Friday, February 25, 2011

Stop! Step away from that nerve... Hands in the air!

Hullo out there.  It's time to pass on more information from newly published research on CRPS/RSD (Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy).  If you want to learn more about the disorder, I just found a pretty good summary written for nurses that you can access HERE

I am gonna have to call on the expertise of my degrees in French literature, once again, because I have "issues" with this first article.  We all know that advanced degrees in foreign languages trump any and all medical training, IF and WHEN the wielder of said degrees has suffered with CRPS longer than a week (in the Northern Hemisphere, at least).

In short, and I am known for my brevity, there's a definite penchant for endoscopic thoracic sympathectomy going on... However, it is generally accepted that most sympathectomy is really just a crap shoot, given the high likelihood that pain/disability will recur, and often with a vengeance.

My understanding about this particular procedure (amplified by my ability to correctly intersperse the passé composé with the imparfait) has been that it is most effective as a treatment for hyperhidrosis (and blushing!) and is not some sort of global pain remedy.  In general, interventions/surgeries/procedures all risk aggravating CRPS and the wisdom of the ages says to try and avoid them.  Yes, this is the same person who will be trying to get into a subanesthetic ketamine treatment program next week... Obviously, endoscopic thoracic sympathectomy can be a useful small surgery, but as I said -- for a very limited type of problem. 

Because CRPS is so challenging to treat and so resistant to extant therapies, there is sometimes a surge in promotion of procedures that really have questionable use.  Again, please apply the caveat of my expertise -- derived solely from having the disease and researching it with an avid eye for anything that seems to help AND which can also mount a logical scientific explanation of its utility.

A major red flag?  The size of the cohort.  Basically, in Tête de Hergé Land, if you cannot cobble together enough people to host a baseball game, don't count on securing my approval based on what can only be called anecdotes.

Sigh.  I was gonna cover a few more articles but my eyes are not working too well and my limbs are at war with one another.  Also, that fish is not going to cook itself and it smells suspiciously like my red beans might be overdone.  Raw fish and burnt beans.  Yum.

So I will see you later, friends.  Just try not to cut any sympathetic nerves unnecessarily, would you?

European Journal of Trauma and Emergency Surgery

Endoscopic thoracic sympathectomy for posttraumatic complex regional pain syndrome *
K. Demey, S. Nijs, W. Coosemans, H. Decaluwé, G. Decker, P. De Leyn, D. Van Raemdonck, A. Sermon, P. Broos and T. Lerut, et al
21 February 2011

Posttraumatic complex regional pain syndrome (CRPS) has a strongly negative impact on rehabilitation and activities of daily living. Treatment is most often unrewarding.
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.
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%.
ETS is effective at decreasing pain and improving quality of life, and should therefore be considered in the treatment of CRPS.

*This paper was presented at the 10th Belgian Surgical Week, 29 April–2 May 2009, Ostend, Belgium, and at the 10th European Congress of Trauma and Emergency Surgery, 13–17 May 2009, Antalya, Turkey.

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