Pankaj A, Kotwal P P, Mittal R, Deepak K K, Bal C S
Department of Orthopedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
J Orthop Surg (Hong Kong). 2006 Dec;14(3):284-90. doi: 10.1177/230949900601400310.
To evaluate the role of sympathetic skin response (SSR) and three-phase bone scintigraphy (TPBS) in the diagnosis of complex regional pain syndrome (CRPS).
60 patients with CRPS of the hand were recruited. TPBS was performed using a bolus injection of 20 mCi of Tc-99m methylene diphosphonate in an antecubital vein and blood flow (first phase) image, blood pool (second phase) image, and delayed (third phase) image obtained. Patients were considered to have CRPS when the blood pool and blood flow images showed diffuse asymmetric uptake, or when the delayed image indicated increased asymmetric periarticular uptake. SSR was measured simultaneously in the affected and unaffected hands. Standard surface electromyogram disc electrodes were applied to the palm and dorsum of both hands. Electrical stimuli were applied to the skin at the base of little and ring fingers of the unaffected hand. Patients were considered abnormal when response was absent or the peak-to-peak amplitude was <50% of the contralateral hand in at least 2 readings.
The delayed phase of TPBS tested positive in all; the first and second phases tested positive in 54 (90%) and 56 (93%) of the patients, respectively. Four of the 6 patients with a negative first phase had had symptoms persisting for more than 6 months, and the other 2 for about 3 to 6 months. No patient presenting within 3 months had a negative scan. SSR was absent in 16 (27%) patients and normal in 44 (73%). 11 (79%) of 14 patients who presented more than 6 months after symptom onset displayed an abnormal SSR, while only 10% of those presenting within 3 to 6 months and 11% of those presenting within 3 months had an abnormal SSR. 12 (75%) of the 16 patients with abnormal SSR had associated decreased sweating, compared with 2 (4.5%) of the 44 patients with a normal SSR.
TPBS is a very sensitive corroborative test to confirm the clinical suspicion of CRPS during the initial stages, but not in late cases. SSR can be used to document the sympathetic dysfunction in cases having an associated sweating abnormality and may have some diagnostic value in late cases of CRPS, when TPBS is less reliable.
评估交感神经皮肤反应（SSR）和三相骨闪烁显像（TPBS）在复杂性区域疼痛综合征（CRPS）诊断中的作用。
招募60例手部CRPS患者。通过在前臂静脉团注20 mCi的锝-99m亚甲基二膦酸盐进行TPBS检查，并获取血流（第一相）图像、血池（第二相）图像和延迟（第三相）图像。当血池和血流图像显示弥漫性不对称摄取，或延迟图像显示关节周围不对称摄取增加时，患者被认为患有CRPS。同时在患侧手和未患侧手测量SSR。将标准表面肌电图盘状电极应用于双手的手掌和手背。对未患侧手的小指和环指基部皮肤施加电刺激。当至少2次读数中反应缺失或峰峰值幅度小于对侧手的50%时，患者被认为异常。
TPBS的延迟相全部呈阳性；第一相和第二相分别有54例（90%）和56例（93%）患者呈阳性。6例第一相为阴性的患者中，4例症状持续超过6个月，另外2例约3至6个月。发病3个月内就诊的患者扫描均无阴性结果。16例（27%）患者SSR缺失，44例（73%）正常。症状出现6个月后就诊的14例患者中，11例（7�%）SSR异常，而发病3至6个月就诊者中只有10%、发病3个月内就诊者中只有11%的SSR异常。16例SSR异常的患者中有12例（75%）伴有出汗减少，而44例SSR正常的患者中只有2例（4.5%）伴有出汗减少。
TPBS是一种非常敏感的辅助检查，可在初始阶段证实对CRPS的临床怀疑，但对晚期病例则不然。SSR可用于记录伴有出汗异常病例中的交感神经功能障碍，并且在CRPS晚期病例中可能具有一定诊断价值，此时TPBS的可靠性较低。
