(Received for publication November ~, 1945)

Transcription

1 M TREATMENT OF CAUSALGIA AN ANALYSIS OF 100 CASES MAJOR THEODORE B. RASMUSSEN, M.C., A.U.S., A~D CAPTAIN HOWARD FREEDMAN, M.C., A.U.S. Surgical Service, l~h Evacuation Hospital (Received for publication November ~, 1945) ANY reports in the literature testify to the emcacy of paralyzing the sympathetic nervous system in the treatment of causalgia, but an adequate body of clinical material is seldom available upon which a comparison can be made of the results of the various methods of producing this sympathetic denervation. A large number of patients with wounds of the extremities have been concentrated in the region in which this hospital has been situated and, since we have been able to follow the great majority of the cases to completion, we have had an unusual opportunity to make such a study. In this series of 100 cases of causalgia of varying degrees of severity we wish to present the results of treatment by means of paravertebral injection of procaine, and preganglionic and postganglionic surgical sympathectomy. Material. All the patients were Chinese soldiers who had been wounded in the North and Central Burma campaigns. In some instances the treatment of the patient had been completed prior to admission to this hospital, in others the treatment had been started in other medical installations and was completed here, and in the remainder all of the treatment was administered here. The wounds were produced by bullets, grenade or shell fragments in 99 patients while the remaining patient sustained a bayonet wound. The ages varied from 18 to 41 years. The upper extremity was involved in 8~ and the lower in 18 patients. Types of Lesions. The maior nerves of the extremity were involved in 81 of the 100 cases and in 10 there was iniury only to bones or joints. There was injury to soft tissues only in 5 patients and injury to cutaneous or digital nerves in 4. The types of lesions are shown in detail in Tables 1 and ~. Of the 8~ patients in whom the arm was involved there was an associated fracture of one or more of the bones in 35. In the lower extremity, fracture without nerve injury was present in 6 patients while in the remaining 1~ there were no instances of associated bone injury. Time of Onset of the Pain. The characteristic pain appeared within 6 hours after the injury in 48 cases and within 1 to 3 days in another ~3 (Table 3). In a few cases its appearance was delayed up to 8 weeks. Characteristics of the Pain. The spontaneous complaint of the patient was usually "numb pain." Careful questioning through an interpreter was necessary to elucidate the characteristics of the pain in greater detail. Although the limited vocabulary of some of the patients tended to obscure the picture 165

2 166 THEODORE B. RASMUSSEN AND HOWARD FREEDMAN at times, as a rule a fairly good description of the pain could be obtained. The pain was present eonstantly in 91 of the cases and was intermittent in the remaining 9. Fifty-five of the patients described the pain as hot or burning in charaeter while the remaining 45 did not associate any sensation of TABLE 1 Types of lesions producing causalgia of the upper extremity Median nerve injury in the arm or forearm 17 cases Multiple injuries of the great nerves 17 Laceration of the brachial artery plus injury to one or more of the great nerves 11 Brachial plexus injury 10 Ulnar nerve injury 9 Radial nerve injury 6 Injury to soft tissues only of arm, forearm or hand 4 Fracture of bone or injury to joint 4 Injury to cutaneous nerves of forearm Injury to digital nerves of hand 8~ cases TABLE Types of lesions producing causalgia of the lower extremity Sciatic nerve injury Tibial nerve injury Peroneal nerve injury Fracture of bone or injury to joint Injury to soft tissues of the calf 8 cases cases TABLE 3 Time of onset of pain after injury Immediately 36 cases 89 to 6 hours l~ 1 to 3 days ~3 6 to 14 days 16 3 to 8 weeks ll Not stated 100 cases temperature with the pain. Since the rest of the clinical picture of these 45 patients was so nearly identical with the others it seemed obvious that the same fundamental pathologic process was involved. Therefore they were included in the series although in the striet etymological sense the term "causalgia" does not apply to them. The term "minor eausalgia" has been used by Homans for eases similar to some of these.

