Response to Dr. Paraskevas' comments.

To the Editor: Dr. Paraskevas and colleagues (1,2) present an interesting and important alternative modality for the treatment of Complex Regional Pain Syndrome (CRPS) with the utilization of intravenous (IV) guanethidine. Guanethidine is available for IV use in other countries but is not commercially available in the United States. Guanethidine exerts its effects at the postganglionic terminals of adrenergic neurons. Sympathetic sprouting can occur in the dorsal root ganglia of patients with CRPS. We hypothesized in our article that stellate ganglion blockade should be done before significant sympathetic sprouting occurs. We further hypothesize that the use of fluoroscopy when doing stellate ganglion blockade improves safety and efficacy as the spread of the injectate can be controlled and detection of intravascular needle tip placement can be readily ascertained. However, as we reported, a significant number of patients experience no pain relief with stellate ganglion blockade. A number of patients with CRPS ultimately require placement of a spinal dorsal column stimulator for attempted pain control. (3) The use of IV guanethidine with lidocaine as proposed by Dr. Paraskevas and colleagues is an excellent alternative and/or adjunct therapy to current accepted therapies and should prove to be cost-effective.

William E. Ackerman, MD

Jun-Ming Zhang, MSc, MD

Division of Pain Medicine

Central Baptist Hospital

Neuroscience Center

Lexington, KY

References

1. Paraskevas KI, Michaloglou AA, Briana DD, Samara M. 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.

2. Paraskevas KI, Samara M, Briana DD, Michaloglou AA. Regarding Ackerman WE, Zhang JM. Efficacy of stellate ganglion blockade for the management of type I complex regional pain syndrome. South Med J 2007;100:411-412.

3. Kemler MA, Barendse GA, van Kleef M, et al. Spinal cord stimulation in patients with chronic reflex sympathetic dystrophy. N Engl J Med 2000;343:618-624.