Regarding "efficacy of stellate ganglion blockade for the management of type 1 complex regional pain syndrome".

To the Editor: We read with interest the article by Ackerman and Zhang (1) examining the efficacy of stellate ganglion blockade (SGB) in patients with complex regional pain syndrome type I (CRPS I) of the hand.

A large percentage of patients achieved complete (40%) or partial (36%) relief of their symptoms. Only 6 of 25 (24%) patients showed no relief. However, as the authors correctly pointed out, SGB is not a totally benign procedure. Furthermore, not all patients with CRPS of the hand respond to this therapy. (1)

We recently published our 2-year results from the treatment of 17 patients with CRPS type I of the hand. (2) Briefly, the protocol we applied consisted of:

1. Five sessions (one every 2nd day) of intravenous regional administration (intravenous regional sympathetic block, IRSB) of 15 mg guanethidine and 1 mg lidocaine/kg body weight each, followed by:

2. Twenty sessions (twice a week) of IRSB of 10 mg guanethidine and 1 mg lidocaine/kg body weight each.

Both short- and long-term (2 year) results of our protocol were excellent. All patients were relieved of their symptoms. Full restoration of both function and movement of their affected hand was successfully accomplished.

A main limitation of both studies (1,2) is the lack of a placebo control group due to obvious ethical reasons. A drawback of our study compared with stellate ganglion blockade (1) is the relatively high cost and duration of treatment protocol (slightly more than 11 weeks).

An early randomized trial (3) comparing the efficacy of IRSB with guanethidine versus SGB on 19 patients with CRPS type I demonstrated that 4 patients who received IRSBs with guanethidine (one every 4 days) were comparable with 8 patients on SGBs (1/day) regarding perception of pain, vasomotor disturbances, trophic changes, edema, and range of motion. However, the IRSBs with guanethidine gave longer lasting and superior results regarding some early pharmacological effects, such as skin temperature, compared with SGB. Furthermore, the risks and contraindications of IRSB with guanethidine are significantly less.

We recognize that this study is probably outdated (3) since it is more than two decades old. Advances in technology, as well as the increased experience of physicians, could explain the better results achieved by Ackerman and Zhang. (1)

Based on these two studies, (1,2) we would propose a combined therapeutic approach for patients with CRPS. Both strategies use the same principle (sympathetic blockade). On the grounds of cost-effectiveness and time, SGB could be tried first for the treatment of CRPS type I. However, if the outcome is not satisfactory, IRSBs with guanethidine and lidocaine, according to our protocol, (1) should be employed.

Kosmas I. Paraskevas, MD, FASA 

Department of Vascular Surgery

Athens University Medical School

Athens, Greece

Department of Clinical Biochemistry (Vascular Disease Prevention Clinic) and Academic Department of Surgery

Royal Free Hospital

London, United Kingdom

Alexandra A. Michaloglou, MD

Maria Samara, MD

Department of Anesthesiology

General Prefecture Hospital of Larissa

Larissa, Greece

Despina D. Briana, MD

Neonatal Division, Second Department of Obstetrics and Gynecology 

Athens University Medical School

Athens, Greece

References

1. Ackerman WE, Zhang JM. Efficacy of stellate ganglion blockade for the management of type 1 complex regional pain syndrome. South Med J 2006;99:1084-1088.

2. Paraskevas KI, Michaloglou AA, Briana DD, et al. Treatment of complex regional pain syndrome type I of the hand with a series of intravenous regional sympathetic blocks with guanethidine and lidocaine. Clin Rheumatol 2006;25:687-693.

3. Bonelli S, Conoscente F, Movilia PG, et al. Regional intravenous guanethidine vs stellate ganglion block in reflex sympathetic dystrophies: a randomized trial. Pain 1983;16:297-307.