To the Editor: - Regarding the medical intelligence article, "Beyond the Needle," by Jacobson et al., I would like to make the following comments. First, the psychologic treatment of pain, also called cognitive restructuring, is unnatural, which is why it is neither successful nor economic, and unprudent. It is unnatural because we are attempting to teach patients to react in ways that are opposite to what nature intended. Many of these patients with chronic nonmalignant pain, including and especially those who show "minimal pathology with maximum dysfunction" are, in fact, patients with sympathetically maintained pain. The expectation of a successful outcome in these patients with sympathetic blocks is as likely as walking on water, because the key to the successful outcome in sympathetically maintained pain is treatment of both the sympathetic dystrophy and the underlying cause. Let me illustrate this with a familiar case scenario.
Sympathetic dystrophy of the right upper extremity develops in a patient after routine carpal tunnel release. The patient is given stellate ganglion blocks, with good response. The patient returns to work. No sooner has the patient started working than the pain, stiffness, and swelling recur. In this patient, the underlying cause is the residual carpal tunnel syndrome. Unless that is corrected, the effect of stellate ganglion blocks will not last.
By residual carpal tunnel syndrome, I mean a carpal tunnel syndrome on which operation was performed, but nothing was performed for median neurodesis secondary to nonspecific flexor tenosynovitis, which is the reason for a poor surgical outcome of carpal tunnel. This neurodesis is at the interface of the radial synovial bursa and the median nerve at the level of the proximal edge of the transverse carpal ligament, which is also the site of maximum tenderness in failed carpal tunnel surgery. Incidentally, superficial to this lesion is the dreadful palmar cutaneous branch of the median nerve, which has not only turned hand surgeons into "scaredy cats," but also has led Mackinnon and Dellon to the erroneous conclusion that the cause of this tenderness is scarring of the palmar cutaneous branch; which explains why we have yet to see a successful outcome of surgery for "scarring of the palmar cutaneous branch."
According to our protocol, this patient will require repeat stellate blocks, and when the pain, stiffness, and swelling are resolved, then and there we will surgically repair the residual carpal tunnel syndrome with complete and methodic flexor tenosynovectomy and neurolysis of the median nerve.
The inextricable link between reflex sympathetic dystrophy and patient dissatisfaction-the long searched-for cause of the so-called "individual predisposition"-calls for competent and compassionate management of these patients to regain their trust.
I conclude with the prediction that, at the end of the day, we will all be convinced that pain is a simple sensory messenger from the damaged tissue crying out loud, "Please fix me."
M. Ibrahim Khan, M.D.
Orthopedic Surgery; Beverly Hills, CA 90212
(Accepted for publication March 25, 1998.)