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Dr Piñal: “There are many patients labeled as sick of reflex sympathetic dystrophy or Sudeck’s dystrophy who actually suffer from a pathology that we haven’t been able to identify”

28 November, 2018

Weeks after cast_CRPS1_Luc03_20181108_2

As a result of his research work, Dr. Piñal believes that after diagnoses of reflex sympathetic dystrophy, we find diagnostic mistakes and lack of knowledge of a hidden pathology. In turn, he has identified that around 20% of these cases can be addressed as neurostenalgies and forms of dynamic compression of the median nerve.

This percentage of diagnoses of reflex sympathetic dystrophy or Sudeck’s dystrophy responds to a situation of very intense pain, severe swelling and nocturnal worsening of the clinic, together with another specific functional factor: the inability to close the fist completely in the affected limb.

Patient diagnosed with reflex sympathetic dystrophy
In the image, a limb diagnosed with reflex sympathetic dystrophy weeks after the removal of the plaster that addresed the initial fracture. One of the cases resolved by Dr Piñal thanks to the new research he will present in the USA.

According to its characteristics, Dr Piñal has named this condition dynamic compression of the median nerve. Likewise, he has identified that around 2 in 10 patients diagnosed with reflex sympathetic dystrophy (CRPS1 or complex regional pain syndrome) have a clinical picture identical to patients with median nerve neurostenalgia, but after going through previous surgery or a traumatic event.

Patient with bilateral carpal tunnel syndrome
79 year old patient. Hands in maximum extension. He presents a picture of affection to both median nerves of the wrists without there being a previous traumatic event.

We speak with the Spanish surgeon about this, before the presentation of his conclusions in the USA.

Dr. Piñal, before entering into this latest investigation, just a nuance: You have always denied the existence of Sudeck’s dystrophy as a specific pathology, why?

My work and experience of decades has led me to the conclusion that reflex sympathetic dystrophy is a sort of catch-all. Let’s say that it is a way to ‘label’ the patient when our diagnostic capabilities and, therefore, of offering adequate treatment, are overcome. Obviously, we are not talking about a harmless phenomenon, but rather one which deprives those affected of the development of a normal daily life and forces them to take an analgesic and neuromodulatory pain medication that they do not need, while the actual key is in an analysis and correct identification of their pathology.

In the last few weeks alone, I have treated several people diagnosed with reflex sympathetic dystrophy or Sudeck’s dystrophy who were masking cases of rheumatoid arthritis, metacarpal fractures, radius malunions or poorly placed prostheses. Without forgetting the percentage of clinical pictures of dynamic compression of the median nerve that constitute the core of my latest research.

Dr Piñal, which is the final goal of this research we are examining?

In essence, it is a question of linking these pathologies using the same surgical approach to nerve release, which has allowed us to reach a high cure rate in this profile of patients with previous diagnosis of reflex sympathetic dystrophy.

In fact, my conclusion is that there is overwhelming practical evidence that posttraumatic sympathetic reflex dystrophy and the neurostenalgies and compressions of the median nerve constitute the same type of pathology, but with different triggers; what puts into question the very existence of CRPS1 as such.

 

However, the diagnoses of reflex sympathetic dystrophy continue despite you have been considering them as diagnostic errors for years …

The reflex sympathetic dystrophy, algodystrophy, CPRS1 … departs from a very intense pain pattern, a disproportionate suffering to what the patient should feel after a traumatic event. In addition, it is accompanied by a whole procession of vasomotor symptoms: swollen, cold or hot hands, sometimes reddened, etc.

So far everything is physiological and can respond to the picture after a fracture or trauma, but when it reaches an intensity well above normal is when the wrong diagnosis of dystrophy usually appears.

What is normal and what is not?.

For the most part it depends on the doctor and this is where the subjective assessment of the professional comes in. Precisely, this subjective variable is a source of doubts in the clinical process that can have negative consequences for the patient.

From this point is where we reach the core of the problem I was referring to: there are many patients labeled as sick with reflex sympathetic dystrophy or Sudeck dystrophy who actually suffer from a pathology that we haven’t been able to identify.

In my opinion, we are not talking about a pathology per se, but of a sort of wild card to which very diverse medical situations are ascribed. The first category and with less incidence is associated with a psychological condition of the patient, such as conversion disorders; the second major category is that of diagnostic errors and lack of identification of the hidden pathology; while the third, on which I have been working with special intensity and whose results I will present at the American Society for Surgery of the Hand (ASSH), corresponds to patients with all the described vasomotor symptoms and dynamic compressions of traumatic origin in one or both median nerves.

Which’s been the key element in reaching this conclusion?

As I noted, the work of years with patients with a very similar symptom picture but without previous trauma, that is, people suffering from other processes with involvement of the median nerve.

Having established this relation, I have used the clinical approach of the aforementioned dynamic compressions of the median nerve with patients diagnosed in the third major category of reflex sympathetic dystrophy, which I previously described. To date I have cured them all, through a minimally invasive procedure.

How’s been your methodology?, Dr Piñal

The observation,which unfortunately is a part of medecine little valued currently. Today, any outstanding progress is only accepted in the company of objective data, statistics and a certain scientific methodology. Although this is appropriate, we can not forget that observation has contributed greatly to the progress of medicine. Through observation, Fleming discovered the bactericidal effect of penicillin, for example.

In hand surgery, thanks to it, syndromes such as “partial thenar atrophy” and “acroparesthesia” (also known as “hysterical nocturnal paresthesia” or “vasomotor neurosis”) merged to give rise to the well-known carpal tunnel syndrome. It is amazing that the operation that’s most often performed by a hand surgeon, the release of the carpal tunnel (CTR) was unknown until 1950.

Any recommendation to patients diagnosed with reflex sympathetic dystrophy?

As I have done on previous occasions, my recommendation is that they do not resign themselves to pain, that they do not give up without at least a second opinion about the medical-surgical approach of their situation. The healing of cases of dystrophy by minimally invasive surgery, that has occupied much of our conversation, is a perfect example of why.

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