Truths, errors, and lies around "reflex sympathetic
dystrophy" and "complex regional pain syndrome"
José L. Ochoa A1
A1 Department of Neurology,
Good Samaritan Hospital and Oregon Health Sciences University, 1040 NW 22nd Ave N-460, Portland, OR 97210, USA e-mail:jsonnad@teleport.com,
Tel.: +1-503-4137293, Fax: +1-503-4138011
Abstract:
Abstract The shifting paradigm of reflex sympathetic
dystrophy-sympathetically maintained pains-complex regional pain syndrome is characterized by vestigial truths and understandable
errors, but also unjustifiable lies. It is true that patients with organically based neuropathic pain harbor unquestionable
and physiologically demonstrable evidence of nerve fiber dysfunction leading to a predictable clinical profile with stereotyped
temporal evolution. In turn, patients with psychogenic pseudoneuropathy, sustained by conversion-somatization-malingering,
not only lack physiological evidence of structural nerve fiber disease but display a characteristically atypical, half-subjective,
psychophysical sensory-motor profile. The objective vasomotor signs may have any variety of neurogenic, vasogenic, and psychogenic
origins. Neurological differential diagnosis of "neuropathic pain" versus pseudoneuropathy is straight forward provided that
stringent requirements of neurological semeiology are not bypassed. Embarrassing conceptual errors explain the assumption
that there exists a clinically relevant "sympathetically maintained pain" status. Errors include historical misinterpretation
of vasomotor signs in symptomatic body parts, and misconstruing symptomatic relief after "diagnostic" sympathetic blocks,
due to lack of consideration of the placebo effect which explains the outcome. It is a lie that sympatholysis may specifically
cure patients with unqualified "reflex sympathetic dystrophy." This was already stated by the father of sympathectomy, René
Leriche, more than half a century ago. As extrapolated from observations in animals with gross experimental nerve injury,
adducing hypothetical, untestable, secondary central neuron sensitization to explain psychophysical sensory-motor complaints
displayed by patients with blatantly absent nerve fiber injury, is not an error, but a lie. While conceptual errors are not
only forgivable, but natural to inexact medical science, lies particularly when entrepreneurially inspired are condemnable
and call for peer intervention. |
