Long-term results of peripheral nerve stimulation for reflex sympathetic dystrophy

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  • 1 Department of Neurosurgery, M.D. Anderson Cancer Center, Houston, Texas; and Pain Management Center, Division of Anesthesiology, and Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio
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✓ This prospective, consecutive series describes peripheral nerve stimulation (PNS) for treatment of severe reflex sympathetic dystrophy (RSD) or complex regional pain syndrome, in patients with symptoms entirely or mainly in the distribution of one major peripheral nerve. Plate-type electrodes were placed surgically on affected nerves and tested for 2 to 4 days. Programmable generators were implanted if 50% or more pain reduction and objective improvement in physical changes were achieved. Patients were followed for 2 to 4 years and a disinterested third-party interviewer performed final patient evaluations. Of 32 patients tested, 30 (94%) underwent permanent PNS placement. Long-term good or fair relief was experienced in 19 (63%) of 30 patients. In successfully treated patients, allodynic and spontaneous pain was reduced on a scale of 10 from 8.3 ± 0.3 preimplantation to 3.5 ± 0.4 (mean ± standard error of the mean) at latest follow up (p < 0.001). Changes in vasomotor tone and patient activity levels were markedly improved but motor weakness and trophic changes showed less improvement. Six (20%) of the 30 patients undergoing PNS placement returned to part-time or full-time work after being unemployed prestimulator implantation. Initial involvement of more than one major peripheral nerve correlated with a poor or no relief rating (p < 0.01). Operative modifications that minimize technical complications are described. This study indicates that PNS can provide good relief for RSD that is limited to the distribution of one major nerve.

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Contributor Notes

Address reprint requests to: Samuel J. Hassenbusch, M.D., Ph.D., Department of Neurosurgery, C9.075, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030.
  • 1.

    Barolat G, , Schwartzman R, & Woo R: Epidural spinal cord stimulation in the management of reflex sympathetic dystrophy. Stereotact Funct Neurosurg 53:2939, 1989 Barolat G, Schwartzman R, Woo R: Epidural spinal cord stimulation in the management of reflex sympathetic dystrophy. Stereotact Funct Neurosurg 53:29–39, 1989

    • Search Google Scholar
    • Export Citation
  • 2.

    Bonica JJ: Causalgia and other reflex sympathetic dystrophies, in Bonica JJ (ed): The Management of Pain, ed 2. Philadelphia: Lea & Febiger, 1990, pp 220243 Bonica JJ: Causalgia and other reflex sympathetic dystrophies, in Bonica JJ (ed): The Management of Pain, ed 2. Philadelphia: Lea & Febiger, 1990, pp 220–243

    • Search Google Scholar
    • Export Citation
  • 3.

    Bossi L, , Conoscente F, & Pellerin I, et al: Algodystrophy: treatment. Funct Neurol 4:157160, 1977 Bossi L, Conoscente F, Pellerin I, et al: Algodystrophy: treatment. Funct Neurol 4:157–160, 1977

    • Search Google Scholar
    • Export Citation
  • 4.

    Broggi G, , Servello D, & Franzini A, et al: Spinal cord stimulation for treatment of peripheral vascular disease. Appl Neurophysiol 50:439441, 1987 Broggi G, Servello D, Franzini A, et al: Spinal cord stimulation for treatment of peripheral vascular disease. Appl Neurophysiol 50:439–441, 1987

    • Search Google Scholar
    • Export Citation
  • 5.

    Campbell JN, & Long DM: Peripheral nerve stimulation in the treatment of intractable pain. J Neurosurg 45:692699, 1976 Campbell JN, Long DM: Peripheral nerve stimulation in the treatment of intractable pain. J Neurosurg 45:692–699, 1976

    • Search Google Scholar
    • Export Citation
  • 6.

    Carron H, & Weller RW: Treatment of post-traumatic sympathetic dystrophy. Adv Neurol 4:485490, 1974 Carron H, Weller RW: Treatment of post-traumatic sympathetic dystrophy. Adv Neurol 4:485–490, 1974

    • Search Google Scholar
    • Export Citation
  • 7.

    Charlton JE: Reflex sympathetic dystrophy: non-invasive methods of treatment, in Stanton-Hicks M, , Jänig W, & Boas RA (eds): Reflex Sympathetic Dystrophy. Norwell, MA: Kluwer, 1990, pp 151164 Charlton JE: Reflex sympathetic dystrophy: non-invasive methods of treatment, in Stanton-Hicks M, Jänig W, Boas RA (eds): Reflex Sympathetic Dystrophy. Norwell, MA: Kluwer, 1990, pp 151–164

    • Search Google Scholar
    • Export Citation
  • 8.

