David Nelson , MD Private Practice, San Francisco Webmaster, eRadius Associate Editor, J Hand Surgery Director, San Francisco Bay Area Hand Club

(14) What is the cause of the RSD? Was it the last surgery? RSD develops about 6 weeks to 2 months after the nerve insult. The initial insult may have been the motorcycle crash 6 weeks previously or the median nerve compression due to swelling that was recognized on a delayed basis. It was not due to the third surgery. However, the timing of the third surgery, although necessitated by timing of his presentation to the office and the nature of the problem, was quite unfortunate. Surgery at the time of the development of the RSD certainly will contribute to the problem. It will also be exacerbated by the prolonged tourniquet times and the development of the median nerve compression. An exploration to "decompress" the already released nerve will make it even worse.

The current situation was quite poignant: Do nothing for a complete median nerve palsy? This is certainly against all of our training. The RSD will certainly get worse due to the continuing median nerve insult.

Or operate without any strong chance of gain, possibly be unable to close the wound, and probably add further insult to the median nerve?

The situation was discussed with several hand surgery colleagues and the patient, as mentioned above, but the final decision and responsiblity is up to the surgeon. Observation plus referral to a pain specialist was chosen.

The pain specialist agreed with the development of RSD and deferring surgery. The patient was started on a hand therapy program, placed on gabapentin (neurontin) and as a trial, was given a ropivicaine stellate ganglion block.

The day after the block the allodynia completely resolved, the induration dramatically decreased, the finger ROM increased, the pain somewhat decreased, and the numbness started to resolve slightly. The patient therefore had a botulinum stellate ganglion block for the purpose of creating a block of greater duration. The symptoms continued to improve. Within one week, the patient was taking nothing more than acetaminophen (paracetamol) and ibuprofen. He was able to tolerate the hand therapy and continued to increase his wrist and finger ROM.

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