rsd thermology international 2001

8/11/2019 RSD Thermology International 2001

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Thermology international 11 / 2 (2001) Original article

Infrared Thermal Imaging As A Tool In Pain

Management - An 11 Year Study, Part I of II

Hooshang Hooshmand, Masood Hashmi, Eric M. Phillis

Neurological Associates Pain Management Center, Vero each, !lori"a, #$A

Summary

The %alue o& 'n&rare" thermal imaging ('T') is limite" to e%aluation o& neuro%ascular "ys&unction 't ro%i"esin"isensa*le in&ormation regar"ing neuroathic ain "ue to eri%ascular microcirculatory symathetic"ys&unction 'T' recor"s suer&icial, an" "ee temerature changes The *ilateral cer%ical cor" temeraturemo"ulation "eman"s care&ul clinical correlation The 'T' is an o*+ecti%e gui"e heling the clinician to choosea roer an" harmless treatment rotocol, esecially a%oi"ing unnecessary surgery

The anatomical tests such as magnetic resonance imaging (MRI), computedtomography (CT),an" hysiological tests such as electromyograhy (M-) an" ner%e con"uction

%elocity (NCV) tests ha%e *een the main "iagnostic tools alie" in the management o& somesthetic(somatic) ain The a*o%e tests usually are not in&ormati%e in the "iagnosis o& neuroathic ain Theneuro%ascular in%ol%ement in neuroathic ain re.uires tests such as 'n&rare" thermal imaging ('T') an"uantitati%e su"omotor aon re&le test ($AT) that a""ress autonomic (eg, thermal) changes &or a moreaccurate "iagnosis an" treatment This is a stu"y o& the role o& 'T' in the "iagnosis an" management o& ainThe results ere comare" ith the in&ormation in me"ical literature

ales $cienti&ic Thermal Processor an" Agema Cameras ere use" &or this stu"y o& 3,245 successi%eatients A re%ie o& our eerience ith 'n&rare" thermal imaging ('T') an" its role in ain managementas con"ucte", an" comare" ith the recent me"ical literature The stu"y as limite" to the role o& 'T' inthe management o& comle chronic ain

$loy techni.ue, an" oor *ac6groun" in *asic neurohysiologic training, ha%e contri*ute" to oor

utili7ation an" interretation o& 'T' !or the 'T' to *e accurate an" clinically use&ul, roer techni.ue,stan"ar"i7ation, an" roer clinical correlation are the minimal re.uirements The *asic hysiology o&autonomic thermoregulation is outline" in "etail to hel the clinician to roerly un"erstan" an" interret thetest The "ys&unction o& thermal sensory ner%es in the all o& arterioles cannot *e "etecte" *y M- or NCVan" eclu"ing the 'T' test may mislea" the clinician to "iagnose the con"ition as 8sychogenic8 or8&unctional8 Our results ere comati*le ith the re%ie o& current me"ical literature

'T' ro%i"es use&ul clinical in&ormation hen alie" ith roer techni.ue 't ro%i"es "iagnostic an"theraeutic in&ormation limite" to "iseases in%ol%ing autonomic, neuro%ascular, an" neuroin&lammatory
http://www.uhlen.at/thermology-international/index.htmlhttp://www.uhlen.at/thermology-international/index.htmlhttp://www.uhlen.at/thermology-international/index.htmlhttp://www.uhlen.at/thermology-international/index.html


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changes Con%ersely, it cannot *e eecte" to hel "iagnose ner%e in+uries ith no micro%ascularin%ol%ement such as somesthetic ner%e in+uries Proer teaching an" un"erstan"ing o& thermoregulationhels the clinician to o*tain in"isensa*le in&ormation &rom this test

Key Words - CP$, 9ea"ache, $ymathectomy ,Thermograhy

Infrarotthermograhie als Hilfsmittel im Schmermanagement - eine 11 !ahres - Studie. 1. Teil

53

Thermology international 11 / 2 (2001)

Introduction

This is a re%ie o& our 11:year eerience ith the alication o& 'n&rare" thermal imaging ('T') in 3,245atients su&&ering &rom chronic ain This stu"y &ocuses on the alication o& 'T' as a "iagnostic an"theraeutic gui"e

Terminology

The nociceti%e ain sensation is "i%i"e" into to "istinct categories; Neuroathic (Ta*le 1) an"somesthetic(somatic) ain The neuroathic ain is associate" ith thermal (%asomotor) changes Thesechanges are in resonse to the a&&erent noious imulses o& the unmyelinate" sensory (c:thermorecetors)


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ner%es in the all o& micro%asculature (1) This is in contrast to the common somatic (somesthetic) ainhich is usually not accomanie" *y circulatory "ys&unction

The somesthetic ain is characteri7e" *y in%ol%ement o& a&&erent somatic(sinothalamic) ner%es usually

ith no circulatory "istur*ance The somatic ain has a "ermatomal attern (!ig 1) in the "istri*ution o&ner%e roots an" ner%e trun6s 'n contrast, the thermatomal "istri*ution (!ig 1) o& neuroathic ain (2,3)&ollos an arterial "istri*ution such as &emoral, caroti" or *rachial arteries 'n athologic states, hyo:an"hyerthermic changes are recor"e" *y 'T' hich can *e .uite hel&ul in the selection o& a roer treatment

rotocol

The neuroathic ain, *y %irtue o& in%ol%ing the neuro%ascular structure, is accomanie" *y circulatory(Thermal) changes lea"ing to a "i&&erent tye o& ain such as causalgia () o& any etiology(eg, ost heretic neuralgia, "ia*etic mononeuroathy,etc

Ta"le 1. #isease$ in %hich neuroatic ain occur.