    Devor M, , Jänig W, & Michaelis M: Modulation of activity in dorsal root ganglion neurons by sympathetic activation in nerveinjured rats. J Neurophysiol 71:3847, 1994 Devor M, Jänig W, Michaelis M: Modulation of activity in dorsal root ganglion neurons by sympathetic activation in nerveinjured rats. J Neurophysiol 71:38–47, 1994

    • Search Google Scholar
    • Export Citation
  • 9.

    Gracely RH, , Lynch SA, & Bennett GJ: Painful neuropathy: altered central processing maintained dynamically by peripheral input. Pain 51:175194, 1992 Gracely RH, Lynch SA, Bennett GJ: Painful neuropathy: altered central processing maintained dynamically by peripheral input. Pain 51:175–194, 1992

    • Search Google Scholar
    • Export Citation
  • 10.

    Gybels JM, & Sweet WH: Neurosurgical Treatment of Persistent Pain. Basel: Karger, 1989, pp 257281 Gybels JM, Sweet WH: Neurosurgical Treatment of Persistent Pain. Basel: Karger, 1989, pp 257–281

    • Search Google Scholar
    • Export Citation
  • 11.

    Jänig W: Pathobiology of reflex sympathetic dystrophy: some general considerations, in Stanton-Hicks M, , Jänig, W, & Boas RA (eds): Reflex Sympathetic Dystrophy. Norwell, MA: Kluwer, 1990, pp 4154 Jänig W: Pathobiology of reflex sympathetic dystrophy: some general considerations, in Stanton-Hicks M, Jänig, W, Boas RA (eds): Reflex Sympathetic Dystrophy. Norwell, MA: Kluwer, 1990, pp 41–54

    • Search Google Scholar
    • Export Citation
  • 12.

    Jänig W: The sympathetic nervous system in pain: physiology and pathophysiology, in Stanton-Hicks M (ed): Pain and the Sympathetic Nervous System. Norwell, MA: Kluwer, 1990, pp 1789 Jänig W: The sympathetic nervous system in pain: physiology and pathophysiology, in Stanton-Hicks M (ed): Pain and the Sympathetic Nervous System. Norwell, MA: Kluwer, 1990, pp 17–89

    • Search Google Scholar
    • Export Citation
  • 13.

    Jänig W, & McLachlan EM: The role of modifications in noradrenergic peripheral pathways after nerve lesions in the generation of pain, in Fields HL, & Liebeskind JC (eds): Progress in Pain Research and Management. Seattle: I.A.S.P., 1994, pp 101128 Jänig W, McLachlan EM: The role of modifications in noradrenergic peripheral pathways after nerve lesions in the generation of pain, in Fields HL, Liebeskind JC (eds): Progress in Pain Research and Management. Seattle: I.A.S.P., 1994, pp 101–128

    • Search Google Scholar
    • Export Citation
  • 14.

    Kesler RW, , Saulsbury FT, & Miller LT, et al: Reflex sympathetic dystrophy in children: treatment with transcutaneous electric nerve stimulation. Pediatrics 82:728732, 1988 Kesler RW, Saulsbury FT, Miller LT, et al: Reflex sympathetic dystrophy in children: treatment with transcutaneous electric nerve stimulation. Pediatrics 82:728–732, 1988

    • Search Google Scholar
    • Export Citation
  • 15.

    Kleinert HE, , Cole NM, & Wayne L, et al: Post-traumatic sympathetic dystrophy. Orthop Clin North Am 4:917927, 1973 Kleinert HE, Cole NM, Wayne L, et al: Post-traumatic sympathetic dystrophy. Orthop Clin North Am 4:917–927, 1973

    • Search Google Scholar
    • Export Citation
  • 16.

    Law JD, , Swett J, & Kirsch WM: Retrospective analysis of 22 patients with chronic pain treated by peripheral nerve stimulation. J Neurosurg 52:482485, 1980 Law JD, Swett J, Kirsch WM: Retrospective analysis of 22 patients with chronic pain treated by peripheral nerve stimulation. J Neurosurg 52:482–485, 1980

    • Search Google Scholar
    • Export Citation
  • 17.

    Long DM: Stimulation of the peripheral nervous system for pain control. Clin Neurosurg 31:323343, 1984 Long DM: Stimulation of the peripheral nervous system for pain control. Clin Neurosurg 31:323–343, 1984

    • Search Google Scholar
    • Export Citation
  • 18.

    Malcolm J, , Arnold O, & Teasell RW, et al: Increased venous alpha-adrenoceptor responsiveness in patients with reflex sympathetic dystrophy. Ann Intern Med 118:619621, 1993 Malcolm J, Arnold O, Teasell RW, et al: Increased venous alpha-adrenoceptor responsiveness in patients with reflex sympathetic dystrophy. Ann Intern Med 118:619–621, 1993

    • Search Google Scholar
    • Export Citation
  • 19.

