Physicians need to be aware of the mechanism of reflex sympathetic dystrophy and to consider it as part of their differential diagnosis when their patients start to complain of peripheral pain.
Reflex sympathetic dystrophy has been termed a “suicide condition” because the pain may be so intense. It is a condition which is usually treatable if diagnosed in the early stages but often becomes untreatable if there is a delay in diagnosis. This can be catastrophic for the patient and may also give rise to a claim of negligence against a physician for failure to diagnose.
The Reflex Sympathetic Dystrophy Condition
Reflex sympathetic dystrophy seems to be an umbrella term for a condition that interferes with the sympathetic nervous system and is often manifested by burning pain. Other terms that appear to be essentially synonymous from a medical-legal view are causalgia, Sudeck’s Atrophy, or simply post traumatic pain syndrome. One of the problems in diagnosing the condition is that its etiology and the mechanism of injury are still not well understood.
Reflex sympathetic dystrophy was first reported during the American Civil War by Dr. Weir Mitchell who reported the syndrome of burning pain in certain incomplete penetrating wounds of the peripheral nerves. …/…
In addition to the disabling burning pain, Dr. Mitchell also described a marked hypersensitivity of the skin causing severe pain response to the slightest pressure and trophic changes in the skin and soft tissue. He called this condition “causalgia” which comes from Greek and means burning pain.
While there are technical distinctions in the various terms that are used to describe the condition, for purposes of this article, we can think of reflex sympathetic dystrophy as a malfunction of the sympathetic nervous system, causing pain in the extremities.
II. Causes of Reflex sympathetic dystrophy
There is confusion about the initiating cause of reflex sympathetic dystrophy, but it seems clear that fractures, sprains, crushing injuries, puncture wounds and even medical treatment can be causes. The result is a painful dystrophic and disabled limb resulting from a reflex pathological disturbance of the autonomic innervation to the limb.
A person with reflex sympathetic dystrophy that has remained untreated and is of long standing is often in a pitiful condition. The pain is excruciating. Sometimes it is continuous and sometimes it comes in paroxysm. It is often unbearable. An individual withdraws in order to protect himself from the stimuli, either physical or emotional, which can set off the pain paroxysm. …/…
A patient who has been suffering from this condition for a long period of time may suffer a permanent personality change. These emotional personality changes often lead to a misdiagnosis of functional overlay or hysteria when in fact we are dealing with an anatomical problem in which the psychiatric or emotional disturbance is secondary. Because the pain is often away from the actual injury (e.g., the tips of the fingers when there is an injury to the arm), there is often a delay in diagnosis.
Reflex Sympathetic Dystrophy & Trauma
Reflex sympathetic dystrophy is usually secondary to trauma. The sympathetic nervous system, which is part of the autonomic nervous system, responds to trauma in an anatomic way. It has been suggested that in some individuals the sympathetic nervous system fails to recognize when the stimulus (response to trauma) has been concluded. The sympathetic nervous system continues in a “reflex” status in which blood vessels dilate which increases the blood flow to the limbs. Blood engorges the area, causing swelling and destruction of cells of blood vessels resulting in pain.” …/…
This pain re-excites the sympathetic nervous system, and the whole malfunctioning system starts to feed upon itself.
The body has a natural defensive mechanism against injury which is supposed to be set in motion when injury occurs and then recede when the injured part is healed. With reflex sympathetic dystrophy the pattern of defense itself becomes disorganized and produces a new and worse affliction than the original injury.
III. Physicians Need to Be Aware
A number of medical theories attempt to explain how something can go wrong in the organization of electronic neurocircuits in the spinal cord and lower brain centers. It is not the purpose of this article to analyze these theories. It is important to recognize that successful treatment relies almost entirely on early diagnosis. It is important to interfere with the sympathetic impulses which are causing the problem. This has been done by using stellate ganglion blocks, or drugs and tranquilizers, and even through surgery. It is clear that, left untreated for a substantial period of time, the condition becomes incurable and an individual can find herself living forever with excruciating pain.
Physicians need to be aware of reflex sympathetic dystrophy and its symptomatology. They should not automatically discount complaints of pain which exceed those expected from a particular injury. A physician should not jump to the conclusion that a patient is malingering or exaggerating. Because the pathology of reflex sympathetic dystrophy violates the physiology of the nervous system, physicians sometimes discount the significance of a complaint and think of it as an emotional overlay. As a result, valuable time is lost before appropriate treatment is begun. …/…
Physicians need to be aware of the symptoms of reflex sympathetic dystrophy. Its existence can usually be confirmed with a sympathetic blockade (an injection of anesthesia into the bundle of nerves from the affected area as they enter the spinal cord).
Where there is a prompt diagnosis, treatment usually results in full recovery. Those who are diagnosed late in the progression of the disease may never be cured and will live a life of pain which is only responsive to a narcotic. (Many of these people have to have implants of morphine pumps).
Because the patient has usually suffered an injury before the onset of reflex sympathetic dystrophy, the patient is usually under a physician’s care before the first symptom is seen. It is not difficult to understand that a patient may feel angry if she has been complaining of pain to the physician and the physician, at least in the patient’s mind, has ignored that complaint until it is too late to treat the condition.
Physicians need to be aware of the mechanism of reflex sympathetic dystrophy and to consider it as part of their differential diagnosis when their patients start to complain of peripheral pain. A failure to do so may give rise to a substantial reduction in the patient’s quality of life and to a significant malpractice action against the physician.