3 TREATI~ENT OF CAUSALGIA 167 Forty-seven patients described the pain as throbbing or jumping. Twenty-six said it was a sharp pain and 7 called it a tight or swollen pain. The usual description was "constant, throbbing, burning pain." In over three-fourths of the cases the pain was more severe on hot sunny days and less severe on cool rainy days. Cold wet applications had been tried by 44 of the patients on their own initiative with partial relief in 35 and no relief in 9. Various tests aimed at changing the tone in the blood-vessel walls were employed without giving sufficiently consistent results to warrant further consideration. These tests included raising and lowering the limb, compression of the extremity with a blood-pressure cuff to just above the diastolic and systolic levels, and the injection of adrenalin, prostigmine and nitroglycerine. TABLE 4 Classification of the patients according to the severity of the pain Grade of Severity of Pain Arm Leg Total Grade 1 1B 6 19 Grade Grade 3 B4 4 B8 Grade Severity of the Pain. This varied from relatively slight pain to extremely severe and incapacitating pain. The patients were all graded on a basis of 1 to 4 (Table 4) according to the following criteria: Grade 4. These were the patients with the most severe pain. They spent most of the day huddled on their beds protecting the involved extremity. The hand or foot was frequently wrapped in a wet cloth and only the most superficial examination was allowed. The facial expression and bodily attitude was so characteristic that the diagnosis could usually be made with a passing glance. Eight of the patients were included in this group. Grade 3. These patients likewise complained of severe pain and refused to use the part under any provocation but allowed closer examination of the painful extremity and were somewhat more active about the ward. There were B8 patients in this group. Grade ~. These patients complained of moderately severe pain, used the extremity a little on occasion and allowed a fairly complete examination to be made. There were 35 patients in this group. Grade 1. The 19 patients in this group complained of moderately severe pain but used the involved extremity somewhat more actively although still much less than their wounds would otherwise have permitted. Despite the wide variation in severity, the qualitative characteristics of the pain were so similar that there was little doubt that we were dealing with varying degrees of severity of the same fundamental pathologic disturbance.

4 168 THEODORE B. RASMUSSEN AND HOWARD FREEDMAN Location of the Pain. In 30 of the 43 patients with isolated injury to one of the great nerves of the extremity, the pain was limited to part or all of the skin distribution of the involved nerve; it involved the entire hand or foot in 7 patients and in the remaining 6 the pain extended up the extremity as well. In these last 13 patients the pain was most severe in the palm or sole even though the more proximal portions of the extremity were also involved. In 40 of the 43 eases the nerve was in anatomical continuity even though in some eases the lesion was clinically complete. In half the patients with injury to various combinations of the great nerves of the arm the pain was limited to the skin distribution of one of the nerves. Less frequently the pain involved the total skin distribution of the involved nerves, and still less frequently the pain was present throughout the entire arm. In 6 out of the 7 eases of multiple nerve injuries in which one of the nerves was completely severed the pain was present only in the distribution of the partially damaged nerve or nerves. With braehial plexus lesions the pain involved either the palm, finger tips, entire hand or arm rather than the distribution of any one nerve. The addition of injury to the braehial or axillary artery to the nerve lesion did not change either the character or the distribution of the pain. In no instance were the great vessels alone injured. The location of the pain was not altered by the addition of fracture of one or more of the bones of the arm to the nerve injury. In all 10 of the eases due to bone or joint injury alone, the pain was localized to the site of the wound. Physical Examination of the Extremity. De Takats has described causalgia as a state of painful vasodilatation of an extremity. In the majority of the cases seen early (within ~ or 3 months after injury) this was strikingly borne out in this series. In some of the patients this vasodilatation persisted for as long as 6 months. Usually after several months the picture changed to one of moderate vasoconstriction in association with various trophic changes of the skin, nails and joints. In the stage of vasodilatation the hand or foot was pink and warm and the skin velvety to the touch. Frequently the vasodilatation was so extreme that tiny drops of blood would appear after gentle testing of sensation with a pin. Perspiration was sometimes decreased and in other cases extremely profuse. This would frequently vary from one examination to the next on succeeding days. Stroking or squeezing the involved area or moving the joints nearly always aggravated the pain. Patients whose pain was severe enough to prevent use of the hand and whose pain was not promptly relieved, quickly developed trophic changes, such as glossy cyanotic appearance of the skin, tapered fingers and periarticular fibrosis. Evidence of these changes was seen as early as 4 weeks after the injury. Diagnostic Aspect of Paravertebral I~jection of Procaine. At least 1 injection was done in 91 of the patients. In cases with involvement of the upper extremity the procaine was injected along the sides of the bodies of the 1st and ~nd thoracic vertebrae. For causalgia of the leg the procaine was placed

