RSD Thermology International 2001

Thermology internationa l 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, #$A
Summary
The %alue o& 'n&rare" thermal imaging ('T') is limite" to e%aluation o& neuro%ascular "ys&unction( 't )ro%i"es
in"is)ensa*le in&ormation regar"ing neuro)athic )ain "ue to )eri%ascular microcirculatory sym)athetic
"ys&unction( 'T' recor"s su)er&icial, an" "ee) tem)erature changes( The *ilateral cer%ical cor" tem)erature
mo"ulation "eman"s care&ul clinical correlation( The 'T' is an o*+ecti%e gui"e hel)ing the clinician to choose
a )ro)er an" harmless treatment )rotocol, es)ecially a%oi"ing unnecessary surgery(
The anatomical tests such as magnetic resonance imaging (MRI), computed
tomography (CT), an" )hysiological tests such as electromyogra)hy (,M-) an" ner%e con"uction
%elocity (NCV) tests ha%e *een the main "iagnostic tools a))lie" in the management o& somesthetic
(somatic) )ain( The a*o%e tests usually are not in&ormati%e in the "iagnosis o& neuro)athic )ain( The
neuro%ascular in%ol%ement in neuro)athic )ain re.uires tests such as 'n&rare" thermal imaging ('T') an"
/uantitati%e su"omotor a0on re&le0 test (/$A1T) that a""ress autonomic (e(g(, thermal) changes &or a more
accurate "iagnosis an" treatment( This is a stu"y o& the role o& 'T' in the "iagnosis an" management o& )ain(
The results 2ere com)are" 2ith the in&ormation in me"ical literature(
ales $cienti&ic Thermal Processor an" Agema Cameras 2ere use" &or this stu"y o& 3,245 successi%e
)atients( A re%ie2 o& our e0)erience 2ith 'n&rare" thermal imaging ('T') an" its role in )ain management
2as con"ucte", an" com)are" 2ith the recent me"ical literature( The stu"y 2as limite" to the role o& 'T' in
the management o& com)le0 chronic )ain(
$lo))y techni.ue, an" )oor *ac6groun" in *asic neuro)hysiologic training, ha%e contri*ute" to )oor
utili7ation an" inter)retation o& 'T'( !or the 'T' to *e accurate an" clinically use&ul, )ro)er techni.ue,
stan"ar"i7ation, an" )ro)er clinical correlation are the minimal re.uirements( The *asic )hysiology o&
autonomic thermoregulation is outline" in "etail to hel) the clinician to )ro)erly un"erstan" an" inter)ret the
test( The "ys&unction o& thermal sensory ner%es in the 2all o& arterioles cannot *e "etecte" *y ,M- or NCV
an" e0clu"ing the 'T' test may mislea" the clinician to "iagnose the con"ition as 8)sychogenic8 or
8&unctional(8 Our results 2ere com)ati*le 2ith the re%ie2 o& current me"ical literature(
'T' )ro%i"es use&ul clinical in&ormation 2hen a))lie" 2ith )ro)er techni.ue( 't )ro%i"es "iagnostic an"
thera)eutic in&ormation limite" to "iseases in%ol%ing autonomic, neuro%ascular, an" neuroin&lammatory
changes( Con%ersely, it cannot *e e0)ecte" to hel) "iagnose ner%e in+uries 2ith no micro%ascular
in%ol%ement such as somesthetic ner%e in+uries( Pro)er teaching an" un"erstan"ing o& thermoregulation
hel)s the clinician to o*tain in"is)ensa*le in&ormation &rom this test(
Key Words - C1P$, 9ea"ache, $ym)athectomy ,Thermogra)hy(
Infrarotthermograhie als Hilfsmittel im Schmermanagement - eine 11 !ahres - Studie. 1. Teil
53

Thermology international 11 / 2 (2001)

Introduction
This is a re%ie2 o& our 11:year e0)erience 2ith the a))lication o& 'n&rare" thermal imaging ('T') in 3,245
)atients su&&ering &rom chronic )ain( This stu"y &ocuses on the a))lication o& 'T' as a "iagnostic an"
thera)eutic gui"e(
Terminology
The nocice)ti%e )ain sensation is "i%i"e" into t2o "istinct categories; Neuro)athic (Ta*le 1) an"
somesthetic(somatic) )ain( The neuro)athic )ain is associate" 2ith thermal (%asomotor) changes( These
changes are in res)onse to the a&&erent no0ious im)ulses o& the unmyelinate" sensory (c:thermorece)tors)
ner%es in the 2all o& micro%asculature (1)( This is in contrast to the common somatic (somesthetic) )ain
2hich is usually not accom)anie" *y circulatory "ys&unction(
The somesthetic )ain is characteri7e" *y in%ol%ement o& a&&erent somatic(s)inothalamic) ner%es usually
2ith 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& neuro)athic )ain (2,3)
&ollo2s an arterial "istri*ution such as &emoral, caroti" or *rachial arteries( 'n )athologic states, hy)o:an"
hy)erthermic changes are recor"e" *y 'T' 2hich can *e .uite hel)&ul in the selection o& a )ro)er treatment
)rotocol(
The neuro)athic )ain, *y %irtue o& in%ol%ing the neuro%ascular structure, is accom)anie" *y circulatory
(Thermal) changes lea"ing to a "i&&erent ty)e o& )ain such as causalgia (<), "ea&&erentation an"
sensiti7ation (5), as 2ell as a*normally e%o6e" )ain; e(g(, hy)er)athic ()roto)athic) regional )ain (4),an"
allo"ynic )ain e%o6e" *y e%en minimal tactile stimulation (=)( These are characteristic )ains accom)anie"
*y neuro%ascular "ys&unction (>) o& any etiology(e(g(, )ost her)etic neuralgia, "ia*etic mononeuro)athy,
etc(

Ta"le 1. #isease$ in %hich neuroatic ain occur.
Mononeuro)athy
Am)utation stum) )ain
Causalgia
?ia*etes mellitus
Neuroma
Ple0us a%ulsion
Posther)etic neuralgia
Traumatic
Vasculitis
Mononeuro)athy
multi)le0

?ia*etes
Polyneuro)athy Alcohol
Nutritional neuro)athy
Chemothera)y
?ia*etes
,hrler ?anlos $yn"rome
!a*r@ "isease
9'V
9y)othyroi"ism
#remia, renal &ailure
Vitamin "e&iciencies
Cancer
Neurosy)hilis (Ta*es)
Trigeminal neuralgia