    McLachlan EM, , Jänig W, & Devor M, et al: Peripheral nerve injury triggers noradrenergic sprouting within dorsal root ganglia. Nature 363:543546, 1993 McLachlan EM, Jänig W, Devor M, et al: Peripheral nerve injury triggers noradrenergic sprouting within dorsal root ganglia. Nature 363:543–546, 1993

    • Search Google Scholar
    • Export Citation
  • 20.

    Merskey H: Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Pain (Suppl 3):S1S225, 1986 Merskey H: Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. Pain (Suppl 3): S1–S225, 1986

    • Search Google Scholar
    • Export Citation
  • 21.

    Merskey H, & Bogduk N (eds): Classification of Chronic Pain. Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, ed 2. Seattle: I.A.S.P., 1994, pp 4043 Merskey H, Bogduk N (eds): Classification of Chronic Pain. Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms, ed 2. Seattle: I.A.S.P., 1994, pp 40–43

    • Search Google Scholar
    • Export Citation
  • 22.

    Muller A, & Farcot JM: Système nerveux sympathique, douleur et morphine par voie péridural. Agressologie 32:283286, 1991 Muller A, Farcot JM: Système nerveux sympathique, douleur et morphine par voie péridural. Agressologie 32:283–286, 1991

    • Search Google Scholar
    • Export Citation
  • 23.

    North RB, , Kidd DH, & Zahurak M, et al: Spinal cord stimulation for chronic, intractable pain: experience over two decades. Neurosurgery 32:384395, 1993 North RB, Kidd DH, Zahurak M, et al: Spinal cord stimulation for chronic, intractable pain: experience over two decades. Neurosurgery 32:384–395, 1993

    • Search Google Scholar
    • Export Citation
  • 24.

    Racz GB, , Browne T, & Lewis R Jr: Peripheral stimulator implant for treatment of causalgia caused by electrical burns. Tex Med 84:4550, 1988 Racz GB, Browne T, Lewis R Jr: Peripheral stimulator implant for treatment of causalgia caused by electrical burns. Tex Med 84:45–50, 1988

    • Search Google Scholar
    • Export Citation
  • 25.

    Racz GB, & Heavner JE: Comments on “A Spiral Nerve Cuff Electrode for Peripheral Nerve Stimulation.” IEEE Trans Biomed Eng 36:11401141, 1989 Racz GB, Heavner JE: Comments on “A Spiral Nerve Cuff Electrode for Peripheral Nerve Stimulation.” IEEE Trans Biomed Eng 36:1140–1141, 1989

    • Search Google Scholar
    • Export Citation
  • 26.

    Racz GB, , Lewis R, & Heavner JE, et al: Peripheral nerve stimulator implant for treatment of causalgia, in Stanton-Hicks M (ed): Pain and the Sympathetic Nervous System. Norwell, MA: Kluwer, 1990, pp 225239 Racz GB, Lewis R, Heavner JE, et al: Peripheral nerve stimulator implant for treatment of causalgia, in Stanton-Hicks M (ed): Pain and the Sympathetic Nervous System. Norwell, MA: Kluwer, 1990, pp 225–239

    • Search Google Scholar
    • Export Citation
  • 27.

    Racz GB, , Lewis R, & Heavner JE, et al: Peripheral nerve stimulator implant for treatment of causalgia, in Stanton-Hicks M, , Jänig, W, & Boas RA (eds): Reflex Sympathetic Dystrophy. Norwell, MA: Kluwer, 1990, pp 135141 Racz GB, Lewis R, Heavner JE, et al: Peripheral nerve stimulator implant for treatment of causalgia, in Stanton-Hicks M, Jänig, W, Boas RA (eds): Reflex Sympathetic Dystrophy. Norwell, MA: Kluwer, 1990, pp 135–141

    • Search Google Scholar
    • Export Citation
  • 28.

    Raj P, , Cannella J, & Kelly J, et al: Multi-discliplinary management of reflex sympathetic dystrophy, in Stanton-Hicks M, , Jänig W, & Boas RA (eds): Reflex Sympathetic Dystrophy. Norwell, MA: Kluwer, 1990, pp 165172 Raj P, Cannella J, Kelly J, et al: Multi-discliplinary management of reflex sympathetic dystrophy, in Stanton-Hicks M, Jänig W, Boas RA (eds): Reflex Sympathetic Dystrophy. Norwell, MA: Kluwer, 1990, pp 165–172

    • Search Google Scholar
    • Export Citation
  • 29.

    Raja SN, , Treede RD, & Davis KD, et al: Systemic alpha-adrenergic blockade with phentolamine: a diagnostic test for sympathetically-maintained pain. Anesthesiology 74:691698, 1991 Raja SN, Treede RD, Davis KD, et al: Systemic alpha-adrenergic blockade with phentolamine: a diagnostic test for sympathetically-maintained pain. Anesthesiology 74:691–698, 1991

    • Search Google Scholar
    • Export Citation
  • 30.

