Sudeck Syndrome: Symptoms, Causes, Treatments

He Sudeck syndrome Or complex regional pain syndrome ( SDRC ) is A type of chronic pathological pathology that is attributed to the development of central or peripheral nervous system dysfunction (Rogers & Ramamurthy, 2016).

At the clinical level, Sudeck syndrome is characterized by the presence of a dysfunction or variable deficit of the neurological system, Skeletal, cutaneous and vascular muscle (Díaz-Delgado Peñas, 2014).

The most prevalent signs and symptoms in this medical condition usually include: recurrent and localized pain in the extremities or affected areas, Anomalies in skin temperature and color, sweating, inflammation, increased skin sensitivity, motor impairment, and significant delay of Functional physical recovery (National Institute of Neurological Disorders and Stroke, 2015).

In addition, as regards its clinical characteristics, two different stages of evolution have been described: stage I or precocious, stage II and stage III (Díaz-Delgado Peñas, 2014).

Although the specific etiological factors of Sudeck syndrome are not accurately known, a wide variety of mechanisms Play an important role both in its genesis and in maintenance.

A good part of the cases are developed after the Trauma or surgical intervention, infectious disease, or even radiotherapy (National Organization for Rare Disorders, 2007).

As for the diagnosis of this pathology, it should be fundamentally clinical and confirmed by other complementary tests (radiology, Scintigraphy, etc.) (Rodrigo et al., 2000).

Although there is no cure for Sudeck syndrome, the therapeutic approach requires a multidisciplinary approach that usually includes therapy Pharmacological, physical rehabilitation, surgical procedures and psychological treatment, among others (Ribera Canudas, X).

Characteristics of Sudeck syndrome

Pain is one of the medical symptoms that all people experience or have experienced at some point.

In this way, we usually seek a referral or relief from it through the available techniques (analgesic, emergency medical care, etc.) and, in addition, The diagnosis is usually more or less evident (Cleveland Clinic, 2016).

However, there are certain cases in which none of these approaches is effective and no specific medical cause can be found (Clevelad Clinic, 2016).

One such case is Sudeck's syndrome, also known as reflex sympathetic dystrophy (DSR) or other terms Less employed such as cotydrophy, algoneurodistrophy, Sudeck atrophy, transient osteoporosis or shoulder-hand syndrome, among others (National Organization for Rare Disorders, 2007).

Syndromes related to chronic pain following trauma have been reported in the medical literature over several centuries. Without However, it is not until 1900 that Sudeck first describes this syndrome as"acute inflammatory bone atrophy"(Rodrigo et al., 2000).

However, the term reflex sympathetic dystrophy (DSR) was proposed and coined by Evans in 1946. Thus, the International Association for the Study of Pain, Defined in 1994, the clinical criteria and the term of this pathology as Complex Regional Pain Syndrome (Ribera Canudas, 2016).

Sudeck syndrome is a rare form of chronic pain that usually affects the limbs (arms or Legs) (Mayo Clinic, 2014).

Generally, the signs and symptoms characteristic of this pathology are presented after a traumatic injury, surgery, Cerebrovascular accident or Heart failure and is associated with poor functioning of the Sympathetic nervous system (Mayo Clinic, 2014).

Our nervous system (SN) is usually divided anatomically into two fundamental sections: the central nervous system and peripheral nervous system (Redolar, 2014):

• Central Nervous System ( SNC ): This division is composed of the brain and the spinal cord . Further, Presents other subdivisions: cerebral hemispheres, brainstem, cerebellum etc.
• Peripheral nervous system ( SNP ): This division is composed essentially of the ganglia and nerves Cranial and spinal. These are distributed by almost all the corporal areas and are in charge of transporting information (sensory and motor) Bidirectionally with the CNS.

In addition, we must emphasize that the peripheral nervous system in turn, presents two fundamental subdivisions (Redolar, 2014):

• Autonomic nervous system ( SNA ) : This functional subdivision is mainly responsible for the control of regulation Internal organism Thus, it has an essential role in the management of the response of the internal organs to the internal conditions of the organ.
• Somatic nervous system ( SNS ): This functional subdivision is mainly responsible for the transmission of Sensory information coming from the body surface, sense organs, musculature and internal organs, towards the CNS. In addition, in turn Is subdivided into three components: sympathetic, parasympathetic and enteric.

Thus, the sympathetic nervous branch, forms part of the autonomic nervous system and is responsible for the regulation of involuntary movements and processes Homeostasis of the organism. Specifically, the sympathetic nervous system is responsible for the production of defense responses to events or Circumstances that represent a danger, potential or real (Navarro, 2002).

The sudden and massive activation of the sympathetic system produces a wide variety of relationships among which we can highlight: pupillary dilatation, Sweating, increased heart rate, bronchial dilatation, etc. (Navarro, 2002).

Therefore, when a damage or injury affects the sympathetic system, it is possible that abnormal responses will occur systematically, as is the case Of Sudeck syndrome.