!igure( 1 : 'n neuro)athic )ain the sensory loss sho2s thermatomal (%ascular) "istri*ution in contrast to
the "ermatomal (ra"icular) "istri*ution o& the somatic )ain( Con%ersely, the malingering sensory loss is
limite" to the +oints( Aith )ermission &rom $)ringer:Verlag Pu*lishers (1)(
5<

Original article
The 'T' e0clusi%ely measures tem)erature changes o& the *o"y( 9ence, its "iagnostic %alue is limite" to the
stu"y o& ner%e "ys&unction 2ith micro%ascular in%ol%ement (neuro)athic )ain)( The thermal regulation is
achie%e" *y coor"ination o& multi)le anatomic areas o& central an" )eri)heral ner%ous system(PN$)( The
PN$ contri*ution is mo"ulate" *y a&&erent im)ulses &rom microsco)ic small c:&i*er thermorece)tors in the
2all o& the microcirculation (arterioles an" %enules) (B,10,11)( $uch minute unmyelinate" microsco)ic
ner%es cannot *e teste" 2ith anatomical tests such as CT an" M1', nor 2ith somatic ty)e o& )hysiological
tests such as electromyogra)hy (,M-), an" ner%e con"uction %elocity (NCV)( The NCV cannot stu"y the
microcirculatory neuro)athic &unction( 't stu"ies the &unction o& the large trun6 myelinate" ner%e &i*ers
2hich are )art o& the somatic (e(g(, s)inothalamic) ner%ous system (12)( 'n contrast, 'T' e%aluates
sym)athetic thermoregulatory &unction more com)rehensi%ely than s2eat test( The s2eat test e(g(, /$A1T
measures the &unction o& a minority (less than 10C) o& cholinergic ner%es in the sym)athetic system(
HIST&'Y
'n ancient me"icine, )hysicians 2ere taught to measure tem)erature *y han"s( This insensiti%e an"
inaccurate metho" is still a))lie" *y )hysicians 2ith )oor 6no2le"ge o& )hysiology( A))ro0imately !our
"eca"es (C(, 2et mu" sal%es 2ere use" to "etect sur&ace *o"y tem)erature( 9i))ocrates a"%ocate" the
metho"( y the en" o& the 14
th
century, -alileo "e%ise" a 8thermosco)e8 as a tool in )atient care( Dohn
9erschel 2as the &irst to )er&orm Thermogra)hy *y using color &ilters in a re&lecting telesco)e( y the early
1B50Es, thermal reco"ing 2as a))lie" *y #$ &orces in the Forean 2ar( ?r( 1ay Ga2son, an" later Pro&essor
,(!(D( 1ing, an" others (13:14) re)orte" clinical a))lication o& thermogra)hy( y 1B>2, thermal imaging 2as
acce)te" as a ne2 la*oratory test in Da)an( At least in 2 states (Cali&ornia an" !lori"a) the 2or6erHs
com)ensation courts ha%e acce)te" the utili7ation o& 'T' &or the "iagnosis o& C1P$(
The American Aca"emy o& Neurology (AAN) (1=) in 1BB0 re%ie2e" the utili7ation o& Thermal imaging in
neurologic )ractice( 't em)hasi7e" the im)ortance o& )ro)er techni.ue( 't &oun" the test not use&ul &or the
"iagnosis o& ra"iculo)athies, entra)ment neuro)athies, hea"aches, stro6e, an" transient cere*ral ischemia
(1=)( As "iscusse" in the )resent )a)er, the 'T' is not use&ul &or "iagnosis o& transient ischemic attac6s,
entra)ment neuro)athy (1>), an" "isc herniation (1B), *ut can contri*ute in&ormation to "iagnosis an"
treatment o& neuro)athic )ain "ue to neuro%ascular "ys&unction(
THE ITI P())*E
The 'T' has *een a*use", an" o%er :an" un"eruse" in the )ast three "eca"es( 'm)ro)er technology on one
han", an" )oor un"erstan"ing o& the *asic anatomy an" )hysiology o& the autonomic ner%ous system (AN$)
has contri*ute" to e0clusion o& this test, "e)ri%ing the )atient o& )ro)er "iagnosis an" treatment(
The erroneous e0)ectation o& a single test to i"enti&y the cause o& a com)le0 clinical syn"rome can lea" the
)hysician to "eem the test useless( $uch a com)le0 syn"rome is )ro)erly "iagnose" *y care&ul history ta6ing
an" clinical correlation rather than *y a))lying a single test( As an e0am)le, M1' o& the s)ine may sho2 an
innocuous "isc *ulging or )rotrusion unrelate" to the )atientHs )ain( Ahereas only 2>:30C o& the )atients
su&&ering &rom chronic *ac6 )ain are "ue to "isc )athology, o%er >0C o& such )atients are "iagnose" as "isc
"isease, lea"ing to unnecessary surgery (20,21)(
TE+H,I+A* ASPE+TS
The "ynamic state o& &lu0 o& the sym)athetic system )lays an im)ortant role in *alancing an" com)ensating
the e0ternal %ersus internal &luctuations o& *o"y tem)erature( Accurate recor"ing o& this so)histicate"
tem)erature regulation re.uires im)ecca*le techni.ue, re)ro"uci*le, consistent recor"ing, an" a controlle"
la*oratory en%ironment( #n&ortunately, the )hysician rarely enters the la*oratory to o*tain &urther, more
sensiti%e, an" accurate )ictures than the stan"ar" techni.ue "one *y the technician (!ig(2)( 'T' can )ro%i"e
&urther in&ormation lea"ing to correct "iagnosis(
The in&rare" camera recor"s the in&rare" electromagnetic s)ectrum (Ta*le 2)( At the short 2a%e *oun"ary
(Ta*le 2 ) the in&rare" s)ectrum starts at the %isual )erce)tion limit o& "ee) re"( At the o))osite e0treme o&
long 2a%elength &re.uency, it *or"ers, an" *len"s 2ith, micro2a%e:ra"io 2a%elength( The in&rare" *an" is
55