5 TREATMENT OF CAUSALGIA 169 along the sides of the bodies of the ~nd, 3rd and 4th lumbar vertebrae. Injections that produced satisfactory sympathetic paralysis of the extremity resulted in complete temporary relief of pain in 73 patients, marked but not complete relief of pain in 16 patients and no relief in 2. THERAPY The maiority of the patients were treated initially by one or more paravertebral injections of procaine and those not responding adequately were then subjected to surgical sympathectomy. Occasionally the sympathectomy was done without the preliminary paravertebral injections in cases in which the operation was indicated to improve the blood supply to the extremity as well as for the relief of pain. Two patients (with pain grade 1 and 2) had gradual recession of their pain without any treatment, but both continued to have slight pain during the 3 months they were followed. Neurolyses alone were done 3 and 489 months after injury in 2 patients (with pain grade 2 and 3) and were followed by gradual lessening of the pain. However there was likewise some pain still present at the time of these patients' discharge 6 months after injury. In another 5 patients (3 with pain grade 2 and 2 with pain grade 3) neurolysis or neurorrhaphy within 2 months after injury produced slight or no relief of pain whereas a subsequent attack on the sympathetic nervous system cured the causalgia. In an additional 30 cases various operative procedures were carried out upon the nerves, after treatment directed at the sympathetic nervous system was begun, without altering the course of the pain. Paravertebral Injection of Procaine. The injections for the arm were done either according to the technique of White and Smithwick, 1 placing 15 cc. of 2 per cent procaine along the sides of the bodies of the 1st and 2nd thoracic vertebrae or, in the case of most of those done prior to admission to this hospital, by injecting the stellate ganglion through an anterior approach. In the case of the leg, the procaine was placed along the sides of the 2nd, 3rd and 4th lumbar vertebrae. The therapeutic results will be presented separately for the milder cases (grades 1 and 2) and for the more severe cases (grades 3 and 4). Grades 1 and 2. The 48 patients in this group were treated with 1 to 4 injections each, given 10 days to 5 months after injury. Five patients were completely and permanently relieved after 1 injection. In 7 patients the pain completely disappeared within 4 weeks after the injections. There was moderate relief of pain in 23 patients and slight or no relief in 13. Further treatment was not considered necessary for 26 of these last 36 patients. In 3 of the remaining 10 patients who had little or no lasting relief after the injections (despite complete relief for the duration of the procaine effect) there was moderate relief of pain after subsequent neurolysis. Sympathectomy was resorted to in the remaining 7 patients when it was evident that the relief produced by the injections was inadequate. The duration of the pain