Mononeuroathy

Amutation stum ain

Causalgia

?ia*etes mellitus

Neuroma

Pleus a%ulsion

Postheretic neuralgia

Traumatic

Vasculitis

Mononeuroathy

multile ?ia*etes

Polyneuroathy Alcohol

Nutritional neuroathy


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Chemotheray

?ia*etes

hrler ?anlos $yn"rome

!a*r@ "isease

9'V

9yothyroi"ism

#remia, renal &ailure

Vitamin "e&iciencies

Cancer

Neurosyhilis (Ta*es)

Trigeminal neuralgia

!igure 1 : 'n neuroathic ain the sensory loss shos thermatomal (%ascular) "istri*ution in contrast tothe "ermatomal (ra"icular) "istri*ution o& the somatic ain Con%ersely, the malingering sensory loss islimite" to the +oints ith ermission &rom $ringer:Verlag Pu*lishers (1)


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54J 15; >J2;125: e+ M?, $chart7man D; A*normalities o& cutaneous *loo" &lo regulation in atients ith re&lesymathetic "ystrohy as measure" *y laser ?oler &lumetry Arch Neuro1 1BB1J ;B12:5

B Arnol" DM, Teasell , MacGeo" AP, ron D, Carruthers $-; 'ncrease" %enous alha:a"renocetorresonsi%eness in atients ith re&le symathetic "ystrohy Ann 'ntern Me" 1BB3J 11>;41B:21

10 illis ?, estlun" FN; Neuroanatomy o& the ain system an" o& the athays that mo"ulate ain DClin Neurohysiol 1BB=J 15J 1; =44:=3

12 9ooshman" 9, 9ashmi 9; Comle regional ain syn"rome (CP$, $?$) "iagnosis an" theray Are%ie o& >2< atients Pain ?igest 1BBBJ B; 1:2


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"i&&erential "iagnosis o& chronic ain syn"romes an" re&le symathetic "ystrohy lectomyogr ClinNeurohysiol 1B>1J 21; 145: >2

1J ==

20 osomo&& 9G; ?o herniate" "isc ro"uce ain Clin D Pain 1B>5J 1;2

21 9ooshman" 9; Chronic Pain; e&le $ymathetic ?ystrohy; Pre%ention an" Management CC Press,oca aton !G 1BB3

22 #ematsu $, "in ?9, Dan6el , Fo7i6os6i D, Trattner M; uanti&ication o& thermal asymmetry,Part '; Normal %alues an" rero"uci*ility D Neurosurg 1B>>J 4B; 552:5

23 Choi DF, Mi6i F, $agaa $, $hira6i F; %aluation o& mean s6in temerature &ormulas *y in&rare"thermograhy 'nternational D o& iometeorology 1BB=J :=5

2


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Original article

30 Arnason -; The symathetic ner%ous system an" the immune resonse The $cienti&ic asis 1BB3J12;11J 25;13=:BJ Craig F?, hit&iel" M! , -runau V, Ginton D, 9a"+ista%rooulos 9?; Pain in the reterm neonate;*eha%ioral an" hysiological in"ices Pain 1BB3J 52;2>=:BB

3B auc6 G; Myo&ascial ain syn"rome an" &i*romyalgia Current e%ie o& Pain 1BB4J 1; 4


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o& the guinea ig D Auton Ner% $ys 1B>4J 14;2>B:30B

5

BJ 34;243:>1

53 $erre 9, $imon G, Claustre D; We&le algo"ystrohy o& the &oot Aroos o& 5J 5;13>0:4

54 !it7geral" M; The srea" o& sensiti7ation o& olymo"al nocicetors in the ra**it &rom near*y in+ury *yanti&romic stimulation D Physiol WGon"X 1B=BJ 2B=; 20=:14

5= Gem*ec6 !, -amse , Duan 9; $u*stance P an" $ensory Ner%e n"ings 'n #$ Vonuler, Perno,e"s $u*stance P 3=th No*el $ymosium, $toc6holm 1B=4 a%en Press Ne Qor6 1B==

5> ar:sha%i , -ol"man , $ta*ins6y Q, -ottlie* P, !ri"6in M, Teich*erg V' et al; nhancement o&hagocytosis:a nely &oun" acti%ity o& su*stance P resi"ing in its N:terminal tetraeti"e se.uenceiochem iohys es Commun 1B>0J B