!igure( 2 : Central hy)erthermic areas o& entrance an" e0it in electrical in+ury( The )ermanent hy)erthermic
"amage is surroun"e" *y %asoconstricti%e hy)othermia( Only a&ter increasing the thermal sensiti%ity (right)
the lesions 2ere i"enti&ie"( This 8*utton hole8 sign is e0clusi%ely seen in electrical in+ury(

su*"i%i"e" to 8near in&rare"8 (0(=5 to 3m m), 8mi""le in&rare"8 (3:4I m), 8&ar in&rare"8 (4:15I m), an"
8e0treme in&rare"8 (15:100I m)( The stan"ar" 'T' units measure the &ar in&rare" (!'1) 2a%e length( To
accurately recor" an" measure su*tle tem)erature changes re.uires a 8 *lac6*o"y8 *o0( The 8*lac6*o"y8
is an o*+ect ca)a*le o& a*sor*ing all ra"iation an" e.ually emitting any 2a%e length (Firchho&& Ga2)(
The thermal imaging la*oratory re.uires minimum s)ace o& 3(50<(5 metersJ 1oom tem)erature o& =0:=2K!J
No shiny (e(g(, Ginoleum) or smooth )lastic &loor to a%oi" heat an" light mirror e&&ectJ The interior o& the
la*oratory shoul" *e in&rare" a*sor)ti%e( Aalls shoul" *e insulate" at minium rate o& 1L1B9r:!t
2
:
K!/T#J 1oom humi"ity o& 50:=0 C( The air con"itioner shoul" )ro%i"e laminar "o2n &lo2 ranging no
more than 1K! (1(> KC) tem)erature( The )atients are coole" "o2n in a 20:21KC stea"y state room &or 30
minutes o& e.uili*ration 2ithout clothing( No )rior smo6ing &or at least B0 minutes, no sun *athing lotion,
no a))lication o& ice )ac6s or heat, no acu)uncture, laser thera)y, ,M- nee"le test, or transcutaneous
electric ner%e stimulation (T,N$) &or at least <> hours )rior to the thermogra)hic testing( The )atient
shoul" not 2ear any ty)e o& +e2elry "uring the test( A stan"ar" sensiti%ity o& 2<:3<KC is the usual staring
)oint( $tan"ar"i7ation o& techni.ue, an" consistent re)ro"uction o& the results are essential &or accuracy o&
the test( A stan"ar"i7e" am*ient tem)erature o&

Ta"le -. The relationshi of electromagnetic sectrum to the infrared "and.
-amma
ray
M:ray #ltra%iolet
1a"io

/ / / | \
Near 'n&rare" S. Mid GA !ar E/treme
Infrared 'nrare" Infrared
10 m 110 m
54

Original article
21:22K C (=0:=2K!), a minimum o& 2:3 sets o& re)ro"uci*le measurements in a cool, controlle" tem)erature, no
smo6ing, an" no )er&umes &or at least 1 hour *e&ore the test, are the minimal technical re.uirements (22) to achie%e a
relia*le com)arati%e si"e to si"e ("elta T) o& N 0(2 : 0(3K C (23)( The re%ie2 o& 'T' "one )rior to )atients *eing
re&erre" to our clinic ha%e re%eale" the ten"ency &or in&le0i*le routine *aseline tem)erature measurements, rather than
a"+usting the sensiti%ity gauge to achie%e a more accurate test(1)(
PHYSI&*&2Y
The sym)athetic ner%ous system is an integral )art o& the com)rehensi%e central an" )eri)heral ner%ous system
)laying a role in
1. TEMPE'AT('E 'E2(*ATI&, o& the *o"y (s6in an" %iscera)(2<:2=),
-. +&,T'&* &3 4ITA* SI2,S ( *loo" )ressure, )ulse, an" res)iration), an"
5. M&#(*ATI&, &3 IMM(,E SYSTEM(
The tem)erature regulation is achie%e" *y mo"ulating heat loss an" heat )reser%ation through "ermal an" su*:"ermal
circulatory (sym)athetic) an" s2eating (cholinergic) changes( 'n contrast to the &ish, the 82arm *loo"e"8 animals can
only sur%i%e in the sta*le, narro2 : range *an" o& the internal en%ironment tem)erature : milieu interne (2>)( The
"ermal an" su*"ermal structures )ro%i"e a gri" style o& %ertical an" hori7ontal %ascular shunting system 2hich
)rotects the *o"y against e0cess am*ient heat *y 2asting the *o"y heat through %aso"ilation an" s2eating( The same
system "oes the o))osite in e0cess am*ient col" en%ironment *y conser%ing heat, an" *y cooling the s6in sur&ace(
The "ee) tissue circulation )lays a ma+or role in the )rotection o& the internal en%ironment (homeostasis)( 'n col"
tem)erature, s6in %asoconstriction increases the "ee) tissue heat an" circulation to )re%ent core hy)othermia( Chronic
)athologic sym)athetic u): regulation causes the %icious circle o& )ersistent "ermal %asoconstriction, an" increase"
"ee) circulation in *one an" muscles, lea"ing to osteo)enia an" muscle 2ea6ness (2B)(
The sym)athetic system mo"ulates the cellular immune &unction (30), lea"ing to mo"ulation o& cellular neurogenic
in&lammation in )athologic con"itions (30:<5)( 'n se%ere an" chronic stages o& sym)athetic "ys&unction,
neuroin&lammation results in *ul*ous lesions (33), )el%ic in&lammatory "isease (P'?), interstitial cystitis (<4), an"
sterile a*scess (<=)( The regional neuroin&lammatory e"ema lea"s to im)ingement o& the )eri)heral ner%es mislea"
the clinician to mista6e the "isease &or con"itions such as car)al tunnel (3>,<>,<B) an" ?u)uytrenHs contracture (50)
(Ta*le 3), thoracic outlet (TO$), tarsal tunnel, an" myo&ascial syn"rome (3B)( The surgical trauma or re)etiti%e trauma
"ue to sym)athetic ganglion *loc6s (Ta*le 3), in turn aggra%ates the in&lammation (12,<0,51:5<), *ecoming a ne2
source o& neuro)athic )ain an" lea"ing to s)rea" o& the "isease (<2,55)( 'T' can s)are the )atient &rom unnecessary
surgery (12,34,3=,3>)( The )rimary a&&erent sensory neuron )lays a ma+or role in mo"ulation o& e0citatory, an" )ro:
in&lammatory neuro)e)ti"es such as su*stance P ($P) (<3,<<,54:44), nitric o0i"e (NO) (4=:>=), an" calcitonin gene:
relate" )e)ti"e (C-1P) (>>), as 2ell as inhi*itory hormones such as corticotro)in:releasing hormone, o)ioi" )e)ti"es,
such as "ynor)hin (5B)(

