Reflex sympathetic dystrophy treated by electroconvulsive therapy: intractable pain, depression, and bilateral electrode ECT

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Abstract
An adult female patient without previous history of pain or psychiatric disorder developed reflex sympathetic dystrophy (RSD) in her left hand and arm after 2 separate injuries, and subsequent arthroscopy and arthroscopic surgery. Traditional management with systemic medications, nerve blocks, and behavioral pain management were unsuccessful. With subsequent development of depression and suicide attempt, electroconvulsive therapy (ECT) was administered using bilateral lead placement. Total resolution of her pain occurred for several hours after the first treatment. Over the course of the full ECT series the pain, vasculature changes of RSD, and depression resolved completely. Prominent psychiatric disturbances were complications arising after ECT and the resolution of the RSD, and during long-term follow-up. A review of the literature from the 1940s revealed numerous cases of chronic, intractable pain treated successfully by ECT, although none of the case series were controlled studies. More recent literature questions if 'modified' ECT, using unilateral lead placement, is less effective than bilateral lead placement, in treating pain syndromes. Resolution of the vascular changes of RSD after ECT raises questions of possible cerebral contributions to the pathophysiology of RSD.