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"ystrohy an" causalgia); management ith a calcium channel *loc6er ni&e"iine an"/or the alha:symathetic *loc6er henoy*en7amine in 5B atients Clin Neurol Neurosurg 1BB=J BB; 24:30

43


41 as*aum A', Clanton CM, !iel"s 9'; Three *ul*osinal athays &rom the rostral me"ulla o& the cat;

an autora"iograhic stu"y o& ain mo"ulating systems D Com Neurol 1B=>J 1; 20B:2; >01:15

44 Mos6oit7 MA; The neuro*iology o& %ascular hea" ain Ann Neurol 1B>

! 'nar M, ratt *M+ Role o nitric oide in physiopathology o pain! o Pain and.ymptom Mgmt!1BB=J 1


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=

== #e6i Q, Miya6e $, Tominaga Q, guchi F; 'ncrease" nitric oi"e le%els in atients ith rheumatoi"arthritis D heumatol 1BB4J 23;230:4

=> %ans ?M, alston $9; Nitric oi"e an" *one D one Mineral es 1BB4J 11; 300:5

=B Ta6ahashi T, Fon"oh T, Famei F, $e6i 9, !u6u"a M, Nagai 9, et al; le%ate" le%els o& nitric oi"e insyno%ial &lui" &rom atients ith temoroman"i*ular "isor"ers Oral $urg Oral Me" Oral Pathol Oral a"iol

n"o" 1BB4J >2; 505:B

>0 Amin A, Attur M, Patel N, Tha66er -?, Marshall PD, e"is6e D et al; $uerin"uction o&cyclooygenase:2 acti%ity in human osteoarthritis:a&&ecte" cartilage 'n&luence o& nitric oi"e D Clin'n%estigation 1BB=J BB; 1231:=

>1 Attur M-, Patel N, A*ramson $, Amin A; 'nterleu6in:1= u:regulation o& nitric oi"e ro"uction inhuman osteoarthritis cartilage Arthritis heum 1BB=J 2 Amin A, ?i Ceasare P, Vyas P, Attur M, T7eng , illiar T, et al; The eression an" regulation o&nitric oi"e synthase in human osteoarthritis: a&&ecte" chron"rocytes; e%i"ence &or u:regulate" neuronalnitric oi"e synthase D t Me" 1BB5J 1>2; 20B=:102

>3 Fang D?, -eorgescu 9', Mc'ntyre:Gar6in G, $te&ano%ic:acic M, ?onal"son ! 3r"; 9erniate" lum*arinter%erte*ral "iscs sontaneously ro"uce matri metalloroteinases, nitric oi"e, interleu6in:4 an"

rostaglan"in :2 $ine 1BB4J 21; 2=1:=

>


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13; 51=: 23J 53B

10> -ule%ich $D, Conell T?, Gane D, Goc6oo" , $chettmann $, osen*erg N, et al; $tress in&rare"telethermograhy is use&ul in the "iagnosis o& comle regional ain syn"rome, tye ' (&ormerly re&lesymathetic "ystrohy) Clin D Pain1BB=J 13; 50:B

10B #ematsu $, Dan6el ; $6in temerature resonse o& the &oot to col" stress o& the han"; a test toe%aluate somatosymathetic resonse Thermology 1B>>J 3; >:1001

112 !erguson AV; Neurohysiological analysis o& mechanisms &or su*&ornical organ an" area ostremain%ol%ement in autonomic control Prog rain es 1BB2J B1;


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in+ury $6in temerature sta*ility *eteen si"es o& the *o"y D Neurosurg 1B>5J 42;=14:20

11B Dan6o%ic D; Post:traumatic mo%ement "isor"ers; Central an" eriheral mechanisms Neurology 1BB


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Part II7 +linical Alications

Hooshang Hooshmand, Masood Hashmi, Eric M. Phillis

Neurological Associates Pain Management Center, Vero each, !lori"a, #$A

Summary

'T' is a neurohysiological tool ro%i"ing "iagnostic an" theraeutic in&ormation in atients su&&ering &romneuroathic ain ith neuro%ascular in%ol%ement This in&ormation cannot *e o*taine" &rom anatomical tests(eg,M' or CT)

ales $cienti&ic Thermal Processor (ales $cienti&ic, alnut Cree6, CA)(=42 atients) an" Agema Cameras(!lir)(2,503 atients) ere use" &or this stu"y o& 3,245 successi%e atients A re%ie o& our eerience ith'n&rare" thermal imaging ('T') an" its role in ain management as con"ucte", an" comare" ith therecent me"ical literature The stu"y as limite" to the role o& 'T' in the management o& comle chronic

ain syn"rome

'T' is hel&ul in roer locali7ation o& hyerthermic &oci "ue to iatrogenic ermanent "amage tothermosensory ner%es, such as seen a&ter reetiti%e symathetic ganglion *loc6sJ or "ue to symathectomyor rolotheray As the result, the hysician stays out o& harms ay *y not causing &urther ermanent"amage 'n a""ition, 'T' i"enti&ies the srea" o& CP$, ointing to the nee" &or treatment o& such srea" 'thels "i&&erentiate migraine &rom neuroathic occiital neuralgia : to "iseases re.uiring to contrastingtreatments

