Controversial Pain Syndrome of M. Sudeck (RSD, CRPS I): Pathogenesis and Surgical Treatment of Resistant Cases

Abstract

The author discovered the “second key” to solution of SD (RSD, CPRS I) pathogenesis in 1985, comparing the symptoms of TOS and SD. Both syndromes showed identical pain localisation only differing in VAS values, whereas allodynia only exists in Sudeck’s dystrophy. Thus dystrophies got a functional phlebography of the subclavian vein, as well. Surprisingly, also stenoses of diverse degrees and shapes were found, being classified in six basic categories.

Typical clinical findings show elevated sympathetic activity in these dystrophies, especially the existence of lower plexus root irritation at the intervertebral foramina and the thoracic outlet, radiologically documented by x-rays of the cervical spine and arteriography of the subclavian artery; the latter can be divided into four basic forms.

Thus the author used the surgical method of transaxillary decompression of the nerve-vessel-bundle with upper thoracic sympathectomy, as presented by Roos in 1977, not only in TOS, as proposed originally, but also in resistant dystrophies. The initial series of 10 patients (1984–1991), surgically treated after an average preoperative course of 9 months, showed excellent results in 70 %, good in 20 %, and a fair outcome in 10 %. A second series of 10 patients (2000–2008/2002) only received surgery after an average of 3.5 years. Results: excellent = 40 %, good = 20 %, fair = 10 %, no success = 20 %.

There are diverse causes for the less favourable results in the second series, especially pain medication given only on demand and passive motion therapy, only resulting in additional pain afferences in pre-operative treatment and also in the post-surgical period. A disturbance or even a loss of the pain-inhibitory posterior horn synapsis system (HHSS), as presented in a lecture by Ziegelgensberger W. in 2004, is seen as an additional cause. An increase in strength and frequency of pain afferences, finally resulting in a complete destruction of the interneuron cell core by massive influx of calcium ions, leading to the loss of pain inhibitory function of HHSS, is held responsible.

Indication for surgery is given until 9 months after onset, in order to achieve good results. In severe stenosis surgery should already take place in the second month, as, due to the unfavourable prognosis the patient should be spared from additional pain by conservative therapy.

In Germany, 23 out of 25 surgical procedures were successfully performed since 1984. Since 1994 successful results were also reached in England in 21 out of 27 patients. This technique can nowadays be generally recommended, as the success rate amounts to 84.61 %.