Abstract
For diagnosis of the pain origin in reflex sympathetic dystrophy (RSD), sympathetic blocks, including the intravenous regional guanethidine (IVRG) block after Hannington-Kiff, are recommended. Since the results obtained with this kind of block are sometimes unsatisfactory, modifications were made to increase its technical efficacy.
Patients and methods
Forty-seven RSD patients were investigated. Among the typical triad of RSD symptoms, all patients showed distally generalized oedema of the affected extremity and complained of spontaneous pain. This pain showed an orthostatic component in all but two patients. The modifications of the IVRG-block were: (1) distal (in contrast to proximal) suprasystolic compression of the affected extremity before i.v. injection of guanethidine (GA); (2) reduction of the recommended dose of GA (10–30 mg) to 2.5 mg GA for each block; (3) no additional local anaesthetics, which are recommended for suppression of the typical pain following GA injection, since this pain allows identification of the distribution of the GA (complete? incomplete?) within the symptomatic area; (4) repeated subsequent injection of physiological saline to improve the distribution of GA within the symptomatic area.
Results
Injection of GA and repeated injections of saline (mean: 43 ml, range: 10–95 ml) elicited pain—lessening in intensity with repetition—in the same region as the spontaneous pain of RSD in all but the two patients mentioned above. Following the modified IVRG block, all but these two patients experienced significant pain reduction (Table 1). In total, 87% of all 47 patients under study were acutely (for at least 1 day) pain-free after the block.
Conclusions
The modified IVRG block seems to have a high diagnostic value with respect to the presence of a sympathetic contribution to the pain in RSD. As a reduced GA dose/block is used, this form of the block appears to be safer than other kinds of sympathetic blocks.
Zusammenfassung
Zur Diagnostik der Spontanschmerzen einer sympathischen Reflexdystrophie (SRD) werden generell Sympathikusblokkaden empfohlen, unter anderem die von Hannington-Kiff eingeführte intravenöse regionale Guanethidin-Blockade (IVRG-Blockade). Da mit diesem Verfahren z.T. unbefriedigende Ergebnisse erzielt werden, wurden hierzu methodische Verbesserungen angestrebt. Aufgrund einer Untersuchung von 47 SRD-Patienten können folgende Modifikationen des IVRG-Blocks empfohlen werden: 1. Grundsätzlich distale Stauung der betroffenen Extremität—im Gegensatz zur empfohlenen proximalen Stauung. 2. Dies erlaubt eine Reduktion des i.v. gegebenen Guanethidins (GA) von den empfohlenen 10–30 mg auf 2,5 mg/Block. 3. Verzicht auf die empfohlene Zugabe eines Lokalanästhetikums, da die Lokalisation der typischen GA-Injektionsschmerzen Hinweise auf die erreichte Verteilung (komplett/inkomplett?) des GA gibt. 4. Nach GA-Gabe über den gleichen Zugang wird NaCl 0,9% injiziert, um eine möglichst komplette Verteilung des GA im symptomatischen Gebiet zu erreichen. Insgesamt 87% der untersuchten Patienten waren nach einer so ausgeführten Blockade akut schmerzfrei. Der modifizierte IVRG-Block bietet offenbar eine hohe diagnostische Sicherheit mit Bezug zu einer sympathischen Beteiligung an den Schmerzen der SRD. Darüber hinaus macht die erreichte Dosisreduktion des GA/Block dieses Verfahren nahezu risikolos gegenüber allen anderen Formen der Sympathikolyse.
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Hoffmann, U., Blumberg, H. Modifikationen der Guanethidin-Blockade zur Diagnostik der sympathischen Reflexdystrophie (Morbus Sudeck). Schmerz 8, 95–99 (1994). https://doi.org/10.1007/BF02530414
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DOI: https://doi.org/10.1007/BF02530414