Baron R, Maier C
Klinik für Neurologie, Christian-Albrechts-Universität Kiel, Germany.
Pain. 1996 Oct;67(2-3):317-26. doi: 10.1016/0304-3959(96)03136-3.
To examine the pathophysiological mechanisms of vascular disturbances and to assess the role of the sympathetic nervous system, 12 patients with reflex sympathetic dystrophy (RSD) of the hand were studied using laser Doppler flowmetry. Cutaneous blood flow, skin resistance and skin temperature were measured at the affected and contralateral hands. Sympathetic vasoconstrictor reflexes were induced bilaterally by deep inspiration. Four patients were treated with unilateral surgical sympathectomy and pain and vascular changes were documented in follow-up investigations. (1) After acclimatization in cold environment (< or = 18 degrees C) blood flow and skin temperature were considerably lower on the affected side in 10 patients. No additional vasoconstrictor reflexes could be elicited. (2) After acclimatization in warm environment (22-24 degrees C) blood flow and skin temperature demonstrated no side differences in all cases. Vasoconstrictor responses were the same on both sides. (3) After sympathectomy vasoconstrictor reflexes were absent. Skin resistance was considerably higher on the affected side. In the first 4 weeks the affected hand was warmer and blood flow was higher compared with the healthy side. Thereafter, skin temperature and perfusion slowly decreased and the affected hand turned from warm to cold. Very regular high amplitude vasomotion waves occurred unilaterally. There were no signs of reinnervation. Two patients had long-term pain relief. We conclude as follows. (1) Side differences in skin temperature and blood flow are no static descriptors in RSD. They are dynamic values depending critically on environmental temperature. Therefore, they have to be interpreted with care when defining reliable diagnostic criteria. (2) Vascular disturbances in RSD are not due to constant overactivity of sympathetic vasoconstrictor neurons. Changes in vascular sensitivity to cold temperature and circulating catecholamines may be responsible for vascular abnormalities. Alternatively, RSD may be associated with an abnormal (side different) reflex pattern of sympathetic vasoconstrictor neurons due to thermoregulatory and emotional stimuli generated in the central nervous system. (3) After sympathectomy, denervation supersensitivity of blood vessels and intense vasomotion may be associated with recurrence of pain in some patients.
为研究血管功能紊乱的病理生理机制并评估交感神经系统的作用，我们采用激光多普勒血流仪对12例手部反射性交感神经营养不良（RSD）患者进行了研究。测量了患侧和对侧手部的皮肤血流量、皮肤电阻和皮肤温度。通过深吸气双侧诱发交感缩血管反射。4例患者接受了单侧手术交感神经切除术，并在随访研究中记录了疼痛和血管变化情况。（1）在寒冷环境（≤18℃）适应后，10例患者患侧的血流量和皮肤温度明显较低。无法诱发额外的缩血管反射。（2）在温暖环境（22 - 24℃）适应后，所有病例中血流量和皮肤温度均无双侧差异。双侧的缩血管反应相同。（3）交感神经切除术后，缩血管反射消失。患侧的皮肤电阻明显更高。在最初4周内，患侧手部比健侧更温暖，血流量更高。此后，皮肤温度和灌注逐渐降低，患侧手部从温暖转为寒冷。单侧出现非常规律的高振幅血管运动波。没有再支配的迹象。2例患者长期疼痛缓解。我们得出以下结论。（1）RSD中皮肤温度和血流量的双侧差异并非静态指标。它们是动态值，严重依赖于环境温度。因此，在定义可靠的诊断标准时必须谨慎解释。（2）RSD中的血管功能紊乱并非由于交感缩血管神经元持续过度活跃。血管对低温和循环儿茶酚胺敏感性的变化可能是血管异常的原因。或者，RSD可能与中枢神经系统产生的体温调节和情绪刺激导致的交感缩血管神经元异常（双侧不同）反射模式有关。（3）交感神经切除术后，血管的去神经超敏反应和强烈的血管运动可能与部分患者的疼痛复发有关。
