Changing Trends in Causalgia

Michael J. Spebar, MD, Fort Sam Houston, Texas

Daniel Rosenthal, MD, FACS, Fort Sam Houston, Texas

George J. Collins, Jr., MD, FACS, Fort Sam Houston, Texas

Bruce S. Jarstfer, MD, FACS, Fort Sam Houston, Texas

Michael J. Walters, MD, FACS, Fort Sam Houston, Texas

For many years, military surgeons have noted that wounds of the extremities resulting in partial tran- section of peripheral nerves caused serious disability, despite the fact that the wounds heal well and with- out significant neurologic deficit. Pain, disability and neurologic symptoms extending beyond the distri- bution of the injured nerve sometimes occur without obvious reason. Mitchell et al [1] described this post-traumatic pain syndrome based on their ob- servations during the American Civil War and later named this syndrome causalgia for the burning pain that resulted [2]. Recently, other forms of post- traumatic disability were recognized and unified by Patman et al [3] under the term mimocausalgia. As the term is currently understood, causalgiu encom- passes a broader spectrum of post-traumatic disa- bilities than the burning pain that Mitchell et al originally described. Recent experience with this disorder was examined to assess the impact of mod- ern therapeutic modalities on the disorder as we now understand it.

Clinical Material

Medical records of patients hospitalized on the Pe- ripheral Vascular Surgery Service at Brooke Army Medical Center during the years 1976 through 1980 with a diagnosis of causalgia, sympathetic dystrophy, &deck’s atrophy or other post-traumatic pain syndromes were reviewed. Those with persistent pain or other post-traumatic disability not confined to a discrete nerve distribution were selected for study. Patients with neuromas or “phanthom-limb” syn-

From the Peripheral Vascular Surgery Service arkI General Sugery Service, Department of Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflacting the views of the Department of the Army or the Department of Defense.

Requests for reprints should be addressed to Michael J. Spebar, MD, Department of Peripheral Vascular Surgery, Brooke Army Medical Center, Fort Sam Houston, Texas 78234.

Presented at the 33rd Annual Meeting of the Southwestern Surgical Congress, Monterey, California, May 4-7, 1981.

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drome were not considered. The patients who presented with uncertain, ill-defined symptoms were likewise elimi- nated. For each patient selected, the following factors were then examined: age, sex, initiating traumatic event, symptoms and their duration, therapeutic methods em- ployed and their effectiveness.

Results

Twenty-two patients satisfying the criteria of this review were identified. Their symptoms were as fol- lows: burning pain, 15 patients; hyperesthesia, 6; dull ache, 7; discoloration, 7; swelling, 11; increased sweating, 2; and decreased sweating, 1. Ten patients presented with pain alone and 12 patients com- plained of multiple symptoms. The most frequent combination was pain and swelling (seven patients). The average duration of symptoms was 11.7 months, ranging from 2 weeks to 4 years after the initial trauma.

The causes of trauma in these patients were as follows: fracture, eight patients; sprain, four; intra- muscular injection, one; angiography, one; laminec- tomy, two; carpal tunnel release, two; trigger-finger release, one; radical mastectomy, one; and unknown, one. Orthopedic injuries such as fractures and sprains were the most common form of injury (54.5 percent). This syndrome occurred as a postoperative compli- cation in six patients (27.3 percent). Clearly definable nerve damage was evident in 10 patients (45.5 per- cent). No nerve injury required operative repair. All injuries were either contusion, partial transection or stretching injuries. The nerve injury resulted from penetrating trauma in three instances (13.6 per- cent).

