56. 56.
    Muizelaar JP, Kleyer M, Hertogs IA, DeLange DC (1997) Complex regional pain syndrome (reflex sympathetic dystrophy and causalgia): management with the calcium channel blocker nifedipine and/or the alpha-sympathetic blocker phenoxybenzamine in 59 patients. Clin Neurol Neurosurg 99:26–30CrossRefPubMedGoogle Scholar
  57. 57.
    Becker WJ, Ablett DP, Harris CJ, Dold ON (1995) Long term treatment of intractable reflex sympathetic dystrophy with intrathecal morphine. Can J Neurol Sci 22:153–159PubMedGoogle Scholar
  58. 58.
    Zuniga RE, Perera S, Abram SE (2002) Intrathecal baclofen: a useful agent in the treatment of well-established complex regional pain syndrome. Reg Anesth Pain Med 27:90–93CrossRefPubMedGoogle Scholar
  59. 59.
    Lundborg C, Dahm P, Nitescu P, Appelgren L, Curelaru I (1999) Clinical experience using intrathecal (IT) bupivacaine infusion in three patients with complex regional pain syndrome type I (CRPS-I). Acta Anaesthesiol Scand 43:667–678CrossRefPubMedGoogle Scholar
  60. 60.
    Farah BA (1993) Ketorolac in reflex sympathetic dystrophy. Clin Neuropharmacol 16:88–89PubMedCrossRefGoogle Scholar
  61. 61.
    King JH, Nuss S (1993) Reflex sympathetic dystrophy treated by electroconvulsive therapy: intractable pain, depression, and bilateral electrode ECT. Pain 55:393–396CrossRefPubMedGoogle Scholar
  62. 62.
    Karakurum G, Pirbudak L, Oner U, Gulec A, Karadasli H, Satana T (2003) Sympathetic blockade and amitriptyline in the treatment of reflex sympathetic dystrophy. Int J Clin Pract 57:585–587PubMedGoogle Scholar
  63. 63.
    Gintautas J, Housny W, Kraynack BJ (1999) Successful treatment of reflex sympathetic dystrophy by bier block with lidocaine and clonidine. Proc West Pharmacol Soc 42:101PubMedGoogle Scholar
  64. 64.
    Cheshire WP, Snyder CR (1990) Treatment of reflex sympathetic dystrophy with topical capsaicin. Case report. Pain 42:307–311CrossRefPubMedGoogle Scholar
  65. 65.
    Hannington-Kiff JG (1974) Intravenous regional sympathetic block with guanethidine. Lancet 1:1019–1020CrossRefPubMedGoogle Scholar
  66. 66.
    Glynn CJ, Basedow RW, Walsh JA (1981) Pain relief following post-ganglionic sympathetic blockade with i.v. guanethidine. Br J Anaesth 53:1297–1302PubMedGoogle Scholar
  67. 67.
    Benelli S, Conoscente F, Movilia PG, Restelli L, Francucci B, Grossi E (1983) Regional intravenous guanethidine vs. stellate ganglion block in reflex sympathetic dystrophies: a randomized trial. Pain 16:297–307CrossRefPubMedGoogle Scholar
  68. 68.
    Field J, Atkins RM (1993) Effect of guanethidine on the natural history of post-traumatic algodystrophy. Ann Rheum Dis 52:467–469PubMedCrossRefGoogle Scholar
  69. 69.
    Field J, Monk C, Atkins RM (1993) Objective improvements in algodystrophy following regional intravenous guanethidine. J Hand Surg [Br] 18:339–342CrossRefGoogle Scholar
  70. 70.
    Vijayan R, Low KH (1993) Pain relief with intravenous regional guanethidine in post-traumatic reflex sympathetic dystrophy—a case report. Med J Malaysia 48:236–239PubMedGoogle Scholar
  71. 71.
    Verre M, De Santis F, Glyronakis S, Grande AM, Renzi A, Santangelo E, Tortorella V, Varano M (2002) Pharmacological sympathetic block in complex regional pain syndrome. Clin Ter 153:367–372PubMedGoogle Scholar