'T' has not *een ro%en use&ul in e%aluation o& cer%ical an" lum*ar ra"iculoathies, stro6e, an" transientischemic attac6s 'T' can "i&&erentiate cer%icogenic hea"aches &rom migraine : each re.uiring oosite &ormso& treatment 'T' is a use&ul rognosticator &or "ia*etic &oot ain, saring some atients &rom amutation 'T'can sare atients &rom unnecessary caral tunnel, sinal "isc, an" TMD surgeries *y i"enti&ying the originalsource o& neuroathic ain '& 'T' shos "i&&use hyerthermia in the etremity alrea"y treate" ith reeate"symathetic ganglion *loc6s (%irtual symathectomy), such atients shoul" *e sare" &rom un"ergoing&urther ganglion *loc6s The hyothermic etremity a&ter symathectomy ro%es the &utility o& this an" othera*lati%e treatments such as chemical symathectomy, or neurolytic *loc6s

Key Words- CP$, 9ea"ache, $ymathectomy ,Thermograhy

Inrarothermographie als /ilsmittel im .chmer0mangement-in "" ahres .tudie,2!Teil+1er linische 3insat0 der Inarrotthermographie

?ie 'n&rarotthermograhie lie&ert als neurohysiologische #ntersuchungsmetho"e "iagnostische un"theraeutische 'n&ormationen R*er Patienten, "ie an neuroathischem $chmer7 mit neuro%as6ulSreregleitsymtomati6 lei"en ?iese 'n&ormation 6ann "urch 6einen anatomischen Test (7NM', Ct) 7ur


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Ver&Rgung gestellt er"en

in ales $cienti&ic Thermal Processor (ales $cienti&ic, alnut Cree6, CA)(=42 Patienten) un" Agema(!lir)Fameras (2,503 Patienten) ur"en in "ieser #ntersuchung an 3245 au&eionan"er &olgen"en Patienten

%eren"et in Y*er*lic6 R*er unsere r&ahrungen mit "er 'n&rarrotthermograhie ir" gege*en un" "erre7enten me"i7inischen Giteratur 7u "iesem Thema gegenR*er gestellt ?ie #ntersuchung ur"e au& "iee"eutung "er 'n&rarotthermograhie im Management %on $chmer7atienten *eschrSn6t?ie'n&rarotthermograhie hil&t in "er nt"ec6ung hyerthermer onen, "ie "urch ie"erholte iatrogene$chS"igung "er thermosensi*len Ner%en&asern entstehen un" "ie *ei ie"erholten $ymathi6us*loc6a"en,$ymathe6tomie o"er theraeutischer -ee*e:$6lerosierung %or6ommen?urch solche VerSn"erungengearnt,

11=


6ann "er Ar7t eitere $chS"igungen %erei"en ?ie 'n&rarotthermograhie 6ann "ie eitere Aus*reitung$chS"igungen %ermei"en ?ie 'n&rarotthermograhie 6ann "ie eitere Aus*reitung eines 6omleenchronischen $chmer7syn"roms (CP$) an7eigen un" au& eine noten"ige Theraie "ieser Aus*reitunghineisen ?ie 'n&rarot:Techni6 6ann auch &Rr "ie ?i&&eren7ierung 7ischen MigrSne un"neuroathischerO67iitalneuralgie hil&reich sein, 7umal "iese Fran6heits*il"er %Zllig unterschie"licheehan"lungen *enZtigen

?ie 'n&rarorthermograhie ist enig *rauch*ar in "er eurteilung %on 7er%i6alen o"er lum*alena"i6uloathien, %on $chlagan&all o"er transitorischen ischSmischen Attac6en Man 6ann a*er mit ihrer9il&e cer%i6ogenen Foschmer7 %on "er MigrSne unterschei"en ?ie 'n&rarotthermograhie hat

rognostische e"eutung *ei !ussschmer7en %on ?ia*eti6ern,un" hat so manchen Patienten eine

Amutation ersart *enso 6Znnen au& -run" %on 'n&rarot*il"ern nicht noten"ige Oerationen egeneines Faraltunnelsyn"roms, einer an"schei*e o"er chirurgische ingri&&e im Fie&er*ereich %ermie"ener"en, "a "ie #rsache eine neuroathischen $chmer7geschehens ein"eutig ge&un"en er"en 6ann enn"ie 'n&rarotthermograhieeine "i&&use 9yerthermie *ei Patienten nach ie"erholten$ymathi6us*loc6a"en 7eigt, sin" eitere loc6a"en nicht mehr ange7eigt ine hyotherme tremitStnach $ymathe6tomie *eeist "ie nt*ehrlich 6eit "ieser un" an"erer "estruieren"er ehan"lungen ie7 "ie chemische $ymathe6tomie o"er Ner%en*loc6a"en