About us

Anyone can have Sudeck syndrome, regardless of age, sex, place of origin or ethnic group.

No significant differences have been identified in the age of onset, however, a higher prevalence of this age has been observed Pathology in women with a mean age of 40 years (National Institute of Neurological Disorders and Stroke, 2015).

In the case of the pediatric population, it does not appear before 5 years of age and, moreover, is scarcely prevalent before 10 years (National Institute Of Neurological Disorders and Stroke, 2015).

Although there are few statistical data related to this pathology, many point to an incidence of 5.6-26, 2 cases per 100,000 Inhabitants of the general population. In addition, the prevalence ratio is 4: 1 in favor of the female sex (Villegas Pineda et al., 2014).

On the other hand, the most frequent triggers are of a traumatic type, usually suffering from bone fractures (Villegas Pineda et al. 2014).

Signs and symptoms

The characteristic clinical picture of Sudeck syndrome includes a wide variety of signs and symptoms which, The temporal evolution of pathology (Díaz-Delgado Peñas, 2014):

Stage I or early

In the initial phase of Sudeck syndrome, symptoms can recur and persist indefinitely. In addition, the Usually slow, may start with a feeling of weakness or burning in some areas, followed by progressive stiffness.

Some of the most common alterations in this stage are:

• Pain : This symptom is the most defining feature of Sudeck syndrome. Many affected people describe it Like a burning or stabbing sensation that appears persistently. In addition, it presents some characteristics: Allodynia (Appearance in the presence of Benign or innocuous stimuli), decreased thresholds of pain or hyperpathy (delayed and exaggerated reaction to a cutaneous stimulus). Normally, Areas most affected by pain are the arms, legs, hands and feet.
• Edema : The affected areas usually show a swelling process due to an abnormal increase or accumulation of fluid in the Tissues.
• Livedo reticularis / extreme : This medical condition refers to the progressive development of a skin discoloration that tends to Appear reddish or bluish. It is fundamentally associated with the presence of edema , Dilation of blood vessels and reduction of body temperature.
• Alteration of body temperature: Changes in cutaneous temperature of affected areas are frequent, may vary Increasing or reducing the usual.
• Hyperhidrosis : Excessive sweating is another frequent medical finding in this pathology. It is usually Located.

Stage II

• Pain: This symptom presents in a similar way to the previous phase, however, it can be extended to other body areas, beyond Of the original surface and have to become more severe.
• Hard edema: As in the previous phase, the affected areas usually show a process of swelling due to an increase or Abnormal accumulation of fluid in the tissues. However, it has a hard, nondepressible structure.
• Alteration of sensitivity: Any stimulus can trigger the pain, in addition, the thresholds related to the Sensitivity and temperature perception are reduced. Touching or touching the affected area can cause deep pain.
• Pallor and cyanotic heat: It is frequent to observe a skin discoloration, tending to pallor. In addition, the affected areas, sometimes May have an elevated or reduced temperature compared to other body surfaces.
• Hair alteration: Hair growth slows or slows significantly. In addition, it is possible to identify Nail abnormalities such as grooves.

Stage III

• Pain: In this phase, the pain may present in an equivalent way to the previous phases, decrease or, in more serious cases, Present itself in a constant and intractable way.
• Muscular atrophy: Muscle mass tends to decrease significantly.
• Development of contractures and stiffness: Due to the muscular atrophy , Muscles may develop contractures and persistent stiffness. For example, the shoulders can remain"frozen"or fixed.
• Functional dependency: The motor capacity is severely reduced, so that many people affected, usually require Assist in carrying out routine activities.
• Osteopenia: Like muscle mass, bone volume or concentration can also be reduced to below normal levels or expected.

Causes

As we have pointed out above, the specific causes of Sudeck syndrome are not known exactly, despite being Related to the sympathetic nervous system (Mayo Clinic, 2014).

Apart from this, it is possible to classify this pathology into two fundamental types, with similar signs and symptoms, but with etiological causes Differentials (Mayo Clinic, 2014):

• Type I: Usually appears after suffering from an illness or injury that does not directly damage the peripheral nerves of the area Originating. This is the most frequent type, approximately 90% of those affected look like Sudeck syndrome type I syndrome.
• Type II : It usually appears after the suffering of a medical condition or event that partially or completely alters any of the branches Nerves of the extremity or originating area.

The etiological factors most related to this pathology include: trauma, surgery, infections, burns, radiation, paralysis, stroke, attacks Heart disease, spinal pathologies, or blood vessel-related disorders (National Organization for Rare Disorders, 2007).

On the other hand, we must emphasize that in some affected it is not possible to identify the precipitating factor and, in addition, cases have also been documented Relatives of the disease, so a potential field of research would seriously analyze the genetic patterns of this pathology.

More recent research suggests that Sudeck syndrome may be influenced by the presence of various factors Genetics. Several familial cases have been identified in which this pathology presents an early parity, with a high presence of Dystonia Muscular and, in addition, several of its members are severely affected (National Institute of Neurological Disorders and Stroke, 2015).

