Keywords

3.27.2013
D. Shaker
Mentor: J. Grass MD

CRPS I: Early Sx
In the first 1-3 months. Pain: Localized, severe, burning. Extremities: warm. Skin: dry and red.
Radiography: normal.

Three stages may occur during the course of CRPS:

Stage 1 Either following an event or without apparent cause, the patient develops pain in a limb. The
essential features include burning and sometimes throbbing pain, diffuse uncomfortable aching,
sensitivity to touch or cold, and localized edema. The distribution of the pain is not compatible with a
single peripheral nerve, trunk, or root lesion. Vasomotor disturbances occur with variable intensity,
producing altered color and temperature. The radiograph is usually normal but may show patchy
demineralization.

Stage 2 The second stage is marked by progression of the soft tissue edema, thickening of the skin
and articular soft tissues, muscle wasting, cold, clamy, and the development of brawny skin. This may
last for three to six months.

Stage 3 The third stage is most severe. It is characterized by limitation of movement, the shoulder-
hand syndrome (capsular retraction producing a frozen shoulder), contractures of the digits, atrophic
changes, shiny and tight skin changes, and brittle ridged nails. Bone radiography reveals severe
demineralization.

Autonomic features including cyanosis, mottling, increased sweating, abnormal growth of hair,
diffuse swelling in nonarticular tissue, and coldness may occur in the later stages. Urologic
manifestations include detrusor hyperreflexia or areflexia, producing urgency, frequency,
incontinence, or urinary retention.

Myofascial pain syndrome: Dx

- Is characterized by widespread aching which is deep and poorly circumscribed. There is
associated erythema, stiffness, and fluctuation in pain intensity.
- It usually occurs in 3rd to 4th decade
- Presence of deep, discrete trigger points which usually lie within muscle.
 - Fatigue, mental stress, cold damp weather and either under or over activity often aggravate
the problem. Rest, heat, massage often improve it.
- Trigger points are often treated successfully with local anesthetic injection.
Diagnosis of myofascial pain is made by palpation of trigger points reproducing pain that is
characterized as explicitly tender and narrowly localized, aching and lingering associated with
stiffness, muscle spasm or muscle weakness as well as some degree of autonomic dysfunction.

Postherpetic neuralgia: Risk factors

Age: rare before age 40, neaqrly 50% in patients > 60 years.
Severe pain during acute phase: these patients are more likely to develop postherpetic neuralgia.
Sensory abnormalities during acute phase: most patients recover over several months but in 10-20%
of patients the pain persists longer.
Herpes zoster is caused by the varicella zoster virus which lies dormant in dorsal root ganglia and
becomes active again during immunosuppression or as immunity declines with advancing age. Herpes
zoster most commonly involves the thoracic and trigeminal dermatomes with the most common
being the thoracic distribution, followed by the ophthalmic division of the trigeminal nerve.
Postherpetic neuralgia is defined as pain in the affected dermatome persisting well beyond healing
of the skin rash (4 weeks to 6 months). The incidence is considerably higher in older patients (16% in
patients younger than 60 years old, 47% in patients older than 60 years). Pain can be spontaneous
and constant, stabbing or shooting, aching, or dyesthetic provoked by light tactile stimulation
(allodynia), which lasts longer than the duration of the stimulus (hyperpathia).

QUESTION:
The stellate ganglion:
A) Contains cell bodies of postganglionic sympathetic fibers that supply the pupil.
B) Is part of the craniosacral outflow
C) Sends gray rami communicantes to the 9th and 10th cervical and 1st and 2nd thoracic nerves
D) Sends preganglionic fibers to the deep cardiac plexus
E) None of the above

Sources:
Openanesthesia.org, big blue, keywords book.