CASE X:   EVALUATION OF REFLEX SYMPATHETIC DYSTROPHY

On 02/20/01 , M.D., surgeon, noted a swollen lymph node left neck in the 30 year old examinee. 

On 2/26/01, the examinee sustained a motor vehicle accident in which her vehicle apparently was totaled, and on 2/28/01 she sought Emergency Department evaluation at Hospital with neck sprain/strain and had pains in the head, neck, back, left leg pain below buttocks and behind the left knee; the examinee also had a urinary tract infection for which she was taking Cipro.  

On 03/05/02 , the examinee signed an Informed Consent authorizing excision of the left scalene node after having been advised by her doctor of the risks, benefits, possible problems and other options to this procedure.   

On 03/06/01, , M.D., surgeon, after preoperative evaluation with chest x-ray and EKG, performed an excisional biopsy of the left scalene fat pad which he noted had enlarged for approximately the past year despite numerous courses of antibiotics; the doctor also noted a thyroid mass at the lower left pole which would soon be aspirated by Dr. F.  using a fine needle.

An incision was made basically parallel to the clavicle separating slightly posterolaterally the subcutaneous tissue; the platysma was divided and retracted, and the  scalene fat pad and overlying external jugular vein were exposed and dissected back, ligated and divided; fat overlying and surrounding adenopathy were separated and hemostasis was caused  with touches of electrocautery and small silk ties. Scalene nodes were exposed and excised, connections clamped and tied with silk ties, electrocautery; a mass of matted nodes were removed and submitted.  The incision site was inspected and closed in several layers with absorbable suture, followed by staples and a dressing.

M.D., pathologist, noted preserved nodal architecture with focal anthracotic pigment deposition and perinodal fatty tissue with features consistent with benign hibernoma (fatty infiltration).

By 03/12/01 , the examinee complained of shooting pain around the incision and , M.D., surgeon, suggested Motrin.

By 03/15/01 , an electric shock like pain had developed in the left arm halfway down the left shoulder and along the left neck to the top of halter/breast and a very tender cord was noted along the left internal jugular from the jaw to the  clavicle.  The examinee was treated by , M.D., surgeon, for internal jugular phlebitis with  deep vein thrombosis which may be extending into the left subclavian and was taking Motrin, Medrol DosePak, Vicodin and Coumadin and instructed to apply local heat. If symptoms persisted, the examinee would be hospitalized.

On 3/15/01, Dr. also opined about a complicating portion of history which did not seem to be pertinent before, i.e. the examinee had been involved in a serious motor vehicle accident on 02/26/01 and developed pain which caused her to present to the emergency room two days later and that the slim  possibility existed that low level trauma at that time could have then been exacerbated by the extended neck position during the scalene node biopsy, and what the examinee was experiencing in the left side of her neck was nerve root compression related to the motor vehicle accident.

From 03/19/01-3/24/01, the examinee was hospitalized at Hospital by  M.D., surgeon, and also was treated by M.D., who also noted left internal jugular vein thrombophlebitis and a thyroid nodule which did not show on ultrasound and M.D., who recommended discontinuing Premarin and substituting a non-estrogenic medication such as Prozac or Adjustin for flashes. The examinee was eventually switched to oral coagulation and discharged.

On 03/30/01 , the examinee was evaluated by M.D., who also noted left internal jugular thrombophlebitis, remarked about the motor vehicle accident and recommended an increase of Neurontin.

On 04/02/01 , a CT demonstrated surgical clips in the left supraclavicular region and a low density 1.8 x 1.7 cm mass in supraclavicular region with negative Hounsfield measurement suggesting fat contents which might represent a lymphocele or a fatty post-operative seroma.

On 4/04/01, M.D., diagnosed persistent left neck and anterior chest/shoulder pain after biopsy of supraclavicular lymph node, rule out reflex sympathetic dystrophy, questionable history of jugular vein thrombosis, not documented on CT scan of the neck and recommended discontinuation of  Coumadin..

04/09/01 , M.D. noted the examinee was suffering with either sympathetic mediated pain or brachioplexus injury presumably related to the surgery or simply developing reflex sympathetic dystrophy as a result of invasion of the skin area with nerve involvement (a blood clot was ruled out).   Dr. noted weakness to the left upper extremity and frustration and depression as a result of not being able to do hairdressing profession and recommended for diagnostic and therapeutic purposes treatment for sympathetic mediated pain with a combination of anticonvulsive, tricyclics and mild analgesic followed by a series of stellate ganglion blocks if not better in addition to increasing Neurontin and Ultram.

By 04/23/01 , M.D. diagnosed possible causalgia, RSD or nerve dysfunction and considered a nerve conduction study.   

