[Surgical treatment of therapy refractory Sudeck's dystrophy by transaxillary decompression of the neurovascular bundle and sympathectomy. On the pathogenesis of Sudeck's disease].

Since 1984, altogether nine cases of otherwise untreatable reflex sympathetic dystrophy (RSD) of the upper extremity were treated by transaxillary decompression of the neurovascular bundle with resection of the upper thoracic ganglia. This resulted in an immediate improvement of the local findings and the entire post-operative course of treatment as well as significantly improved functional results (seven excellent, one good, one fair). Average follow-up was 7.5 years. All patients returned to their original work. Clinical as well as intraoperative studies show that the acute edema of RSD is caused by a stenosis of the subclavian vein, which was proven in all cases by preoperative phlebography. Surgical decompression of the subclavian vein thus can result in an essential improvement of venous backflow and also significant improvement of the lesion-caused misproportion between increased arterial inflow and venous outflow with all resulting consequences for peripheral edema, subfascial pressure, microcirculation, perfusion of tissue and metabolism. By decompression of the subclavian artery and the lower plexus roots as well as by simultaneous transaxillary sympathectomy, the sympathetic efferents are drastically reduced or rather interrupted, leading to immediate improvement of the acute pain-syndrome. The so-called "individual predisposition" for RSD can mainly be attributed to a venous stenosis in the area of the subclavian vein and to an increase in sympathetic tonus by irritation of the lower parts of the brachial plexus and the postganglionic fibres accompanying the subclavian artery. The consequences for the pathogenesis of RSD are discussed in detail.