Ta"le 5. The role of ITI in selection of treatment modalities.
1( '"enti&ication o& 6Virtual $ym)athectomy8( ( Permanent hy)erthermia "ue to "amage &rom re)etiti%e ganglion
*loc6 nee"le insertion)( 'T' s)ares the )atient &rom &urther *loc6s(
2( Al)ha:rece)tor su)ersensiti%ity to circulating Nor:e) sho2s "i&&use hy)othermia in"icating the &utility o& any
other chemical, ra"io&re.uency, or surgical )roce"ures(
3( 'T' i"enti&ies the )ermanent hy)erthermia in the in+ure" e0tremity( The a)e0, central )art o& )ermanent
sym)athetic ner%e "amage is surroun"e" *y hy)othermia( Any &orm o& nee"le insertion, ner%e *loc6, or to)ical
Cloni"ine s6in )atch a))lication to the "amage" ner%e area aggra%ates an" enlarges the lesion( The treatments
shoul" *e a))lie" )ro0imally at e)i"ural an" )ara%erte*ral le%els o& s)ine corres)on"ing to the area o& ner%e
"amage(
<( Thermal e%i"ence o& neuro%ascular insta*ility on 'T' )ro%es a"%ance" stage o& sym)athetic "ys&unction non:
res)onsi%e to sym)athetic ganglion *loc6 or sym)athectomy(
5( 'T' i"enti&ies re&erre":)ain &ocal hy)othermic area( Massage or ner%e *loc6 in this &ocus relie%es the )ain(
5=

!igure( 3 : Cer%ical neuro)athic )ain re)resente" 2ith hy)othermia on 'T' in the )ara%erte*ral area( -entle
)ressure e0erte" o%er the cer%ical s)ine (Ge&t) re%eale" reacti%e release o& in&lammatory chemicals an"
*lushing o& the s6in in the hy)othermic area( Treatment 2ith )ara%erte*ral ner%e *loc6s (1ight) )ro%i"es
)ain relie&, an" "issemination o& irritati%e su*stances ($P, NO, etc)( Massage thera)y a&ter *loc6 enhances
the reco%ery(

#sually, in chronic stage, the re&erre" )ain such as seen in shoul"er:han" syn"rome, results in anti"romic
s)rea" (>B) o& the in&lammatory su*stances (5B) causing secon"ary in%ol%ement o& the )ara%erte*ral
sensory ner%es( The sym)athetic "ys&unction lea"s to in&lammatory res)onse in the e0tremity, as 2ell as in
the e)i"ural an" )ara%erte*ral regions o& s)ine( 'T' hel)s i"enti&y these in&lammatory changes( ,)i"ural
(B0) an" )ara%erte*ral (B1) ner%e *loc6s in these regions hel) relie%e the in&lammation (!ig( 3)( $uch
*loc6s achie%e )ain relie&, as 2ell as anti:in&lammatory e&&ect through in+ection o& minute (2(5 to 10 mg)
"oses o& "e)o:me"rolO (methyl)re"nisolone) (12,B2)(
PE'IPHE'A* A,# +E,T'A* 'E2(*ATI&, &3
#EEP A,# S('3A+E TEMPE'AT('E
The sym)athetic system )artici)ates in regulating the core *o"y tem)erature 2ithin a narro2 *an"( The
normal *loo" &lo2 to the s6in is 200 ml/mm 2hich is <C o& the car"iac out)ut (B3)( This out)ut &ar
e0cee"s the *aseline o0ygen an" nutrient re.uirements o& s6in( The rich arterio%enous anastomoses in
acral areas o& the )alm o& han"s, &eet, an" a0illa, allo2 a large %olume o& *loo" to &lo2 through the s6in(
This lea"s to hy)erthermia an" heat emission( The )arallel anatomical structure o& large arteries an" %eins
in the e0tremities allo2s countercurrent e0change o& heat lea"ing to su)er&icial %asoconstriction, an"
simultaneous shunting o& *loo" &rom the su)er&icial to the "ee) %enous systems, lea"ing to sur&ace heat
)reser%ation (B3)(
+E,T'A* ,E'4&(S SYSTEM THE'M&'E2(*ATI&,
The thermal changes in *loo" circulation are "etecte" *y neurons in the )reo)tic nuclei o& the
hy)othalamus(B<)( The thermorece)tors &or col" : an" 2armth sensations in the s6in an" )eri%ascular
areas )lay an im)ortant role in this tem)erature "etection (B<)( The )osterior hy)othalamus mo"ulates
)ro)er heat:generation or "issi)ation mechanisms( The inhi*ition o& sym)athetic out)ut results in
cutaneous %aso"ilation an" heat loss (B<)( Moreo%er, the same inhi*ition results in more cholinergic
s2eating (*y 1/10 o& ner%e &i*res in the e&&erent
5>