Schlssel!"rter - CP$, Fo&schmer7e, $ymathe6tomie ,Thermograhie

THE '&*E &3 ITI I SE*E+TI& &3 E'4E 8*&+;S

'T' ro%i"es in"isensa*le in&ormation hich gui"es the hysician to stay out o& harms ay, an" to re%entiatrogenic trauma One eamle is the role o& 'T' in selection o& roer ner%e *loc6 mo"ality Tra"itionally,the ner%e *loc6 o& choice in CP$ has *een stellate ganglion ner%e *loc6s A&ter more than a "o7en stellate,or lum*ar ganglion ner%e *loc6s, the reetiti%e nee"le insertion traumati7es the ganglion enough to result in

ermanent hyerthermia in the etremity (8Virtual $ymathectomy8) (1) 'n such atients, 'T' o& theetremity shos ermanent hyerthermia in &ace o& no ain relie& Fo7in, in his re%ie o& 500 atientstreate" ith symathetic ganglion *loc6s, reorte" 8the ma+ority o& atients ha%e transient or no signi&icant

ain relie&8 (2) Another meta:analysis o& retrosecti%e an" rosecti%e ran"omi7e" controlle" trials o& 11


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CP$(3)

&utcome7'T' i"enti&ie" the 8%irtual symathectomy8 henomenon, an" sare" the atients &rom &urther"amage *y canceling the roce"ure (1) (Ta*le 1) eetiti%e ganglion ner%e *loc6s are routinely alie" &or"iagnosis () shoe" 13 success&ul results o&

symathectomy in >< years o& long term &ollo:u 'n contrast, De*ara an" $aa"e, on their short :termsymathectomy &ollo:u o& 24:40 "ays among teenage sol"iers shoe" %ery goo" results (B) O*%iously,a*lation surgery ro%i"es temorary alliati%e relie& The rest o& the literature re%ie shos ran"om &ollo:us an" results (10) The high ercentage grou has *een artime sol"iers hich ha%e *een "iagnose"early , un"ergone surgery ithin a &e "ays , an" sent home to *e lost to &ollo:u (10:31) eali7ing thatchil"ren an" teenagers (such as sol"iers), sho a strong lasticity an" healing oer as comare" to a"ults(32,33), an" reali7ing that early "iagnosis an" treatment is more success&ul (3

e%ie

Ta"le 1. The influence of treatment on +'PS stages during years or longer follo%-u in


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([[) $ymathectomyJ rotator cu&&J thoracic out syn"romeJ comression neuroathyJ elorationJ etc

([[[) $tage ' L ?ys&unctionJ $tage ''L ?ystrohyJ $tage '''L Atrohy

([[[[) Accor"ing to the tye o& treatment stage ''' may re%erse to stage ' an" %ice:%ersa

Ta"le 1A. Surgical and on-Surgical 2rou

@Note high ercentage o& stage ''' in the surgical grou

2rou Tye Stage I Stage II Stage III

$urgical -rou320 Patients

2@135 Patients

Non : $urgical -rou52> Patients

3114< Patients

341B0 Patients

331=< Patients

elain the *ene&icial, al*eit temorary, results o& artime symathectomy 'n contrast, the symathectomy "one instage ''' CP$@has *een reorte" to sho 7ero ercent relie& (34) #sually, *y the time the hysician resorts to thesymathectomy roce"ure, the atient is in a"%ance" stages o& the "isease 'n such late stages, the ner%ous system haslost its lasticity an" cannot reson" roerly to surgical symathectomy(3=,3>) More o%er, the "isease srea"s(1,3=,3B:


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11

Accor"ing to Cheema (


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120


&utcome7 Thirty:si atients ha" un"ergone Prolotheray *e&ore they ere re&erre" to our Clinic 'T'shoe" &ocal hyerthermia in the area o& Prolotheray None ha" e&&ecti%e long:term relie& &rom this

rolotheray

#ISTA* EBT'EMITY EE#*E ISE'TI&

'n the area o& original ner%e "amage, the hyerthermia oints to "amage an" aralysis o& %asoconstricti%e&unction o& symathetic system (1) The hyerthermia area surroun"e" *y hyothermia usually oints to theae o& "amage" thermosensory ner%e resulting in heat lea6age, as ell as accumulation o& su*stance P ( atients, stum in%ol%ement ith $? ma"e it imossi*le to ear a

rosthesis (5=) 'T' can i"enti&y the roer le%el o& the etremity un"ergoing amutation (5B) This saresthe atient &rom losing any ecess tissue in the amutee stum (5B)

&utcome7'T' ro%i"e" in&ormation that re%ente" amutation in 5 o& 4 atients re&erre" to us &ore%aluation an" &or consi"eration o& amutation O& the 5 atients, < shoe" enough armth an" intactcirculation to re%ent amutation The 5 thatient as &oun" to su&&er &rom "ia*etic neuroathy ith multile

athologic right &oot &ractures aggra%ate" *y 2 years o& non:eight *earing #n"er roer analgesia, theatient as instructe" to start eight *earing A&ter 3 months, the &ractures heale" enough to a%oi" thenecessity &or amutation