  72. 72.
    Bonezzi C, Miotti D, Bettaglio R, Stephen R (1994) Electromotive administration of guanethidine for treatment of reflex sympathetic dystrophy: a pilot study in eight patients. J Pain Symptom Manage 9:39–43CrossRefPubMedGoogle Scholar
  73. 73.
    Nielsen FB, Olesen AS (1992) Guanethidine blockade for palliative treatment in reflex dystrophy. Ugeskr Laeger 154:1500–1502PubMedGoogle Scholar
  74. 74.
    Jeandel P, Prigent D, Gilette B, Imbert P, Angel G, Aubert M (1989) Treatment of reflex algoneurodystrophies by sympathetic blockade with guanethidine. Ann Med Interne (Paris) 140:166–168Google Scholar
  75. 75.
    Eulry F, Lechevalier D, Pats B, Alliaume C, Crozes P, Vasseur P, Coutant G, Felten D, Pattin S (1991) Regional intravenous guanethidine blocks in algodystrophy. Clin Rheumatol 10:377–383CrossRefPubMedGoogle Scholar
  76. 76.
    Jacquemoud G, Chamay A (1982) Treatment of algodystrophy using intravenous guanethidine regional block. Ann Chir Main 1:57–64CrossRefPubMedGoogle Scholar
  77. 77.
    Jadad AR, Carroll D, Glynn CJ, McQuay HJ (1995) Intravenous regional sympathetic blockade for pain relief in reflex sympathetic dystrophy: a systematic review and a randomized double-blind crossover study. J Pain Symptom Manage 10:13–20CrossRefPubMedGoogle Scholar
  78. 78.
    Rocco AG, Kaul AF, Reisman RM, Gallo JP, Lief PA (1989) A comparison of regional intravenous guanethidine and reserpine in reflex sympathetic dystrophy. A controlled, randomized, double-blind cross-over study. Clin J Pain 5:205–209PubMedCrossRefGoogle Scholar
  79. 79.
    Blanchard J, Ramamurthy S, Walsh N, Hoffman J, Schoenfeld L (1990) Intravenous regional sympatholysis: a double-blind comparison of guanethidine, reserpine and normal saline. J Pain Symptom Manage 5:357–361CrossRefPubMedGoogle Scholar
  80. 80.
    Kaplan R, Claudio M, Kepes E, Gu XF (1996) Intravenous guanethidine in patients with reflex sympathetic dystrophy. Acta Anaesthesiol Scand 40:1216–1222PubMedGoogle Scholar
  81. 81.
    Geertzen JHB, deBruijn H, deBruijn-Kofman AT, Arendzen JH (1994) Reflex sympathetic dystrophy: early treatment and psychological aspects. Arch Phys Med Rehabil 75:442–446CrossRefPubMedGoogle Scholar
  82. 82.
    Livingstone JA, Atkins RM (2002) Intravenous regional guanethidine blockade in the treatment of post-traumatic complex regional pain syndrome type 1 (algodystrophy) of the hand. J Bone Joint Surg Br 84:380–386CrossRefPubMedGoogle Scholar
  83. 83.
    Ramamurthy S, Hoffman J (1995) Intravenous regional guanethidine in the treatment of reflex sympathetic dystrophy/causalgia: a randomized, double-blind study. Guanethidine Study Group. Anesth Analg 81:718–723CrossRefPubMedGoogle Scholar

Copyright information

© Clinical Rheumatology 2005

Authors and Affiliations

  • Kosmas I. Paraskevas
    • 1
    • 4
  • Alexandra A. Michaloglou
    • 2
  • Despina D. Briana
    • 3
  • Maria Samara
    • 2
  1. 1.Department of Vascular SurgeryAthens University Medical SchoolAthensGreece
  2. 2.Department of AnesthesiologyGeneral Prefecture Hospital of LarissaLarissaGreece
  3. 3.Athens University Medical SchoolAthensGreece
  4. 4. AthensGreece

Personalised recommendations