The treatment methods employed are summarized in Table I. Paravertebral sympathetic blockade and sympathectomy were the most commonly employed forms of therapy. Eight patients underwent sympa- thectomy. Four of these were cured and two were

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Changing Trends in Causalgia

improved after the procedure. One of these patients had undergone an extended ipsilateral sympathec- tomy for recurrence of symptoms after successful lumbar sympathectomy. Two of the patients who had undergone sympathectomy remained unchanged in the immediate postoperative period but were later cured after rhizotomy in one and laminectomy in another. Overall, 90.5 percent of the study patients were cured or improved on discharge from the hos- pital. Seven patients were asymptomatic (31.8 per- cent) and 13 were symptomatically improved (59.1 percent) with objective evidence of increased func- tion. Only one patient remained unchanged despite treatment. The remaining patient died from unre- lated illness before treatment was instituted.

Comments

From the time of Ambrose Pare’s first case de- scription and Mitchell’s naming and description of the syndrome, causalgia has been a sequela of mili- tary trauma [4,5]. Penetrating wounds from swords, bayonettes or missiles may partially sever or contuse peripheral nerves of the extremities. Causalgia is a sequela in 2 to 5 percent of these injuries 161. Severe functional disability of the extremity results despite the apparent anatomic integrity of the injured nerve and muscle groups. As other causalgia-like post- traumatic disabilities were subsequently described, Mitchell’s original definition of burning pain began to blur. Many synonyms were used in an attempt to broaden Mitchell’s term but each new synonym only obscured the concept. Patman et al [3] appreciated the similarity of these “causalgia-like” states and unified them under the concept of mimocausalgia.

The term causalgia as presently understood de- scribes a syndrome of post-traumatic disability en- compassing more than the burning pain that Mitchell originally intended for the term. His writings also described the atrophy, trophic changes, edema, temperature alterations and sweating abnormalities of the affected extremities associated with nerve in- juries [I]. Over the century since the term causalgia appeared, these observations were incorporated into the meaning of this word. As now understood, the burning pain is a prominent feature but no longer an essential element in the diagnosis and application of the term causalgia. It is apparent from this series that there are a variety of symptoms resulting in long-term disability of a previously injured extrem- ity. The burning pain as described by Mitchell is the most commonly encountered form but only a part of a spectrum of post-traumatic disabilities. The com- mon denominator in this continuum appears to be the involvement of the sympathetic nervous system [3,71.

Although the cause of causalgia is unknown, cur- rent knowledge suggests that the sensory input nor- mally modulated by the sympathetic nervous system

TABLE I Results of Treatment Methods

Treatment

Total Patients Performed Cured or

(n) Improved (n)

Sympathetic blockade 15 7 Peripheral nerve injections 1 0 Physical therapy 4 0 Transcutaneous nerve stimulation 5 3 Sympathectomy 8 7 Rhizotomy 1 1 First rib resection 1 0 Carpal tunnel release 1 0 Laminectomv 1 None .

0 1 0

is disturbed. The resulting sympathetic dysfunction allows extraordinary sensory input from ordinary stimuli that the brain interprets as pain [3]. The patient uses the affected extremity less. After a pe- riod of time, this results in muscle atrophy, trophic changes of the skin and demineralization of the bones. Aside from the pain and disuse, other symp- toms of sympathetic dysfunctions such as flushing, rubor, alterations in temperature, sweating and edema are seen. Only when the focus of therapy is the sympathetic nervous system is the treatment of this syndrome successful.

Earlier forms of treatment directed towards the injured nerves were rarely successful and often worsened the disability. In 1930, Spurling [8] dem- onstrated that sympathetic interruption cured this disorder. Treatment directed at the sympathetic nervous system was frequently employed in this se- ries. Initially used were epidural morphine injections or percutaneous sympathetic blockade with local anesthetics. These measures were sometimes curative after single or repeated injections and no further treatment was necessary. When symptoms returned after temporary relief by local sympathetic blockade, permanent relief usually followed surgical removal of a portion of the cervical or lumbar sympathetic chain. In the few patients whose symptoms recurred or failed to respond, more radical neural interruption was later successful.

Relief of pain was only a part of the therapeutic program. Relieving pain permitted the patient to effectively participate in the physical therapy pro- gram. To regain normal function, restoration of normal muscle tone, strength and range of motion are important [9]. The physical therapist is a valuable participant in the patient’s rehabilitation.

