P 1-5 (717).pub

Thoracoscopic sympathectomy for causalgia:
Local experience
Mohammed Kassem, Hatem Badr, Hazem El Kosha, Abd Elwahab Ibrahim
The purpose of this study was to assess the efficacy of thoracoscopic cervicodorsal sympathectomy for the
reduction of pain severity and disability associated with causalgia.

From 2006 - 2009, 13 patients referred to Mansoura University Hospital with causalgia. All 13 patients
share the following diagnostic criteria: 1) history of trauma and peripheral nerve injury, 2) burning pain, 3) sympathetic
symptoms e.g. wet extremities, 4) pain aggravated by physical and/or emotional stimuli and 5) pain relieved by
sympathetic block.
All 13 patients underwent video-assisted thoracoscopic (lower third of stellate ganglia to T3) sympathectomy.

The mechanisms of trauma include motor vehicle accidents in 3 patients, stab wound (3 patients), surgical
procedure in 1 patient (carpal tunnel release), fracture (2 patients), wrong injection (1 patient), electrical injury (1
patient) and missile fragment injuries (2 patients). The most common presenting symptoms were as follows: burning
pain (100%), wet extremity (100%), cold extremity in 11 cases (92%), paraesthesia 10 cases (78%), and colour
changes in the extremities in 5 cases (38%). In all patients pain was relieved by sympathetic block. All patients had
complete relief of symptoms in the immediate postoperative period and for follow-up from 1 - 4 years.
Conclusion: Causalgia is a syndrome associated with burning pain, hyperaesthesia and symptoms of sympathetic
over-activity. Sympathectomy is effective and the treatment of choice, particularly for patients who respond temporarily
to sympathetic blocks. (p1-5)
Key words: Thoracoscope, causalgia, sympathectomy and pain management.
In 1867, Weir Mitchell first described the syndrome of
“heat” (kayso) and “pain” (algo), i.e., burning pain. causalgia during the American Civil War.9 Since then, Causalgia is a syndrome that develops after partial injury to multiple and often confusing terms arose to describe various a major peripheral nerve and is characterized mainly by pain disorders. As a result, multiple revisions of the nomen- burning pain (a constant feature), not following the distribu- clature were undertaken by the International Association for tion of the injured nerve, and signs of sympathetic over- the Study of Pain (IASP), which reproduced the new activity, as sudomotor abnormality, and skin temperature taxonomy of complex regional pain syndrome (CRPS).2 alterations.6 However, pain associated with causalgia is Complex regional pain syndrome is further classified into differentiated into 2 types.5 Both types should be clearly type I (formerly known as reflex sympathetic dystrophy distinguished to plan the proper modality of treatment for (RSD), and type II (formerly known as causalgia).10 causalgia. The first type is called sympathetically main- tained pain (SMP), in which the sympathetic system is The word “causalgia” comes from the Greek and means involved and sympathectomy is considered a must.5 The other type is called sympathetically independent pain (SIP), in which the sympathetic system has nothing to do, and Once the diagnosis of causalgia with SMP is established,

surgical sympathectomy should be carried out immediately, as spontaneous disappearance of causalgia pain is rare. 2 Patients and methods
Over a period of about 3 years from 2006 - 2009, 25 VOLUME 15, NO. 1, APRIL 2011
patients referred to Mansoura University Hospital with cold. The treatment modality was sympathectomy, which causalgia were evaluated. We performed a prospective was preceded by evaluating the response to sympathetic study in which all patients fulfilled the following selection 1. History of trauma with clinically and/or electro physio- Medical sympathetic block
logically documented partial nerve injury (hypoaesthesia/ For cases with upper limb causalgia, the satellite ganglion anaesthesia along distribution of the injured nerve or was selected to be anaesthetized using 15 ml of lidocaine to muscle atrophy of the supplied muscle/s by the injured produce an upper extremity sympathetic block. The block nerve, also EMG and NCV were done to document was considered successful if transient Horner syndrome and a warm dry extremity were produced. A warm, dry extrem- 2. International Association for the Study of Pain ity after the injection was considered a successful block diagnostic criteria for causalgia (Table 1).
(increase in temperature by 2°C or more after a sympathetic 3. Failure of conservative treatment (corticosteroids, block). A negative response was defined as no pain relief Gabapentine, tricyclic antidepressants, and NSAIDs) despite an otherwise successful block. However, if pain was for a maximum period of 3 months (beyond this period relieved with the block, it is considered a positive response no additional benefit is acquired by non-responders). and the diagnosis of causalgia with SMP was confirmed. 4. Patients showing positive response (such as when the Patients, in whom the response was temporary were scheduled limb increased in temperature by 2°C or more after a for surgical sympathectomy, up to 3 trials. All cases sympathetic block, and 90% or more of the pain was underwent sympathetic block by an expert anaesthesiologist. eliminated) after successful sympathetic block.

