Case history number 96. Reflex sympathetic dystrophy in a 6 yr old: successful treatment by transcutaneous nerve stimulation
A 6 yr old healthy girl suffered a traction injury to her right sciatic nerve. Within 24 hours after the accident, she complained of well-localized pain in the right knee and reported that the area was exquisitely sensitive to touch. Another well-localized sensitive area developed on the plantar surface of the right foot; this became so severe over the next 2 days that she was unable to bear weight, necessitating the use of crutches. The mother noted that very light touch to either of the areas would awaken the child from a sound sleep. Occasionally, the right leg was observed by the mother to be swollen, blue, and blotchy. This tended to occur after painful stimuli, such as attempts at walking. The condition persisted unchanged to the time of admission, 3 months after her initial injury. On the basis of clinical findings, the presence of positive thermography and temperature differentials, and absence of evidence of infection or fracture, a presumptive diagnosis of reflex sympathetic dystrophy was made. A neurolytic lumbar sympathetic block under general anesthesia (because of the patient's age) was recommended, but the parents were reluctant to have this performed. Therefore, it was decided to initiate a trial of transcutaneous nerve stimulation, using a Neuromod Transcutaneous Nerve Stimulator, Model #3700 (Medtronic). Electrodes were arbitrarily placed over the right femoral triangle and the dorsum of the right foot. The frequency of stimulation was set at 90 Hz and the current at 2.5 ma, at which point a tingling but not painful sensation was noted by the patient. Later, these settings were changed to 50 Hz and 3.5 ma, which produced better pain relief. Within 24 hours after initiation of the stimulation, definite improvement in color and reduced hyperesthesia were noted, although repeat thermograms at 24 hours were essentially unchanged. The patient returned to the Pain Clinic 2 weeks after her initial visit. At the time there were no complaints of pain and no findings of hyperesthesia, edema, or cyanosis of the right leg. There was minimal limp on the right side, but she bore body weight without complaint. Skin temperature was equal in both legs, and thermography revealed no difference between the extremities. She was still pain free 1 month after discontinuing treatment.
Stilz, RJ; Carron, H; Sanders, DB
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