Original article
sym)athetic ner%es )( On the o))osite e0treme, col" e0)osure stimulates increase" sym)athetic out)ut &rom
)osterior hy)othalamus lea"ing to %asoconstriction, an" heat conser%ation (B<)( The shunting o& *loo" into
the "ee) %enous system acts as an insulator in the su*cutaneous &at layers *et2een the *loo" an" the col"
am*ient tem)erature( The )rotecti%e e&&ect o& su*cutaneous &at is im)ortant( The o*ese in"i%i"uals can
maintain a higher internal tem)erature on col" e0)osure( They also ha%e chronically cooler s6in tem)erature
(B5,B4)( The a*o%e multi)le &actors contri*ute to maintenance o& a constant core tem)erature o&
a))ro0imately 3=K C against a range o& e0ternal tem)erature &luctuations:usually *et2een 15K C an" 5<K C
(40K !: 12>K !) (B=)(
ITI 'E+&'#I,2 &3 #EEP TEMPE'AT('E +HA,2ES
Thermal imaging in me"icine a""resses the thermal %ariations in su)er&icial an" "ee) structures o& the *o"y
(!ig( 2)( ,%en though the ol" literature has claime" that 'T' stu"ies the sur&ace s6in tem)erature, as claime"
*y the #($( !e"eral 1egister (B>), to a "e)th o& 4 mm( The research con"ucte" *y ,lam, et al (BB) has sho2n
the test to *e in&ormati%e in e%aluating "ee) tem)erature changes as 2ell( The s6in is an almost )er&ect
ra"iator o& the "ee) heat( This ra"iator hel)s )re%ent hy)erthermia an" "amage to internal organs
(s)eci&ically the *rain)( This ra"iator, 2ith B>C emissi%e e&&iciency, allo2s the "ee) heat to ra"iate an"
"issi)ate in the am*ient en%ironment (BB)( This heat ra"iation is recor"e" *y 'T' (!ig( 2)( The 'T' recor"s
)athological tem)eratures at least as "ee) as 2= mm (!ig( 2) in the e0tremities, an" e%en "ee)er in the *reast(
?i&&erent metho"s ha%e *een a))lie" to stu"y su)er&icial an" "ee) circulation (e(g(, scintigra)hic *one
scanning, an" 'T')(100)( The &irst clinical a))lication o& 'T' 2as to recor" the thermal changes o& "ee)
structures such as *reast cancer (101,102), an" arthritis (103:105)( 'T' in PagetHs "isease has sho2n
)athological hy)erthermia in "ee) structure o& %erte*ral *o"ies( The 'T' in PagetHs "isease sho2e" "irect
correlation 2ith im)ro%ement an" re%ersal o& osteo)enia an" )ain a&ter )ro)er treatment (104)( This is
another e0am)le o& the sensiti%ity o& 'T' in i"enti&ying the "ee) tissue )athology (BB)(
*IMITATI&,S &3 ITI
The 'T' )ro%i"es accurately measura*le in&ormation regar"ing su*tle thermal changes(100)( The 'T' sho2s
any ol" or ne2 sym)athetic ner%e "amage or "ys&unction, thus con&using the e0aminer an" "eman"ing
care&ul an" )ro)er clinical correlation( The e0aminer inter)rets the ol" lesion as the main )athology( The
con&using results "ue to multi)le ol" an" ne2 li&e time in+uries may mislea" the )hysician to en" u) losing
&aith in 'T'( Only )ro)er history ta6ing an" inter)retation can sol%e such a )ro*lem( 9o2e%er, in a "ou*le
*lin" stu"y the a*o%e e0am)le o& 'T' 2ill *e tagge" as in%ali"(
Another source o& con&usion is s)rea" o& the thermal changes to the contralateral e0tremity : ma6ing it
"i&&icult to com)are the "elta T *et2een the t2o e0tremities( As the "isease *ecomes chronic an" the
sym)athetic thermal "ys&unction *ecomes *ilateral (1,41,10=), the 'T' sho2s i"entical *ilateral tem)erature
changes causing "i&&iculty in "iagnosis( This is true *oth in stan"ar" 'T', an" in col" stress tests (10>,10B)(
The *ilateral re)resentation o& central sym)athetic tem)erature regulation is mo"ulate" at the &ollo2ing
centers; The &irst center is at the chain o& sym)athetic ganglia on each si"e o& s)ine( These ganglia relay the
transmission o& )ain or thermal im)ulses hori7ontally an" %ertically(21,110) (!ig( 3)( This *ilateral
integration o& the im)ulses at the sym)athetic chain le%el ser%es the )ur)ose o& transmitting the stress&ul
im)ulses to the rest o& the *o"y, an" coor"inating the sym)athetic stress regulation (21)( The secon" center is
at the s)inal cor" le%el (41) 2here the tem)erature mo"ulation is e0erte" symmetrically an" *ilaterally 2ith
si"e to si"e tem)erature %ariation ("elta:T) o& N 0(2 : 0(3K C (23)( This e0)lains the s)rea" o& thermal changes
to the contralateral si"e (1)( The ne0t relay center &or neuro)athic a&&erent ner%es an" tem)erature regulation
is the hy)othalamic mo"ulation centers (10=)( !inally, at the cere*ral hemis)heric le%el, the Central
autonomic net2or6 (CAN) e0erts its in&luence on %asomotor, %isceromotor, neuroen"ocrine, car"io%ascular,
an" )ain mo"ulation( The CAN inclu"es the lim*ic system:s)eci&ically the mesial &rontal an" insular corte0,
amyg"ala, stria terminalis hy)othalamus, an" nucleus solitarius (111,112)(
SI2,I3I+A,+E &3 HYPE'THE'MI+ 'E2I&,S
'n early stage o& ner%e "ys&unction, the in%ol%e" area is hy)erthermic "ue to release o& "estructi%e cyto6ines
(21,<=)( A&ter a &e2 2ee6s, the hy)erthermic area shrin6s(
5B


!igure( < : A )re%iously un"iagnose" right leg
arterio%enous mal&ormation (AVM)o%er 2=mm "ee),
com)licate" *y C1P$ (1$?) ( 'T' i"enti&ie" the
"ee) lesion an" s)are" the )atient &rom the
sche"ule" sym)athectomy( Vascular surgery
correcte" the con"ition(
!igure( 5 : The )ara%erte*ral chain o& ganglia
transmit the neuro)athic )ain an" a*normal
sym)athetic "ys&unction %ertically (e(g(, &rom &oot to
han" an" %ice %ersa), an" hori7ontally (&rom si"e to
si"e)( This e0)lains the remote sym)toms an"
thermal mani&estations o& C1P$ )atients( With
permission from Springer-Verlag Publishers (1).

!igure( 4 : C1P$ ner%e "amages to right toes a&ter
8neuroma e0)loration8( The sym)athectomy "i"
nothing &or the )ain( 'T' s)are" the )atient &rom the
sche"ule" chemical sym)athectomy( The le&t &oot
sho2e" com)ensatory hy)othermia a&ter
sym)athectomy(
!igure( = : 8Virtual sym)athectomy8 secon"ary to
re)eate" stellate ganglion ner%e *loc6s lea"ing to
)ermanent sym)athetic ner%e "amage an"
hy)erthermia (heat lea6age) in u))er e0tremities(
The 'T' s)are" the )atient &rom &urther sym)athetic
ner%e *loc6s(
40