    Rauck RL, , Eisenach JC, & Jackson KE, et al: Epidural clonidine for refractory reflex sympathetic dystrophy. Anesthesiology 75 (Suppl):A657, 1991 (Abstract) Rauck RL, Eisenach JC, Jackson KE, et al: Epidural clonidine for refractory reflex sympathetic dystrophy. Anesthesiology 75 (Suppl): A657, 1991 (Abstract)

    • Search Google Scholar
    • Export Citation
  • 31.

    Robaina FJ, , Dominguez M, & Díaz M, et al: Spinal cord stimulation for relief of chronic pain in vasospastic disorders of the upper limbs. Neurosurgery 24:6367, 1989 Robaina FJ, Dominguez M, Díaz M, et al: Spinal cord stimulation for relief of chronic pain in vasospastic disorders of the upper limbs. Neurosurgery 24:63–67, 1989

    • Search Google Scholar
    • Export Citation
  • 32.

    Robaina FJ, , Rodriguez JL, & de Vera JA, et al: Transcutaneous electrical nerve stimulation and spinal cord stimulation for pain relief in reflex sympathetic dystrophy. Stereotact Funct Neurosurg 52:5362, 1989 Robaina FJ, Rodriguez JL, de Vera JA, et al: Transcutaneous electrical nerve stimulation and spinal cord stimulation for pain relief in reflex sympathetic dystrophy. Stereotact Funct Neurosurg 52:53–62, 1989

    • Search Google Scholar
    • Export Citation
  • 33.

    Sato J, & Perl ER: Adrenergic excitation of cutaneous pain receptors induced by peripheral nerve injury. Science 251:16081610, 1991 Sato J, Perl ER: Adrenergic excitation of cutaneous pain receptors induced by peripheral nerve injury. Science 251:1608–1610, 1991

    • Search Google Scholar
    • Export Citation
  • 34.

    Stanton-Hicks M, , Jänig W, & Hassenbusch SJ, et al: Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain (In press, 1996) Stanton-Hicks M, Jänig W, Hassenbusch SJ, et al: Reflex sympathetic dystrophy: changing concepts and taxonomy. Pain (In press, 1996)

    • Search Google Scholar
    • Export Citation
  • 35.

    Sweet WH: Causalgia; sympathetic dystrophy (Sudeck's atrophy), in Wilkins RH, & Rengachary SS (eds): Neurosurgery. New York: McGraw-Hill, 1985, pp 18861893 Sweet WH: Causalgia; sympathetic dystrophy (Sudeck's atrophy), in Wilkins RH, Rengachary SS (eds): Neurosurgery. New York: McGraw-Hill, 1985, pp 1886–1893

    • Search Google Scholar
    • Export Citation
  • 36.

    Tasker RR, & Lougheed WM: Neurosurgical techniques of sympathetic interruption, in Stanton-Hicks M (ed): Pain and the Sympathetic Nervous System. Norwell, MA: Kluwer, 1990, pp 165190 Tasker RR, Lougheed WM: Neurosurgical techniques of sympathetic interruption, in Stanton-Hicks M (ed): Pain and the Sympathetic Nervous System. Norwell, MA: Kluwer, 1990, pp 165–190

    • Search Google Scholar
    • Export Citation
  • 37.

    Watson HK, & Carlson L: Treatment of reflex sympathetic dystrophy of the hand with an active “stress loading” program. J Hand Surg 12:779785, 1987 Watson HK, Carlson L: Treatment of reflex sympathetic dystrophy of the hand with an active “stress loading” program. J Hand Surg 12:779–785, 1987

    • Search Google Scholar
    • Export Citation
  • 38.

    Wilson PR: Sympathetically maintained pain: diagnosis, measurement, and efficacy of treatment, in Stanton-Hicks M (ed): Pain and the Sympathetic Nervous System. Norwell, MA: Kluwer, 1990, pp 91124 Wilson PR: Sympathetically maintained pain: diagnosis, measurement, and efficacy of treatment, in Stanton-Hicks M (ed): Pain and the Sympathetic Nervous System. Norwell, MA: Kluwer, 1990, pp 91–124

    • Search Google Scholar
    • Export Citation
  • 39.

    Woolf CJ, & Thompson SWN: The induction and maintenance of central sensitization is dependent on N-methyl-D-aspartic acid receptor activation; implications for the treatment of post-injury pain hypersensitivity states. Pain 44:293299, 1991 Woolf CJ, Thompson SWN: The induction and maintenance of central sensitization is dependent on N-methyl-D-aspartic acid receptor activation; implications for the treatment of post-injury pain hypersensitivity states. Pain 44:293–299, 1991

    • Search Google Scholar
    • Export Citation

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