6 170 THEODORE B. RASMUSSEN AND HOWARD FREEDMAN at the time the injections were performed (up to 5 months in this group) did not have any definite relationship to their efficacy in curing the causalgia. Grades 3 and 4. There were 43 patients in this group and they received 1 to 10 injections over a period from r weeks to 5 months after injury. One patient was completely relieved after 1 injection. Six patients had marked or moderate relief. One patient had moderate relief after ~ injections and then complete relief ~ weeks after a subsequent neurolysis. Two patients obtained no persistent relief after the injections but had nearly complete relief of pain after later resection of a thrombosed segment of the brachial artery and a neurolysis of the median nerve respectively. In the remaining 33 patients the pain relief was inadequate and sympathectomy was considered necessary. A compilation of the results of paravertebral injection of procaine in this entire group of 91 patients (Table 5) shows that there was complete relief of pain after 1 injection in 6 cases and complete relief within 4 weeks after TABLE 5 Results of paravertebral injection of procaine for causalgia of the arm and leg (91 cases) Immediately after 1 injection Complete Relief of Pain Within 1 month Adequate but Incomplete Relief of Pain Inadequate Relief of Pain 6 7 3~ 46 1 to 3 injections in an additional 7 eases. Moderate relief of pain, such that further treatment was not indicated or was refused by the patient, was obtained in 32 eases. The relief of pain was inadequate in the remaining 46 patients. Sympatheetomies were performed in 40 of these and in 6 operations on the nerves produced satisfactory relief of the pain. Surgical Sympathetic Denervation of the Arm. Three types of operations were performed: a postganglionie denervation through an anterior approach, usually associated with a periarterial sympatheetomy of the subclavian artery; a preganglionie denervation through the anterior approach (Telford's operation); and a preganglionie denervation through the posterior approach (Smithwiek's operation). The first two types of operations were done prior to the patients' admission to this hospital. All the Smithwiek type operations were done at this hospital. Seven patients were in the grade group, 24 in the grade 3 group and 6 in the grade 4 group. The 37 patients can be considered together since there was no correlation between the severity of the pain and the operative results. In ~ of the patients sympatheetomy was indicated to improve the circulation of the arm as well as for the relief of pain and the operations were not preceded by paravertebral injections. In the other 35 patients 1 or more injections had been done without producing adequate lasting alleviation of the pain. The temporary relief

7 TREATMENT OF CAUSALGIA 171 produced by these injections was important, however, in that proof was thus obtained that the sympathectomy was indicated. The postganglionic procedure was done on s patients at intervals varying from 10 days to 8 months after injury. There was immediate complete relief of pain in 5 cases and marked immediate relief with complete disappearance of all remaining pain during the month following the operation in an additional 5 cases. There was marked relief in ~ patients, moderate relief in 7 and slight relief in ~, with persistence of some pain in 7 of these 11 patients throughout the follow-up period of 3 to 16 months. The results of this operation were probably somewhat better than these figures would indicate since there may have been some patients who were completely relieved of pain and were able to return to duty without coming through this hospital for further convalescence. All these patients had a marked Horner's syndrome and anhydrosis of the arm, testifying to the completeness of the denervation. TABLE 6 Results of surgical sympathectomy for causalgia of the arm (35 cases) Type of Operation Immediately Complete Relief of Pain Within 1 month After several months Patients with Some Persistent Pain Postoperatively Postganglionic denervation Preganglionic denervation 13 l 0 0 The Smithwick preganglionic operation was performed on 13 patients 7 weeks to 4 months after the injury. There was immediate complete relief of pain in 1,o, while the remaining patient had marked immediate relief and then complete relief during the following month. There was no recurrence of pain in any of these patients during the follow-up period of 1 to 19 months. A 14th patient was operated upon but developed repeated convulsive seizures during the operation so the procedure was abandoned and the sympathetic chain merely cut at its most accessible point, between the ~nd and 3rd thoracic ganglia. He obtained marked relief but still had some slight residual pain when he returned to duty a month later. The Telford preganglionic operation was done on 1 patient ~89 months after injury with immediate complete and permanent relief of pain. The results of the two types of operations are summarized in Table 6. In the last case in this group of 37 a preganglionic operation and a subsequent postganglionic operation both failed to give relief, but after an aneurysm of the axillary artery was excised the pain gradually completely disappeared. This patient and the one with the simple section of the sympathetic chain, mentioned above, are omitted from Table 6. Surgical Sympathetic Denervation of the Leg. Excision of the ~nd and 3rd lumbar ganglia was done in 5 patients ~ to 5 months after injury, with the

