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Navigator: CRPS Type I (RSD) ˆ

Complex Regional Pain Syndrome (Type I)

Diagnostic Evidence:  Photographs and Bone Scans

Maturing Taxonomy: Causalgia / RSD / CRPS

1864:  Causalgia

During the American Civil War, experimental physiologist Silas Mitchell studied soldiers from the battlefield who suffered peripheral nerve injuries which didn't heal, but led to long-term sequela of burning pain.

In 1864 Mitchell named the condition causalgia from the Greek word kausos, meaning heat.

1946:  Reflex Sympathetic Dystrophy

As physiology advanced, the enduring pain was ascribed to hyperactivity of the sympathetic nervous system within the injured limb.

In 1946 this organic cause was incorporated into a new name for the disease, Reflex Sympathetic Dystrophy.

1993:  Complex Regional Pain Syndrome

Pain clinics worldwide compared notes: Sympathetic nerve blocks were proving futile for many patients. A question emerged: Did different subsets of the disease exist, each mediated through a different axis?

Three mediators were proposed: sympathetic nervous system, central nervous system, and inflammation.

This question drove a change in taxonomy: The modern name is Complex Regional Pain Syndrome (Type I), an umbrella term for all nerve injuries which are diffuse rather than localized.

RSD Right Foot:  Surgical Complication

I developed Reflex Sympathetic Dystrophy in my right foot – or to use its modern name, Complex Regional Pain Syndrome (Type I). My RSD was the sequel of a surgical bone biopsy performed by orthopedist Dr. Jeff McKerrell of Saskatoon, Canada. Beforehand, I was led to believe it would be a core biopsy, and I should be walking again in two days.

Instead, Dr. Jeff McKerrell performed an open biopsy through a two-inch incision on the top of my foot. Within an hour of the biopsy, clear evidence of a complication emerged.

Before I left the OR Recovery Room, my right foot was morbidly swollen. There were also color changes: my foot was blue from my toes up past my ankle. Pain was intense: My right foot felt like a vast brick of sharp stabbing and deep aching. Constant elevation was needed to relieve these symptoms.

Despite these signs – and despite my repeated visits to his office – my orthopedic surgeon Dr. Jeff McKerrell did not diagnose my case of RSD until three months later.

Reflex Sympathetic Dystrophy is uncommon, with little medical expertise available in small centers such as Saskatoon. After a year of no improvement in my foot, I asked for a referral out-of-province to see rheumatologist Dr. Milton Baker in Victoria, B.C.

Below is a pictorial record of the Reflex Sympathetic Dystrophy in my right foot including photographs (taken from video), and two Nuclear Medicine Bone Scan films. Timeline:

Date Procedure Circumstance
1999 February Nuclear Medicine
Three-Phase Bone Scan
Full-Body plus Close-Up of Feet
Before onset of RSD
1999 September Surgical Bone Biopsy Caused RSD in right foot
2000 January Nuclear Medicine
Three-Phase Bone Scan
Close-Up of Feet
After onset of RSD
2003 November
& December
Photographs and Video During RSD flare

The two Nuclear Medicine Bone Scans happen to bracket the onset of my case of Reflex Sympathetic Dystrophy, and form a useful pictorial comparison:

First Bone Scan: Before Onset of RSD

A full-body Three-Phase Bone Scan was done routinely to monitor my Lupus arthritis. In Feb 1999, new hot spots – high uptake of the radioactive tracer – emerged in my right foot. Close-up scans were then taken of my feet. The hot spots led to the bone biopsy. These hot spots did not have the characteristic appearance of RSD, however, and at that time I had no RSD symptoms.

Second Bone Scan: After Onset of RSD

A Three-Phase Bone Scan (close-up of the feet only) was done post-surgery for the express purpose of imaging the new symptoms in my right foot (gross swelling, color changes from blue to red, hair growth on toes, brittle nails, intense pain). The scan verified the diagnosis of Reflex Sympathetic Dystrophy. The optimal time window to image Stage I of RSD is 0 to 20 weeks from disease onset. My Scan was performed 20.7 weeks from RSD onset.

Georgena Sil: Patient Log RSD (p 3)

Patient Log: Georgena Sil
Reflex Sympathetic Dystrophy

Three-Phase Bone Scan Film / Diagnosis: Reflex Sympathetic Dystrophy

Scan Date: January 31, 2000
Time Delay: 20 weeks, 5 days after RDS onset
Patient: Georgena Sil, Saskatoon
Marker: Black dot indicates right side

Film: Three-Phase Bone Scan (closeup of both feet). Diagnostic of Reflex Sympathetic Dystrophy in Right Foot. Scan 20.7 weeks after symptom onset.

Three-Phase Bone Scan Film / Hot Spots, Right Foot

Scan Date: February 8, 1999
Patient: Georgena Sil, Saskatoon
Marker: Black dot indicates right side

Film: Three-Phase Bone Scan (close-up of both feet). Before onset of Reflex Sympathetic Dystrophy.

Photo Gallery: Reflex Sympathetic Dystrophy (CRPS Type I)

Images: Freeze-frames from Hi8 Analog Video
Patient: Georgena Sil
Status: Severe flare of RSD symptoms

RSD right foot: Compare lower limbs, both sides (long view)

View of both limbs for comparison: RSD symptoms are prominent in the right foot, with swelling and color changes extending up the calf to the knee.

© Georgena S. Sil, Saskatoon

RSD right foot: Dusky red color toes to knee; swelling

Close-up of right foot: Gross swelling. Foot is uniformly bright red; the ankle is fiery. Dark, dusky red extends up to the knee. Toes can go blue. Pain is intense.

© Georgena S. Sil, Saskatoon

RSD right foot: Red blaze across inner ankle; inflammation

Close-up of right ankle: The angry red flare blazing across the inner aspect of the ankle points out the inflammatory component of RSD (modern name CRPS Type I).

© Georgena S. Sil, Saskatoon

RSD right foot: 2-inch scar atop foot from bone biopsy

Two-inch scar from bone biopsy is visible atop the right foot. That surgical procedure caused the immediate onset of RSD. In OR Recovery, foot was swollen and blue.

© Georgena S. Sil, Saskatoon

RSD right foot: Ankle swollen and stiff; nails brittle

The vast swelling in the right foot makes it stiff. To bend the ankle is a work project. Other symptoms: nails are brittle; sweating in that limb is abnormal.

© Georgena S. Sil, Saskatoon

RSD right foot: Compare lower limbs, both sides (close-up)

RSD measures at 42 out of a maximum 50 on the McGill Pain Scale. Specialists in Pain Management say RSD is the most painful chronic disease known.

© Georgena S. Sil, Saskatoon

Georgena S. Sil
Saskatoon, Canada
Physicist & Technical Writer
Alumnus: University of British Columbia
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