Reflex sympathetic dystrophy of the face: current treatment recommendations

Reflex sympathetic dystrophy (RSD) of the face is an infrequently reported clinical pain syndrome characterized by dysesthesia, hyperalgia, hyperpathia, and allodynia. Treatment strategies, extrapolated from RSD and causalgia of the extremities, remain variable and poorly defined. Sympathetic blockade is generally the diagnostic and therapeutic treatment of choice; however, the frequency, timing, and duration of injections; need for neurolytic blocks; and role of sympathectomy are not well understood. The objectives of this report are to highlight the clinical behavior of facial RSD and contrast its essential differences from extremity RSD in response to standard treatment regimes. The case studies of two patients with this syndrome, following vascular surgery in the neck, are retrospectively reviewed with existent reported cases. Age, gender, etiology, symptoms, onset, triggers, and examination findings; timing, duration, and method of treatment; and outcome are summarized, forming the database for this study. Findings demonstrate an infrequent association of vasomotor and sudomotor changes with facial RSD, and lack of progression to a dystrophic or an atrophic stage, in contrast to extremity RSD. Furthermore, treatment response to sympathetic blockade is durable and less critically dependent on timing. The authors conclude that facial RSD has a favorable prognosis and should be managed conservatively with nonneurolytic stellate ganglion blocks, even when initiated as a delayed and repetitive injection series.