Table 1 - International Association for the Study of Pain diag-
nostic criteria for CRPS type II.
For upper limb causalgia we performed video-assisted Pain diagnostic criteria
thoracoscopic sympathectomy (VATS) under general anaes-thesia using double lumen endotracheal tube. With the The presence of continuing pain, allodynia, or hyperalgesia after a nerve injury not necessarily limited to the distribution of the patient in the supine position, we insert 2 trocars through half centimetre incisions, one in the 3rd intercostal space Evidence at some time of oedema, changes in skin blood flow, (ICS) along the anterior axillary line (AAL), and the other or abnormal sudomotor activity in the region of the pain. in the 4th ICS along the mid-axillary line (MAL). We used a This diagnosis is excluded by the existence of conditions that 30 cm long rigid straight 0 degree telescope, and a would otherwise account for the degree of pain and dysfunction. diathermy enabled endograsper in all cases. An endoscissor Note: All three criteria must be satisfied. From Merskey and Bogduk, 1994.10 was used in one patient to cut adhesions involving the lung apex and obscuring the view of the upper sympathetic The following patients were excluded from our study: chain. Resection included diathermy ablation of T2 and T3 1. Those with non-proven nerve injury (to avoid confusion sympathetic ganglia (to avoid permanent Horner syndrome if stellate ganglion was injured) and continued laterally over 2. Those suspected to have local causes that would the 2nd and the 3rd ribs to cut the nerve of Kuntz (the most account for the degree of pain and dysfunction (not common cause of failure if not cut). A chest tube was not routinely inserted (used once due to incomplete lung 3. Those showing considerable improvement (as deter- mined by patient’s satisfaction) on conservative 4. Those with permanent relief of pain after sympathetic Among 576 patients whom attended our outpatient clinic in the interval from June 2006 - July 2009, with variable 5. Those with negative response to successful sympa- degrees of peripheral nerve injuries, 25 patients were thetic block after up to 3 trials. Those patients were diagnosed as causalgia (4.3%), of which 13 patients were grouped as having SIP and are considered not suitable considered in this study (12 patients were excluded; 2 patients improved conservatively, 1 patient improved permanently following sympathetic block, and 9 patients Data collected from selected patients included age, sex, with SIP). The clinical characteristics for each patient are mechanism of injury, nerve and limb involved, associated presented in Table 2. The ages ranged from 18 - 52 years.
injuries, and time from injury to onset of pain. The clinical There were 8 males (61%) and 5 females (39%). manifestations included type and distribution of pain, sweating, limb warmness, colour changes and sensitivity to The mechanisms of trauma included: crush injuries during PAN ARAB JOURNAL OF NEUROSURGERY
Table 2 - Clinical characteristics of patients.
Other injuries Onset of pain
Abbreviations: Md = median nerve, Ur = ulnar nerve, Rd = radial nerve, UL = upper limb, # = fracture, Un = ulna, Brach art = brachial artery.
motor vehicle accidents in 3 patients (23%), stab (sharp one patient developed partial recurrence of pain, a condition objects as a knife) injuries in 3 patients (23%), missile that was controlled using pharmacological agents like fragment injuries in 2 patients (15%), iatrogenic injury NSAIDs and Gabapentine. This gives us 92% long-term during carpal tunnel release in 1 patient (8%), fractures in 2 complete recovery of symptoms and 100% long-term patients (15%), wrong injection in the median nerve in 1 satisfactory results in patients with causalgia carefully patient (8%), and electrical injury in 1 patient (8%). In crush selected to undergo surgical sympathectomy. injuries, and 1 stab injury, there was more than one major nerve injured, usually partial, while in other injuries, only The postoperative hospital stay was 24 - 48 hours, except one nerve was affected, prominently the median nerve in for one case which needed a chest tube, removed after 72 hours, due to delayed lung expansion. During surgery, one case had accidental small lung contusion during trocar Upper extremities were involved in 9 patients (3 crush insertion due to the presence of adhesions involving lung injuries, 2 stab injuries, 1 fractured humerus, an electrical injury, an iatrogenic injury and a wrong injection). Discussion
In most cases there were no associated injuries, except for The higher incidence of causalgia with high-velocity bone fractures in 2 patients, vascular injury (brachial artery) injuries made it a war-related syndrome, being relatively rare in civilian life. Although Mansoura is a referral hospital, serving more than four governments, we detected All patients developed pain within the first 48 hours from just 25 cases of causalgia over a period of about 3 years. injury, except one case in which the onset of pain occurred Out of these cases, only 13 entered our study. after 5 days (the case of stab wound with brachial artery injury). Eight patients reported their pain during the first 24 Six patients (46%), were between 18 - 22 years, while 10 hours. The most common presenting symptoms were as patients (77%) were below the age of 30. This reflects an follows: burning pain in all (100%), sudomotor abnormality increase in the incidence among the working age groups. in all (100%), cold extremity in 11 cases (92%), sensory Although, CRPS was reported to occur in children