E+; A# 8A+; PAI

The 1B=0Es an" 1B>0Es literature re&lects con&using reorts on "iagnostic %alue o& 'T' in cer%ical an" lum*arra"iculoathies, *ac6 ain, "isc herniation, an" sciatica (5


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'n the resent stu"y, the 'T' "one in atients su&&ering &rom &aile" sine, nec6 or *ac6 ain, an" ain in theetremitiesre%eale" con&licting results : esecially hen comare" ith the thermal imaging tests "one onthe same atients in other la*oratories The con&usion has its roots in technical limitations, an" imroerclinical alications o& the test(4=,4>) 9arer (=3) an" Cha&et7 (=0) A&ter a &e ee6s, the hyerthermic area shrin6s 'n some cases (>0) the

hyerthermia ersists "ue to ermanent "amage to symathetic ner%e &i*ers (1) This is a har*inger o& oorrognosis The hyothermic area surroun"ing the hyerthermic eicenter o& the "amage" ner%e re&lects u:regulation an" suersensiti%ity o& sensory ner%es to noreinehrine (>1:>


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atients, seci&ic in >B , ositi%e re"icti%e %alue (PPV) o& B0, an" negati%e re"icti%e %alue (NPV) o&B


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con"ition to "iscontinue the "estructi%e cryotheray as*aum (11=), an" others (11>:121) ha%e"emonstrate" lesions a&&ecting large myelinate" aons secon"ary to ice eosure These lesions are in the&orm o& Valerian "egeneration an" segmental "emyelination (11=,11>,121) The cryotheray causesiatrogenic hyothermia ith islan"s o& ermanent hyerthermia "ue to &rost*ite ner%e "amage mentione"a*o%e

&utcome7'T' as hel&ul in i"enti&ying the areas o& thermosensory ner%e "amage, an" as ell as"iagnosing the henomenon o& CP$ srea"

#IA8ETI+ E('&PATHY A# #IA8ETI+ 3&&T

'n a"%ance" stages o& "ia*etic neuroathy, the "isease is comlicate" *y neuroin&lammatory changes,&ractures (CharcotHs &oot), an" *y &oot ulcers (122:125) The 'T' changes in these atients are the

rototyical eamles o& ner%e "amage causing irre%ersi*le hyerthermia in "i&&erent "egrees Armstrong etal (122) ha%e utili7e" 'T' as the re"ictor o& early sign o& "eterioration o& ulcers an" trohic &racture Theyha%e use" the high "elta:T o& 2KC *eteen the in%ol%e" an" contralateral etremities to initiate theraeuticinter%ention

&utcome7'n our stu"ies, in all 11 "ia*etic &oot atients hyerthermic &oci ere o*ser%e" These 11atients ere re&erre" to us &or a secon" oinion *e&ore amutation None o& these atient en"e" u ithamutation 'T' laye" a i%otal role in saring these atientsH etremities The recognition o&neuroin&lammatory henomenon (101) in these atients le" us to treat them ith eight:*earing,mo*ili7ation, ner%e *loc6s, 'V Mannitol, hysical theray, etc, saring these atients &rom amutation asell as relie%ing neuroin&lammation an" ain ith ner%e *loc6s an" 'V Mannitol (100gm/500cc ?5treatment)(124,12=)

TEIS E*8&

&utcome7'T' is use&ul in "iagnosing Traumatic lateral eicon"ylitis (12>,12B), or tennis el*o The 'T'

shoe" a &ocali7e" hyerthermia at the lateral eicon"yle in 53 o& 54 atients (B5)(12>) $imilar &in"ing o&hyerthermia is also note" in tarsal tunnel entrament neuroathy These areas o& hyerthermia shoul" not *eaggra%ate" *y nee"le insertion Any trigger oint in+ection or ner%e *loc6 shoul" *e er&orme" roimal tothe hyerthermic area 'n+ections aime" at the &oot, an6le, han", or rist causes &urther trauma an" u:regulation o& the symathetic system lea"ing to a source o& ain, an" &urther thermal "ys&unction (3=)

TH&'A+I+ &(T*ET SY#'&ME>T&S?