Diagnosis

The initial diagnosis of Sudeck syndrome is based on clinical observation (Kirkpatrick et al., 2003).

The medical specialist should recognize some of the features and manifestations most common in this pathology, therefore, the diagnosis is usually The following protocol (Kirkpatrick et al., 2003):

• Evaluation of the characteristics of the pain (temporal evolution, affected areas, etc.).
• Analysis of the function of the sympathetic nervous system.
• Analysis of the possible presence of edema and inflammation.
• Assessment of the presence of possible movement disorders.
• Evaluation of cutaneous and muscular structure (presence of dystrophy, atrophy, etc.).

In addition, once a consistent suspicion has been formed about the condition of this pathology, it is necessary to use different laboratory tests to Discard the presence of other differential pathological processes.

Some of the most commonly used tests include x-rays, tomography, Computed axial tomography , the nuclear magnetic resonance or the Scintigraphy (Cuenca Gonzáles et al., 2012).

In addition, the literature has also indicated the use of other tests such as intra-bone phlebography, thermography, skin fluximetry or The Q-SART (Cuenca Gonzáles et al., 2012).

Treatment

There is currently no cure identified for Sudeck syndrome, mainly due to the lack of knowledge of the mechanisms Etiological and pathophysiological.

However, there is a wide variety of therapeutic approaches that can be effective in controlling and alleviating the signs and symptoms that Affected people.

Thus, the National Institute of Neurological Disorders and Stroke (2015) points out some of the most commonly used therapies:

• Physical rehabilitation.
• Pharmacological treatment: analgesics, non-steroidal anti-inflammatory drugs, corticosteroids, anticonvulsants, Antidepressants , Morphine, among others.
• Pharmacological nerve sympathectomy (blocking sympathetic nerve branches through injection of anesthetics.
• Surgical nerve sympathectomy (injury or destruction of some nerve areas of the sympathetic branch).
• Nerve stimulation.
• Intratectal infusion of analgesic and opiate drugs.
• Emergent or in the test phase treatments: intravenous immunoglobulin, ketamine or hyperbaric chambers, among others.

Medical Forecast

The medical prognosis and evolution of pathology varies significantly among the affected individuals. In some cases, it is possible to observe a Complete and spontaneous remission of symptoms.

However, in other cases, both pain and other pathologies are usually present in an irreversible, persistent and resistant to the therapies of Pharmacological type.

Apart from this, specialists in the treatment of pain and Sudeck syndrome, point out that it is essential to approach Early pathology, as it helps to limit its progression.

Sudeck syndrome is still a poorly understood disease, there are few clinical studies to clarify the causes, the Clinical course and the role of experimental therapies.

References

1. Cleveland Clinic. (2016). Complex Regional Pain Syndrome . Obtained from Cleveland Clinic.
2. Cuenca González, C., Flores Torres, M., Méndez Saavedra, K., Barca Fernández, I., Alcina Navarro, A., & Villena Ferred, A. (2012). Pain Syndrome Regional Complex. Rev Clin Med Fam , 120-129.
3. [Links] Complex Regional Pain Syndrome. Spanish Association of Pediatrics , 189-195.
4. Gómez Jiménez, M., Viñolo Gil, M., Iglesias Alonso, A., Martínez Martínez, I., & Aguilar Ferrándiz, E. (2009). Symptoms and Treatment of Syndrome Regional pain Complex. Physiotherapy , 60-64.
5. Kirkpatrick, A., Román, G., & Nuñez Gudás, M. (2013). SYMPATHETIC DYSTROPHY REFLEX / REGIONAL PAIN SYNDROME COMPLEX (DSR / SRDC) . Obtained Of the International Research Foundation for RSD / CRPS.
6. Mayo Clinic. (2014). Complex regional pain syndrome . Obtained from Mayo Clinic.
7. NIH. (2015). Complex Regional Pain Syndrome Fact Sheet . Retrieved from the National Institute of Neurological Disorders and Stroke.
8. NORD. (2007). Reflex Sympathetic Dystrophy Syndrome . Retrieved from the National Organization for Rare Disorders.
9. Redolar, D. (2010). Cognitive Neuroscience. Madrid: Panamericana.
10. Ribera Canudas, M. (2016). Complex Regional Pain Syndrome Type I and Type II.
11. Rodrigo, M., Perena, M., Serrano, P., Pastor, E., & Sola, J. (2000). Complex regional pain syndrome. Rev. Soc. , 79-97.
12. Rogers, J., & Ramamurthy, S. (2016). Complex regional pain syndrome. Elsevier .
13. Villegas Pineda, M., Herera, C., León Martínez, T., & Ordoéz Fernández, V. (2014). Impact of management with neurostimulation in a patient with syndrome Painful complex and severe trophic changes. Case report. Rev. Anestesiol. , 321-324.
14. Image source .