Original article
'n some cases (<=) the hy)erthermia )ersists "ue to )ermanent "amage to the thermosensory ner%e &i*ers (1)
(!ig( <)( This *o"es a )oor )rognosis(
Tra"itionally, hy)erthermic areas recor"e" on 'T' ha%e *een ignore" "ue to the uni%ersal ol" an" )artially
true "ictum em)hasi7ing the im)ortance o& hy)othermic &oci as the main sign o& sym)athetic "ys&unction(
This has resulte" in the e0aminer usually not )aying attention to hy)erthermic &oci 2hich are e.ually
signi&icant( #sually, the hy)erthermic areas )oint to either irre%ersi*le "amage to the sym)athetic system in
the traumati7e" &ocus, or a re&erre" )ain area un"ergoing a *ac6log o& neural transmission o& the anti"romic
a&&erent sensory ner%e &i*ers (>>) to the s)inal cor" in the &orm o& algogenic chemicals such as nitric o0i"e
(NO) (4=:>=,113,11<), $P ( <3,<<,54:5>,40), C-1P (<<,115), an" o0i"ati%e stress agents (114) (!ig( 5)(
These algogenic )ro:in&lammatory chemicals )lay a ma+or role in the &unction o& immune regulation, an"
2hen accumulate" in large "oses cause mo%ement "isor"ers such as tremor, an" )ro:in&lammatory re&erre"
)ains such as hea"aches, nec6 )ain, *ac6 )ain (12,113)( Traumatic )roce"ures such as surgical
e0)loration(12), nee"le insertion in han"s or &eet &or ner%e *loc6s, or ,M- nee"le insertion shoul" not *e
a))lie" to the "amage" hy)erthermic area in the e0tremity 2hich may lea" to &urther "eterioration an"
aggra%ation o& the con"ition (22,11=,11>)( On the other han", the a*o%e treatment shoul" *e a))lie" to the
re&erre" )ain areas in cer%ical, thoracic an" lum*ar regions 2hich ha%e un"ergone no &ocal ner%e "amage
*ut are re&lecting the *ac6log an" accumulation o& cyto6ines in the )ath &rom the "istal e0tremity ner%e
"amage to the "orsal horn o& the s)inal cor" (>>) (!ig( 3)( This i"enti&ication o& hy)erthermic ner%e in+ury is
a ma+or thera)eutic contri*ution o& 'T'(
Physiologic hyper - and hypothermia are the refection of the dynamic function of
sympathetic system(22) to achiee homeostasis! These changes are the end-results of
multiple factors such as hyperthermia due to damage to thermoregulatory
sympathetic nerous system (""#,""$) (%ig! 2)! The up-regulation of the sympathetic
system leads to asoconstriction and hypothermia! The "o2n:regulation or "amage o& this
system lea"s to a "ermal hy)erthermic &ocus surroun"e" *y a com)ensatory hy)othermia (1) (!ig( 4 )(
The re&erre" )ain )henomenon may *e accom)anie" *y hy)o : or hy)erthermia in )ara%erte*ral regions
(!ig(3)( This &orm o& hy)erthermia is "ue to accumulation o& )ro:in&lammatory cyto6ines outline" a*o%e(
These cyto6ines )lay a ma+or role in "e%elo)ment o& in&lammation (<2,55), mo%ement "isor"er (11B:122),
an" immune regulation (<<,5B,113)( 'n contrast, in chronic late stages, the hy)erthermic area *ecomes more
&ocal an" .uite small in si7e surroun"e" *y com)ensatory hy)othermia o& the rest o& the region (12)( The
contralateral normal si"e also un"ergoes com)ensatory hy)othermia( The en" result is t2o col" e0tremities
2ith no statistically signi&icant thermal "i&&erence ("elta T)( This )ro*lem can only *e sol%e" *y )ro)er
clinical correlation(
SI2,I3I+A,+E &3 HYP&THE'MI+ 'E2I&,S
$ym)athetic "ys&unction causes sym)athetic u):regulation an" regional hy)othermia( This )henomenon has
*een *lame" as Al)ha:rece)tor su)ersensiti%ity to circulatory nore)ine)hrine (N,) a&ter )rolonge"
"ener%ation(2<,25)( This )henomenon is usually seen in the sym)athectomi7e" lim*( The lim*, instea" o&
*eing 2arm, *ecomes col"er a&ter surgery "ue to en" : organ su)ersensiti%ity to al)ha rece)tors (2<,25,123)
(!ig( 4)( This is a ma+or cause o& sym)athectomy &ailure (!ig( 4)( 'T' i"enti&ies this &orm o& hy)othermia,
s)aring the )atient &rom &urther harm&ul surgical treatment(12) (!ig( 4)( 'n this regar", 'T' )oints to the
&utility o& sym)athectomy( Commonly, as the sym)athetic system *ecomes chronically "ys&unctional, the
)rolonge" )athologic %asoconstriction yiel"s to inconsistent tonus o& the %asomotor ner%es( This lea"s to the
"e%elo)ment o& neuro%ascular "ys&unction, mottling, an" insta*ility (12<)( This re&ers to *lotching, an"
&luctuation o& s6in tem)erature( 'T' i"enti&ies this con"ition more accurately, an" s)ares the )atient &rom
sym)athectomy an" ganglion ner%e *loc6s (!ig( 4) 2hich cannot *e e0)ecte" to hel) an unsta*le an" &aile"
stage o& sym)athetic "ys&unction (1,12)(

THE '&*E &3 ITI I, PAI, MA,A2EME,T
The )ro)er i"enti&ication o& hy)er : an" hy)othermic areas gui"es the clinician in management o& )ain, more
accurate "iagnosis, an" a%oi"ance o& &urther traumati7ing the alrea"y "amage" ner%es *y a%oi"ing
unnecessary surgical )roce"ures (51:53),(!ig( =), or im)ro)er ner%e *loc6s( 'T' can i"enti&y these areas o&
ner%e "ys&unction in )ara%erte*ral regions o& the s)ine (B1) in &orm o& hy)othermic &oci( ,)i"ural ner%e
*loc6s (2ith *u)i%acaine an" "e)o:me"rol) in these regions )ro%i"e *oth somatic an" sym)athetic )ain
relie& (12,21,B1)( Accor"ing to $tein (>>) the cyto6ines an" in&lammatory chemicals are transmitte" %ia
s)inal ner%es to the s)inal cor" an" %ice %ersa, mo"ulating the s)inal cor" &unction o& nocice)tion( The
thera)eutic e&&ect o& these *loc6s lasts >:12 2ee6s (1,12,21) %ersus ganglion *loc6s 2hich last a &e2 hours
or "ays(
41

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Original article
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43

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4<

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Address for correspondence
9( 9ooshman", M(?(
Neurological Associates Pain Management Center
1255 3=
th
$treet, $uite
Vero each, !lori"a, #$A(
(Manuscri)t recei%e" on =(03(2000( re%ision acce)te" 1B(03(2001)