&utcome7Another &re.uently o%er:"iagnose" an" o%er: treate" syn"rome in neuroathic ain is ThoracicOutlet $yn"rome (TO$)(130) ?ue to the in&lammatory nature o& neuroathic ain, esecially in CP$ inuer etremities, *rachial leitis is &re.uently mista6en &or TO$ an" is imroerly manage" *y surgeryThe surgical roce"ure *ecomes a ne source o& neuroathetic ain, &urther "eteriorating the con"ition(130,131) 'T' has *een instrumental in i"enti&ying the nature o& athology in "istal ortion o& the etremityin &orm o& ehatic hyerthermia: ointing to the original source o& athology rather than the secon"aryin&lammation o& *rachial leitis 'T' sare" such atients &rom surgery &or TO$ in 1< o& >2< CP$ atientsith resumti%e "iagnosis o& TO$ (3=)

+E'4I+&2EI+ HEA#A+HES

'T' can hel "iagnose an" "i&&erentiate cer%icogenic hea"aches &rom migraine The cer%icogenic hea"acheshos areas o& hyer : an" hyothermia in the "istri*ution o& osterior sensory ner%e *ranches o& C2 through


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C< ner%e roots, an" occiital ner%es Ner%e *loc6s in these areas ro%i"e ecellent relie& (11,3=) On theother han", ra"io&re.uency "amage to articular &acet (,132,133), or rhi7otomy (13:15B)

123


This %aso"ilation an" in&lammation elains the hyerthermia in the area o& ner%e in+ury The trigeminal%ascular symathetic &unction is in&luence" *y many &actors inclu"ing, *ut not limite" to, chemical changesin the *loo" (140), cranio%ascular circulatory changes (141,142), an" stimulation o& trigeminal nucleus *yre&erre" ain originating &rom the osterior ner%e *ranches o& the C1 to C< ner%e roots (143)

&utcome7'T' hels i"enti&y the craniocer%ical hyerthermic areas, an" "i&&erentiate this hea"ache &rommigraine here as in migraine hea"aches thermal &luctuations are .uite unsta*le, in cer%icogenic hea"achesthe hyerthermia is resent in the occiital ner%e region an" the craniocer%ical +unction (11) These totyes o& hea"aches re.uire to oosite &orms o& treatment $umatritan aggra%ates cer%icogenic hea"achesJcon%ersely ner%e *loc6s "o not usually relie%e the true migraine hea"aches

MI2'AIE HEA#A+HES

#n&ortunately the term migraine has *een relati%ely loosely alie" to any tye o& neuro%ascular hea"ache,migraine or otherise This results in contamination o& stu"ies "one on this su*+ect The 'T' has *eenreorte" as ha%ing no %alue &or e%aluation o& true, generic migraine hea"aches (140,14TM#?

'T' she"s more light on the comle su*+ect o& temoroman"i*ular "ys&unction (TM?); 'n ain&ul, clic6ingtye o& TM?, Mceth et al, shoe" 'T' to ha%e a "iagnostic sensiti%ity o& >= (144) This as in contrastith normal controls shoing normal seci&icity o& >4 (144) 'T' an" li.ui" crystal thermograhies ereusually normal in *eteen &lare us o& trigeminal neuralgia or trigemino%ascular &acial ains (14=) ?uringthe symtomatic attac6s 'T' shoe" hot or col" sots in o%er >0 o& atients (>


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ta6ing an" 'T' : sol%e" the u77le, an" elaine" the reason &or oor reco%ery

&utcome7 The 'T' re%eale" an a*normal symathetic "ys&unction in the cer%ical (14 atients), lum*ar (Batients), an" thoracic sine regions (= atients) Only one atient ha" shon no sinal in%ol%ement : instea"the atient as &oun" to su&&er &rom maillary *one osteonecrosis an" a*normal thermal changes in theTrigeminal ner%e "istri*ution

+&+*(SI&

A roerly er&orme" 'T', ro%i"es "iagnostic theraeutic in&ormation not o*taine" *y M-, NCV, CT, orM' This in&ormation is in"isensa*le in heling to arri%e at an accurate "iagnosis, an" in i"enti&ying the

athologic areas 't hels the hysician to a%oi" &urther in%asi%e *loc6s or surgical roce"ures

Gac6 o& such in&ormation lea"s to mis"iagnosis, an" to la*eling the atients &or *eing a malingerer, or assu&&ering &rom con%ersion reaction

AcCno%ledgment

e are most grate&ul to Mr ric Phillis &or his in"isensa*le, an" etensi%e research an" rearation o& thisreort

#isclaimer

The authors ha%e no &i"uciary interest in any me"ical sulies, or any me"ications "iscusse" in this aer

12J B5; 5B; =4


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23J 45;4


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one Doint $urg 1BB5J ==;2=0:3

5B McCollum PT, $encer VA, al6er !; Amutation &or eriheral %ascular "isease; the case &or le%elselection r D $urg 1B>>J =5; 11B3:5

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41 #ematsu $; Thermograhic imaging o& the sensory "ermatome, $ociety &or Neuroscience A*stracts1B>3J B; 325J 42; =11:5

4= ?e%ul"er D, ?umoulin F, ?e Gaat M, olly -; 'n&ra:re" thermograhic e%aluation o& sinal cor"electrostimulation in atients ith chronic ain a&ter &aile" *ac6 surgery r D Neurosurg 1BB4J 10; 3=B:>3

4> McCulloch D, !rymoyer D, $teurer P, ia7 -, 9urst !; Thermograhy as a "iagnostic ai" in sciatica D$inal ?isor" 1BB3J 4; >J 2B;24:32