The presenting symptoms in this series differ somewhat from those described in many previously presented reviews [3,6,10]. Penetrating trauma was present in only 13.6 percent of these patients and clearly definable antecedent nerve injury was evident in only 45.5 percent. The near-total absence of gun- shot wounds in this peacetime series altered the

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Spebar et al

distribution so that orthopedic injuries emerged as the most common form of trauma. In many of these injuries such as sprains and fractures, nerve injury was obscure or absent.

Shumacker et al [IO] and Patman et al [3] both emphasized the decreased possibility of improve- ment if treatment is delayed beyond 6 months. The average duration of symptoms in this review was 11.7 months. Several patients were treated with analge- sics, exercise, local injections and reassurance before the true nature of their disability was appreciated. This reflects a lack of awareness of the multiple presentations and extent of disability that may result in patients with causalgia. Despite the relatively long period of time which elapsed until a diagnosis of causalgia was established and appropriate therapy instituted, 90.5 percent of patien ts in this series were cured or improved. These results point out that sympathetic interruption is still an effective mode of therapy, even in patients with a delayed diagnosis of causalgia.

Summary

The term causalgia as currently understood en- compasses a wider range of post-traumatic disabili- ties than Mitchell’s original definition as burning pain. In this series, orthopedic injury replaced pen- etrating trauma as the most common initiating event. Injury to a peripheral nerve may be ill-defined or absent. Serious disability may arise from what ap- pears to be a minor injury. When causalgia is recog- nized and appropriate therapy instituted, nearly all patients improve.

References 1. Mitchell SW, Morehouse GR, Keen WW. Gunshot wounds and

other injuries of nerves. Philadelphia: JB Lippincott, 1864. 2. Mitchell SW. Injuries of nerves and their consequences. Phil-

adelphia: JB Lippincott, 1872.

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Patman RD, Thompson JE, Persson AV. Management of post- traumatic pain syndromes: report of 113 cases. Ann Surg 1973;177:780-7.

Kirklin JW, Chenoweth Al, Murphey F. Causalgia: a review of its characteristics, diagnosis and treatment. Surgery 1946;21:321-42.

De Takats G. Causalgia states in war and peace. JAMA 1945; 128:699-704.

Freeman NE. The treatment of causalgia arising from gunshot wounds of the peripheral nerves. Surgery 1947;22:68-82.

Nathan PW. On the pathogenesis of causalgia in peripheral nerve injuries. Brain 1947;70:145-70.

Spurling RG. Causalgia of the upper extremity: treatment by dorsal sympathetic ganglionectomy. Arch Neurol Psychiatr 1930;23:784-8.

Shumaker HB, Abramson DI. Post-traumatic vasomotor dis- orders with particular reference to late manifestations and treatment. Surg Gynecol Obstet 1949;88:417-34.

Shumaker HB, Speigel IJ, Upjohn RH. Causalgia: the role of sympathetic interruption in treatment. Surg Gynecol Obstet 1948;86:76-86.

Discussion

Don L. Christensen (Las Vegas, NV): I recently had a patient with radical mastectomy who had causalgia and no evidence of recurrent breast disease, and sympathetic blockade on two occasions had been unsuccessful in re- lieving the pain. Would you consider sympathectomy in this type of situation?

Michael J. Spebar (closing): We did not see any patient that had neuritis after surgical sympathectomy. However, two patients in our series failed to respond after sympa- thetic blockade and sympathectomy but later responded to radiofrequency rhizotomy and laminectomy. Their disability was probably due to sympathetic neuritis. We also had one patient who had causalgia of the arm after radical mastectomy. This patient had a good response to percutaneous blockade and subsequently underwent cer- vical sympathectomy with a good result. It is very difficult to figure out what to do with the patient who does not re- spond to percutaneous blockade. In that situation we go ahead with sympathectomy, knowing that our results may not be completely successful, but that it does offer some chance for relief.

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