Pu"lished "y the7
*ud%ig 8olt9mann 'esearch Institute for Physical #iagnostics
Austrian Society of Thermology
Please :isit Thermology International at7
http://www.uhlen.at/thermology-international/index.html
Infrared Thermal Imaging As A Tool In Pain
Management - An 11 Year Study.
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 neuro)hysiological tool )ro%i"ing "iagnostic an" thera)eutic in&ormation in )atients su&&ering &rom
neuro)athic )ain 2ith neuro%ascular in%ol%ement( This in&ormation cannot *e o*taine" &rom anatomical tests
(e(g(,M1' or CT)(
ales $cienti&ic Thermal Processor (ales $cienti&ic, Aalnut Cree6, CA)(=42 )atients) an" Agema Cameras
(!lir)(2,503 )atients) 2ere use" &or this stu"y o& 3,245 successi%e )atients( A re%ie2 o& our e0)erience 2ith
'n&rare" thermal imaging ('T') an" its role in )ain management 2as con"ucte", an" com)are" 2ith the
recent me"ical literature( The stu"y 2as limite" to the role o& 'T' in the management o& com)le0 chronic
)ain syn"rome(
'T' is hel)&ul in )ro)er locali7ation o& hy)erthermic &oci "ue to iatrogenic )ermanent "amage to
thermosensory ner%es, such as seen a&ter re)etiti%e sym)athetic ganglion *loc6sJ or "ue to sym)athectomy
or )rolothera)y( As the result, the )hysician stays out o& harms 2ay *y not causing &urther )ermanent
"amage( 'n a""ition, 'T' i"enti&ies the s)rea" o& C1P$, )ointing to the nee" &or treatment o& such s)rea"( 't
hel)s "i&&erentiate migraine &rom neuro)athic occi)ital neuralgia : t2o "iseases re.uiring to contrasting
treatments(
'T' has not *een )ro%en use&ul in e%aluation o& cer%ical an" lum*ar ra"iculo)athies, stro6e, an" transient
ischemic attac6s( 'T' can "i&&erentiate cer%icogenic hea"aches &rom migraine : each re.uiring o))osite &orms
o& treatment( 'T' is a use&ul )rognosticator &or "ia*etic &oot )ain, s)aring some )atients &rom am)utation( 'T'
can s)are )atients &rom unnecessary car)al tunnel, s)inal "isc, an" TMD surgeries *y i"enti&ying the original
source o& neuro)athic )ain( '& 'T' sho2s "i&&use hy)erthermia in the e0tremity alrea"y treate" 2ith re)eate"
sym)athetic ganglion *loc6s (%irtual sym)athectomy), such )atients shoul" *e s)are" &rom un"ergoing
&urther ganglion *loc6s( The hy)othermic e0tremity a&ter sym)athectomy )ro%es the &utility o& this an" other
a*lati%e treatments such as chemical sym)athectomy, or neurolytic *loc6s(
Key Words - C1P$, 9ea"ache, $ym)athectomy ,Thermogra)hy(

Infrarothermographie als /ilfsmittel im .chmer0mangement-in "" -ahres .tudie,
2!Teil+1er 2linische 3insat0 der Infarrotthermographie
?ie 'n&rarotthermogra)hie lie&ert als neuro)hysiologische #ntersuchungsmetho"e "iagnostische un"
thera)eutische 'n&ormationen R*er Patienten, "ie an neuro)athischem $chmer7 mit neuro%as6ulSrer
egleitsym)tomati6 lei"en( ?iese 'n&ormation 6ann "urch 6einen anatomischen Test (7((NM1', Ct) 7ur
Ver&Rgung gestellt 2er"en(
,in ales $cienti&ic Thermal Processor (ales $cienti&ic, Aalnut Cree6, CA)(=42 Patienten) un" Agema
(!lir)Fameras (2,503 Patienten) 2ur"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&rarrotthermogra)hie 2ir" gege*en un" "er
re7enten me"i7inischen Giteratur 7u "iesem Thema gegenR*er gestellt( ?ie #ntersuchung 2ur"e au& "ie
e"eutung "er 'n&rarotthermogra)hie im Management %on $chmer7)atienten *eschrSn6t(?ie
'n&rarotthermogra)hie hil&t in "er ,nt"ec6ung hy)erthermer Tonen, "ie "urch 2ie"erholte iatrogene
$chS"igung "er thermosensi*len Ner%en&asern entstehen un" "ie *ei 2ie"erholten $ym)athi6us*loc6a"en,
$ym)athe6tomie o"er thera)eutischer -e2e*e:$6lerosierung %or6ommen(?urch solche VerSn"erungen
ge2arnt,
11=


