Reflex sympathetic dystrophy—the surgeon's role in management

Abstract

Olcott et al.,1Olcott C.IV Eltherington LG Wilcosky BR Shoor PM Zimmerman JJ Fogarty TJ. Reflex sympathetic dystrophy—the surgeon's role in management.J Vasc Surg. 1991; 14: 488-495Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar describe an extensive surgical experience with a widely varying array of patients with reflex sympathetic dystrophy. They believe that complete removal of the stellate ganglion is essential for complete pain relief in those suffering from reflex sympathetic dystrophy involving the upper extremity. Cervical sympathectomy in 17 patients resulted in postsympathectomy neuralgia in 23%, and resolved spontaneously in all cases. I have had the opportunity to perform video-assisted thoracoscopic sympathectomies on four patients in the past year with complete relief of symptoms in each case. Three patients were in the dystrophic phase, and one patient was in stage three. All had a good response to preoperative sympathetic blockade. Of interest is that I specifically avoided coagulation of the sympathetic ganglion to avoid a Horner's syndrome, which is often disconcerting to the patient. Instead, I coagulated the T2 ganglion and sympathetic chain down to T3, along with the lateral nerve of Kuntz and the post ganglionic gray fibers running laterally from the stellate ganglion to the brachial plexus. This “selective sympathectomy” described by Roos2Roos DB. Sympathectomy for the upper extremities: anatomy, indications, and techniques.in: Vascular surgery. WB Saunders, Philadelphia1977Google Scholar not only prevents Horner's syndrome, but also accounts for the absence of postsympathectomy neuralgia in these patients. Use of the video-assisted endoscopy and coagulator enable the surgical procedure to be performed through two incisions 1 inch in length, and requires a hospitalization that averages 48 hours. This newer simplified procedure may warrant consideration at an earlier stage of the disease process when postsurgical success rates are higher. Prolongation of medical management in conjunction with physical therapy and repetitive sympathetic blockade beyond 3 months may not be serving the patients' best interests. Disability and loss of work for several painful months is the price paid, in the hopes of spontaneous resolution of symptoms. For many patients this does not occur, and their chances for surgical success are also diminished as they slip into progressive stages of the disease process. Now that newer, less invasive surgical approaches are available, it may be time to reconsider the timetable of management of this disease.