=2 Mills -9, ?a%ies -F, -etty CD, Conay D; The e%aluation o& li.ui" crystal thermograhy in the

in%estigation o& ner%e root comression "ue to lum*osacral lateral sinal stenosis $ine 1B>4J 11;


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124

e%ie

=5 Thomas ?, Cullum ?, $iahamis -, Ganglois $; 'n&rare" thermograhic imaging, magnetic resonanceimaging, CT scan an" myelograhy in lo *ac6 ain r D heumatol 1BB0J 2B; 24>:=3

=4 -ule%ich $D, Conell T?, Gane D, Goc6oo" , $chettmann $, osen*erg N, et al; $tress in&rare"telethermograhy is use&ul in the "iagnosis o& comle regional ain syn"rome, tye ' (&ormerly re&lesymathetic "ystrohy) Clin D Pain1BB=J 13; 50:B

== Miller ?, Munger G, Poell P; Chronic ain an" local anesthetic neural *loc6a"e 'n; Cousins DDan" ri"en*augh P, e"s Neural *loc6a"e in clinical anesthesia an" management o& ain Phila"elhia; DGiincott 1B>0J 414:34

=> enarroch ; The central autonomic netor6; &unctional organi7ation, "ys&unction, an" ersecti%e

Mayo Clinic Proc 1BB3J 4> ; B>>:1001

=B $tee" PA; The utili7ation o& contact li.ui" crystal thermograhy in the e%aluation o& temoroman"i*ular"ys&unction Cranio 1BB1J B; 120:>

>0Vel"man P9, eynen 9M, Arnt7 ', -oris D; $igns an" symtoms o& re&le symathetic "ystrohy;rosecti%e stu"y o& >2B atients Gancet 1BB3J 31 Callo '?, Camisi P, Gam*ert MG, !eng , Arnol" DM; nhance" in %i%o alha 1: an" alha 2:a"renocetor:me"iate" %enoconstriction ith in"omethacin in humans Am D Physiol 1BB>J 2=5; >3=:2 ?rummon" P?, !inch PM , $mythe -A; e&le symathetic "ystrohy; the signi&icance o& "i&&ering

lasma catecholamine concentrations in a&&ecte" an" una&&ecte" lim*s rainJ 1BB1J 113 $ato D, Perl ; A"renergic ecitation o& cutaneous ain recetors in"uce" *y eriheral ner%e in+ury$cience 1BB1J 25;140>:10

>5 ir6lein !, ie"l , Claus ?, Neun"or&er ; 8Pattern o& autonomic "ys&unction in time course o&comle regional ain syn"rome8 Clinical Autonomic esearch 1BB>J >; =B:>5

>4 Ochoa D, Tore*+or6 9, et al; Mechanisms o& neuroathic ain A"%ances in Pain esearch an" Theray

"ite" *y 9G !iel"s, et al a%en Press, Ne Qor6 1B>5J 1B; = o*erts D; A hyothesis on the hysiological *asis &or causalgia an" relate" ains Pain 1B>4J 2>.o*erts D, !oglesong M; '"enti&ication o& a&&erents contri*uting to symathetically e%o6e" acti%ity ini"e "ynamic range neurons Pain 1B>>J 3


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>B 9o**ins ; Thermograhy an" Pain 'n iome"ical Thermology Ne Qor6 Alan Giss 1B>2J 341:=5

B0 9erric6 A, el:9a"i"y F, Marsh ?, Dayson M; A*normal thermoregulatory resonses in atients ithre&le symathetic "ystrohy syn"rome D heumatol 1BB:


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12=


10= $cheulein D; Mechanism o& temerature regulation in the s6in 'n; !it7atric6 T, isen A, ol&&F,!ree"*erg 'M, Austen F!, e"s ?ermatology in -eneral Me"icine 3r"e" Ne Qor6 Mc-ra: 9ill 1B>=J3 Gi%ingston F; Pain mechanisms; A hysiological interretation o& causalgia an" its relate" states 'nGon"on, MacMillan 1B=J =;1>J 3; 5B:41

113 Gi%ingston F; Pain Mechanisms Ne Qor6; MacMillian 1B


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121 Gi CG; &&ect o& cooling on neuromuscular transmission in the rat Am D Physiol 1B55J 130;53:=J 20; 52B:35

13


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alie" casaicin D 'n%est ?ermatol 1B>1J =4; 3B4J 14;2>B:30B

1


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'n%estigation 1BB=J BB; 1231:=

152 Attur M-, Patel N, A*ramson $, Amin A; 'nterleu6in:1= u:regulation o& nitric oi"e ro"uctionin human osteoarthritis cartilage Arthritis heum 1BB=J 2; 20B=:102

15


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&acial ain D Oro&ac Pain 1BB5J B; 13>: -ratt M, -ra&&:a"&or" $, $hetty V, $ol*erg F, $ic6les A; A 4 year clinical assessment o&electronic &acial thermograhy ?entomaillo&ac a"iol 1BB4J 25; 22; 1

rsd thermology international 2001

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