Reflex Sympathetic Dystrophy – Surgical Option

What Is Reflex Sympathetic Dystrophy?

Reflex Sympathetic Dystrophy (RSD) — now more commonly referred to as Complex Regional Pain Syndrome (CRPS) — is a chronic pain condition where patients experience severe, disproportionate pain in a limb following an injury. The pain is thought to originate from abnormal or increased activity in the sympathetic nervous system — the same nerve chain involved in hyperhidrosis treatment.

CRPS is a rare diagnosis. It typically emerges after a triggering event such as electrocution, a fracture, surgery, or soft-tissue injury, and it is initially managed by pain management specialists. It is only when standard pain management approaches fail that surgical sympathectomy enters the picture.

The Sympathetic Nervous System Connection

In CRPS, current theories suggest the sympathetic nervous system becomes dysregulated following injury — continuing to fire abnormal signals that amplify and sustain pain far beyond what the original injury would produce. This is described as sympathetically maintained pain.

This is the same sympathetic chain targeted during Endoscopic Thoracic Sympathectomy (ETS) for hyperhidrosis. Because Dr. Basseri has extensive expertise in sympathectomy procedures, he is one of the few surgeons qualified to evaluate whether surgical sympathectomy may help patients with refractory CRPS.

How Does CRPS Present?

Patients with CRPS typically experience a cluster of symptoms in the affected limb that go well beyond normal injury pain:

• Disproportionate chronic pain — burning, aching, or stabbing sensations that persist long after the initial injury should have healed
• Skin changes — discolouration, abnormal texture, increased sensitivity to touch or temperature
• Temperature abnormalities — the affected limb may be noticeably warmer or cooler than the other side
• Swelling and stiffness — reduced range of motion in the affected area
• Sweating changes — either increased or decreased sweating in the affected limb, consistent with sympathetic dysregulation

The condition can affect the upper extremities (hands, arms) or lower extremities (feet, legs). Because the sympathetic chain controls circulation, sweat gland activity, and pain signalling in the limbs, disrupting it — either chemically or surgically — can interrupt the cycle of sympathetically maintained pain.

How Is CRPS Diagnosed?

CRPS is not easy to diagnose. It requires a thorough, multidisciplinary evaluation that rules out other causes of chronic limb pain. There is no single definitive test. Diagnosis is typically made based on:

• Clinical history — nature of the precipitating injury and progression of symptoms
• Physical examination — skin changes, temperature asymmetry, allodynia
• Imaging studies — bone scans, MRI, or X-rays to exclude other pathology
• Response to sympathetic nerve blocks — a favourable response to chemical sympathectomy is both diagnostic and therapeutic

Multiple failed attempts at conventional pain management are typically required before sympathectomy is considered.

From Chemical to Surgical Sympathectomy

The standard evaluation pathway for CRPS involves a trial of chemical sympathectomy — an injection of alcohol or similar agents to temporarily interrupt sympathetic nerve signalling in the affected region. This serves two purposes:

• Diagnostic: If chemical sympathectomy provides meaningful pain relief, it confirms that the pain is sympathetically mediated — and therefore potentially responsive to surgical interruption
• Therapeutic: Repeated chemical blocks can themselves provide ongoing relief for some patients

If chemical sympathectomy consistently relieves the pain and the relief can be replicated, surgical sympathectomy becomes a genuine option. By permanently interrupting the sympathetic nerve chain, the surgical procedure may provide lasting relief where temporary blocks have succeeded.

Who Is a Candidate for Surgical Sympathectomy for CRPS?

Surgical sympathectomy for CRPS is appropriate only for a carefully selected subset of patients. Criteria typically include:

• A confirmed CRPS diagnosis following extensive evaluation
• Failure of standard conservative pain management approaches
• Documented, reproducible relief from repeated chemical sympathetic blocks
• A thorough surgical consultation confirming that the anatomy and clinical picture support a surgical approach

Dr. Basseri evaluates each CRPS case individually and with full clinical rigour. Not every patient will be a surgical candidate — but for those who are, sympathectomy offers a meaningful path to lasting relief.