8 17~ THEODORE B. RASMUSSEN AND HOWARD FREEDMAN production of marked relief in ~ and moderate relief in 3. Four of the 5 patients had some persistent residual pain on discharge from the hospital 1 to 10 months after operation. The pain in the case of the 5th patient gradually disappeared during the year after operation. In a 6th patient a high thoracic chordotomy was done ~,89 months after injury with moderate relief of pain. However, subsequent periarterial femoral sympathectomy 789 months after injury and lumbar sympathectomy ~ weeks later failed to lessen his residual pain. COMMENT In addition to the relief of pain prompt and adequate treatment of even mild cases of causalgia is important because of the rapid appearance of trophic changes when the pain is allowed to persist. Paravertebral injections of procaine are valuable both diagnostically and therapeutically and can be done early. If satisfactory injections produce temporary cessation of the pain and if adequate relief of the pain is not obtained within a few weeks, sympathectomy should be done as soon as the patient's general condition will permit. A summary of the results of paravertebral injection of procaine in this series of cases shows that complete relief of pain was obtained either immediately or within 4 weeks in 14 per cent and moderate relief was produced in 35 per cent while in the remaining 51 per cent the relief of pain from the injections alone was inadequate. In this series, if 3 or 4 injections did not produce satisfactory relief of pain within a few weeks, further injections were seldom of much help.* A consideration of the results of the sympathectomies for causalgia of the upper extremity indicated that while any type of denervation produced improvement in nearly all cases, in this series the preganglionie operations were definitely superior to the postganglionic type. The White and Smithwick dictum that "sympathectomy should be preganglionic in type and anatomically complete" seems to apply to causalgia of the arm as well as to Raynaud's disease. On the other hand, sympathectomy for causalgia of the lower extremity did not give quite such satisfactory results, even though these operations were also preganglionic in type. We have no explanation for this discrepancy. Surgical attention to the damaged nerves produces satisfactory relief of the pain occasionally but in the majority of the cases these operations are ineffective. In addition, the infection that accompanies so many war wounds frequently causes some delay before the nerves can be explored. A primary attack on the sympathetic nervous system usually gives one the best chance of relieving the pain and should be done as soon as possible. The required work on the nerves can then be done when the local conditions permit. The * A preliminary report is in preparation on the use of a slowly absorbed local anesthetic agent for paravertebral injection. This promises to increase materially the percentage of cures with the use of this procedure.

9 TREATMENT OF CAUSALGIA 173 treatment of the pain should not be delayed in the hope that the nerve exploration will produce a cure. Occasionally a thrombosed segment of a major artery or an aneurysm will produce a source of continuing irritation and the resulting causalgic pain may not be completely relieved until the offending structure is excised, SUMMARY 1. The results of treatment in 100 cases of causalgia are presented. o. The types of lesions involved are listed. 8. The time of onset, the Characteristics and location of pain are discussed. 4. Diagnostic paravertebral injection of procaine was done in 91 of the patients, producing complete temporary relief of pain in 73, marked relief in 16 and no relief in 2 of the patients. 5. From the therapeutic standpoint, paravertebral injections of procaine produced complete and perwanent relief of pain either immediately or within 4 weeks after the injections" in 13 of the 91 patients. Moderate relief of pain was produced in 32 patients while in the remaining 46 the relief of pain produced by the injections alone was inadequate. 6. Postganglionic operations for causalgia of the arm resulted in immediate complete relief of pain in 5 cases and complete disappearance of all pain within one month after the operation in an additional 5 cases. There was gradual disappearance of the pain several months after the operation in 4 patients and in the remaining 7 patients in this group of ~1 some residual pain persisted throughout the follow-up period. 7. Preganglionic~0perations for causalgia of the arm were done in 14 patients with immediate complete and permanent relief of pain in 13. In the remaining case in this group there was marked immediate relief followed by complete disappearance of the residual pain during the first month after the operation. 8. The results of sympathectomy for causalgia of the leg were not quite as satisfactory as for the arm. Four of the 5 patients in this group continued to have some residual pain. CONCLUSIONS l. Treatment directed toward the sympathetic nervous system should be instituted promptly once the diagnosis of causalgia is made. 2. _Paravertebral injection of procaine is both an important diagnostic aid and a valuable therapeutic agent in the treatment of causalgia. 3. If the paravertebral injections of procaine do not result in adequate relief of pain within a few weeks, surgical sympathectomy should be done without delay. 4. The preganglionic type of denervation seems to be the operation of choice when sympathectomy is indicated for causalgia of the arm. REFERENCES 1. WgtwE, J. C., and SMITH'WICK,. It. The autonomic nervous system. Anatomy, physiology, and aurgical application. New York: Macmillan Co., 1941, 2nd ed., xxii, 469 pp.