By 06/07/01, M.D., neurologist, noted the area of numbness did not correspond to a single dermatome and probably represented complex regional pain syndrome or RSD and recommended a Lidoderm patch over the left clavicle and ordered a bone scan, which was negative, and follow up with pain management; Dr. noted the examinee had the scalene lymph node for about 14 years..

On 07/05/01 , a cervical and upper extremity thermogram by M.D., physical medicine and rehabilitation, was abnormal with rather widespread thermal asymmetry and relative cooling of left upper extremity suspicious for complex regional pain syndrome, formerly known as reflex sympathetic dystrophy.

  On 7/19/01, M.D., reconstructive surgery of the hand and upper extremity, peripheral nerve surgery, diagnosed chronic pain syndrome following cervical node biopsy, rule out nerve injury and noted besides the examinee’s persistent symptoms a well healed surgical incision from the scalene biopsy and that details of operative report made it unlikely that the upper trunk had been affected.

On 09/25/01, additional diagnostic studies including (1) MRI neck and brachioplexus with and without gadolinium demonstrated denervation atrophy of the left musculature of the shoulder girdle with fatty replacement of the scalene and serratus muscle, diffuse mild hyperintensity of the trunks and cords without post-gadolinium enhancement or enlargement of the roots most likely representing mild inflammation,  no mass involving the brachioplexus or vascular anomaly and normal vascular flow; (2) nerve conduction and electromyelogram left upper extremity, normal; and (3) MRI left shoulder demonstrating mild tendonosis of the supraspinatus tendon without evidence of space-occupying lesion or lymphadenopathy.

QUESTIONS:

1.                    Should the surgeon have postponed the surgery in light of recent trauma to the area?

2.                    How likely is it to have this type of reaction after biopsy?

3.                    Could the surgeon have inadvertently cut a nerve?

4.                    Should fine needle aspiration been an initial course of action?

5.                    What is a hibernoma?

6.             Do general principles exist with regard to doing surgery near a recently traumatized   nerve?

7.             The examinee has a permanent injury subsequent to surgery; would this be considered a risk             of  procedure or an effect of negligence, ie surgeon having had the information about recent             trauma,14 year history of node, etc.?

8.                    Would a patient be advised of potentially getting RSD after such a procedure?

  INTERNET RESEARCH:

1.                No consensus about the pathogenesis of RSD.

2.                The traditional theory of how RSD works holds that damage to a peripheral nerve causes a malfunctioning of other nerve fibers, presumably of the sympathetic nervous system, which misfire in some way causing a burning pain as well as an abnormally hot or sometimes cold hand; also theory that peripheral nerve injury causes permanent changes in the central nervous system.

3.                Each medical specialty sees the disorder somewhat differently.

4.                No article found in the initial search specifically referencing the development of chronic regional pain syndrome subsequent to left scalene node biopsy

CONSULTATION WITH BOARD CERTIFIED SURGEON AND TWO BOARD CERTIFIED NEUROLOGISTS:

BOARD CERTIFIED SURGEON:

1.                      This is a rare occurrence in a procedure frequently performed with a risk justified by the               possibility of diagnosing cancer.

2.                      Technically, from the operative report description, no gross severance of phrenic or vagus             nerves; superficial nerves, especially cutaneous nerves may be partially severed by the                 dissection.

3.                      Perhaps a suture was tied around a nerve.

4.                      After minor traumas, various surgeries may precipitate such a syndrome though this is a rare             event, and most surgeons are not particularly aware of such consequences, especially in light             of the potential for misdiagnosis or lack of diagnosis should the biopsy, in this case, be a             cancer.

5.                      People have major traumas, which are operated without the development of such a syndrome.

BOARD CERTIFIED NEUROLGISTS:

1.                No prescribed standard or guideline with regard to the relationship of minor traumas and the performance of elective surgery.

2.                Suprascapular nerves, relation to severed cutaneous nerves and proximity to sympathetic ganglia predispose to potential development of complex regional pain syndrome.

3.                After neck and lower back trauma, probability of using arms to support and lift from sitting posture may contribute to increased load on the nerves of the neck and arm and in a recently traumatized situation potentiate the development of regional pain syndrome.

  CONCLUSION:

In my opinion within a reasonable degree of medical probability:

1.                The examinee, with the development of complex regional pain syndrome of the left upper extremity, sustained a permanent impairment as a consequence of the biopsy of the left scalene node.                                  

2.                Minor traumas, especially of the joints, predispose an individual to the development of complex regional pain syndrome after surgical treatment to that area.

3.                Lack of prescribed or accepted standards within the medical community with regard to the relationship of minor traumas and the performance of elective surgery and varying interpretations as to the pathogenesis of complex regional pain syndrome make the case that the examinee’s resultant condition was a consequence of negligence difficult to prove and rather was, indeed, a possible risk of the surgical procedure as indicated in the informed consent.

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