by changes (hyperalgesia, allodynia and/or hyperpathia) in 10 Cimaz et al,(5) we did not encounter any case in that age cases (78%), and colour changes in the extremities in 5 group. Some studies reported higher incidence in females(7), this was not noticed in our study, in which males represented about two thirds of patients, which may be All selected patients showed transient stoppage of pain related to the less outdoor activity of females in our society, following successful sympathetic block. These patients making them less prone to develop nerve injuries. However, underwent surgical sympathectomy and had complete relief by comparing the number of males and females in our of symptoms in the immediate postoperative period. On study to the number of their correspondents presented with follow-up of the patients over a period of 1 - 4 years, only peripheral nerve injuries, we found higher incidence of VOLUME 15, NO. 1, APRIL 2011
causalgia among females, a condition that needs further interventions were all done during the early posttraumatic period (during stage I of causalgia) to avoid dependence on analgesics, antidepressants and steroid complications. The median nerve was injured in 9 cases, in 5 of which it Moreover, delayed sympathectomy (during stage II or III), was the only injured nerve. The ulnar nerve was the only may be associated with poor outcome, when the irreversible injured nerve in one case, while associated with median musculoskeletal atrophic changes become evident. nerve injury in 4 cases. The radial nerve was responsible for causalgia in 3 cases (fractured humerus), and associated In our study, we started doing sympathectomy before with both median and ulnar nerve injuries in another case. repairing the injured nerve, because nerve repair is ineffec- This makes the median nerve to be the major nerve affected tive for relief of causalgia, as reported by White et al, so in upper extremity causalgia in our study. These results nerve repair in our patients was delayed till the burning pain coincide with most reports in the literature.6,8-11 Eight has been relieved by sympathectomy.16 patients in our study had pain begin within the first 24 hours (62%), which is the usual onset reported in other series.12,13 Complications
The cases with onset of pain delayed after 24 hours were The only intraoperative complication was a small surface those having crush injuries (3 cases), and 2 cases with stab lung laceration induced by trocar insertion. There were injury, one of which was shocked due to profuse bleeding multiple adhesions anchoring the lung apex and causing from torn brachial artery. This may explain the reason of the incomplete lung collapse. This patient was a 20-year-old female suffering from rheumatoid arthritis, which explains the presence of the adhesions encountered. No postop- All patients (100%) in our study suffered from severe erative complications happened apart from chest tube burning pain in the limb, distal to the site of injury, and not insertion for 72 hours due to delayed lung reexpansion. This respecting the distribution of injured nerves. This makes patient was a 52-year-old male, with no evident chest pain a constant feature as supported by other investi- problems. The condition may be due to age-related changes gators.11,14,15 Other manifestations included: sudomotor or technical problems. Following the patients up, over 1 - 4 abnormality (100%), temperature changes (92%), and years, proved the efficacy of sympathectomy in achieving colour changes (38%), representing the classic picture of long-term complete recovery, since only one case showed increased sympathetic activity. The complexity of symp- recurrence of pain which is much less severe than the initial toms in addition to the regional distribution of pain, make one. This may be due to incomplete sympathectomy or the clinical picture of patients in our study closely related to the new taxonomy reproduced by the IASP defining causalgia as CRPS type II.2 Conclusions
Although a relatively rare syndrome in civilian life, one All patients selected for sympathectomy were positive should be oriented by the possibility of causalgia develop-responders to sympathetic block. This confirmed the ing in patients with partial injury to major peripheral nerves. diagnosis of SMP, which is a selection criterion, but not The cardinal manifestations include, burning pain, sudo- necessarily a diagnostic criterion. The term of SMP was motor abnormality, changes in skin temperature and used first by Roberts to describe that type of pain associated sensory changes. The pain usually develops shortly after with causalgia and RSD, in which the sympathetic nervous trauma, and may be SMP or SIP, something that should be system is involved, and when interrupted, relief of confirmed by sympathetic block. Positive responders symptoms occurs.12,16 However, Roberts recognized that in should undergo surgical sympathectomy without delay, to some patients with nerve injuries, the sympathetic nervous achieve better prognosis. Sympathectomy is an effective system is not involved and sympathetic blockade and/or modality of treatment in causalgia patients with SMP, sympathectomy will not be of value.12 For these patients he causing rapid recovery and return to normal life. used the term SIP. Either SMP or SIP can be found in causalgia, making selection of patients that would benefit References
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Descriptions of Chronic Pain Syndromes and Definitions
VOLUME 15, NO. 1, APRIL 2011

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