6ann "er Ar7t 2eitere $chS"igungen %erei"en( ?ie 'n&rarotthermogra)hie 6ann "ie 2eitere Aus*reitung
$chS"igungen %ermei"en( ?ie 'n&rarotthermogra)hie 6ann "ie 2eitere Aus*reitung eines 6om)le0en
chronischen $chmer7syn"roms (C1P$) an7eigen un" au& eine not2en"ige Thera)ie "ieser Aus*reitung
hin2eisen( ?ie 'n&rarot:Techni6 6ann auch &Rr "ie ?i&&eren7ierung 72ischen MigrSne un"
neuro)athischerO67i)italneuralgie hil&reich sein, 7umal "iese Fran6heits*il"er %Zllig unterschie"liche
ehan"lungen *enZtigen(
?ie 'n&rarorthermogra)hie ist 2enig *rauch*ar in "er eurteilung %on 7er%i6alen o"er lum*alen
1a"i6ulo)athien, %on $chlagan&all o"er transitorischen ischSmischen Attac6en( Man 6ann a*er mit ihrer
9il&e cer%i6ogenen Fo)schmer7 %on "er MigrSne unterschei"en( ?ie 'n&rarotthermogra)hie hat
)rognostische e"eutung *ei !ussschmer7en %on ?ia*eti6ern,un" hat so manchen Patienten eine
Am)utation ers)art( ,*enso 6Znnen au& -run" %on 'n&rarot*il"ern nicht not2en"ige O)erationen 2egen
eines Far)altunnelsyn"roms, einer an"schei*e o"er chirurgische ,ingri&&e im Fie&er*ereich %ermie"en
2er"en, "a "ie #rsache eine neuro)athischen $chmer7geschehens ein"eutig ge&un"en 2er"en 6ann( Aenn
"ie 'n&rarotthermogra)hieeine "i&&use 9y)erthermie *ei Patienten nach 2ie"erholten
$ym)athi6us*loc6a"en 7eigt, sin" 2eitere loc6a"en nicht mehr ange7eigt( ,ine hy)otherme ,0tremitSt
nach $ym)athe6tomie *e2eist "ie ,nt*ehrlich 6eit "ieser un" an"erer "estruieren"er ehan"lungen 2ie
7(( "ie chemische $ym)athe6tomie o"er Ner%en*loc6a"en(
Schlssel!"rter - C1P$, Fo)&schmer7e, $ym)athe6tomie ,Thermogra)hie
THE '&*E &3 ITI I, SE*E+TI&, &3 ,E'4E 8*&+;S
'T' )ro%i"es in"is)ensa*le in&ormation 2hich gui"es the )hysician to stay out o& harms 2ay, an" to )re%ent
iatrogenic trauma( One e0am)le is the role o& 'T' in selection o& )ro)er ner%e *loc6 mo"ality( Tra"itionally,
the ner%e *loc6 o& choice in C1P$ has *een stellate ganglion ner%e *loc6s( A&ter more than a "o7en stellate,
or lum*ar ganglion ner%e *loc6s, the re)etiti%e nee"le insertion traumati7es the ganglion enough to result in
)ermanent hy)erthermia in the e0tremity (8Virtual $ym)athectomy8) (1)( 'n such )atients, 'T' o& the
e0tremity sho2s )ermanent hy)erthermia in &ace o& no )ain relie&( Fo7in, in his re%ie2 o& 500 )atients
treate" 2ith sym)athetic ganglion *loc6s, re)orte" 8the ma+ority o& )atients ha%e transient or no signi&icant
)ain relie&8 (2)( Another meta:analysis o& retros)ecti%e an" )ros)ecti%e ran"omi7e" controlle" trials o& 11<<
)atients re%eale" the local anaesthetic sym)athetic *loc6a"e 2as as ine&&ecti%e as )lace*o in treatment o&
C1P$(3)(
&utcome7 'T' i"enti&ie" the 8%irtual sym)athectomy8 )henomenon, an" s)are" the )atients &rom &urther
"amage *y canceling the )roce"ure (1) (Ta*le 1)( 1e)etiti%e ganglion ner%e *loc6s are routinely a))lie" &or
"iagnosis (<) an" treatment o& neuro)athic )ain such as com)le0 regional )ain syn"rome (C1P$)( 9o2e%er,
9ogan et al (5), ha%e re)orte" only 2=C o& stellate ganglion *loc6 achie%e" the goal o& i)silateral 2arming
to e0cee" the contralateral s6in tem)erature( This 2=C success is not 2orth the traumatic com)lications o&
ganglion *loc6a"e( Moreo%er, they note" (5) that cer%ical )aratracheal *loc6s &re.uently &aile" to )ro"uce
e%i"ence o& sym)athetic interru)tion to the arm( The sym)athetic ganglion *loc6a"e "one in )eri)heral
occlusi%e %ascular "isease or C1P$ may*e )otentially "angerous an" harm&ul1 (1,2,3,4)(
SYMPATHE+T&MY
The sym)athectomy results in )artial hy)erthermia, 2ith com)ensatory contralateral e0tremity hy)othermia,
this result in the s)rea" o& )ain in the contralateral e0tremity( Out o& "es)eration, sym)athectomy has *een
a))lie" &or treatment o& causalgia since 1B14 (=)( The literature re%ie2 o& sym)athectomy literature &or
treatment o& C1P$ sho2s high rates o& &ailure( Aelch et al (>) sho2e" 13C success&ul results o&
sym)athectomy in >(< years o& long term &ollo2:u)( 'n contrast, De*ara an" $aa"e, on their short :term
sym)athectomy &ollo2:u) o& 24:40 "ays among teenage sol"iers sho2e" %ery goo" results (B)( O*%iously,
a*lation surgery )ro%i"es tem)orary )alliati%e relie&( The rest o& the literature re%ie2 sho2s ran"om &ollo2:
u)s an" results (10)( The high )ercentage grou) has *een 2artime sol"iers 2hich ha%e *een "iagnose"
early , un"ergone surgery 2ithin a &e2 "ays , an" sent home to *e lost to &ollo2:u) (10:31)( 1eali7ing that
chil"ren an" teenagers (such as sol"iers), sho2 a strong )lasticity an" healing )o2er as com)are" to a"ults
(32,33), an" reali7ing that early "iagnosis an" treatment is more success&ul (3<,35),
11>

1e%ie2
Ta"le 1. The influence of treatment on +'PS stages during - years or longer follo%-u in
<-= atients. Amutation or symathectomy deteriorate the disease from stage I to stage III.
+haracteristics of
treatment
><-= atients?
Stage I @@@@
num"er of atients
Stage II
num"er of atients
Stage III
num"er of atients
9istory o& Am)utation [
11 Patients (1(3C)
0 (0C) 2 (1BC)
B (>1C)
(PL0(025)
Chemical $ym)athectomy
13 Patients (1(5C)
0 (0C) 2 (15(<C) 11(><(4C)
$urgical $ym)athectomy
22 Patients (2(4C)
0 (0C) 3 (13(4C) 1B (>4(<C)
$urgical Treatment [[
2B5 Patients (34C)
2< (>C) 104(34C)
145 (54C)
(P\0(001)
([) Many )atients ha" more than one treatment mo"ality 2hich change the total )ercentage(
([[) $ym)athectomyJ rotator cu&&J thoracic out syn"romeJ com)ression neuro)athyJ e0)lorationJ etc(
([[[) $tage ' L ?ys&unctionJ $tage ''L ?ystro)hyJ $tage '''L Atro)hy(
([[[[) Accor"ing to the ty)e 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 -rou)
320 Patients
2<(=C
=B Patients
33(13C
104 Patients
5B(>C@
135 Patients
Non : $urgical -rou)
52> Patients
31C
14< Patients
34C
1B0 Patients
33C
1=< Patients

e0)lain the *ene&icial, al*eit tem)orary, results o& 2artime sym)athectomy( 'n contrast, the sym)athectomy "one in
stage ''' C1P$@ has *een re)orte" to sho2 7ero )ercent relie& (34)( #sually, *y the time the )hysician resorts to the
sym)athectomy )roce"ure, the )atient is in a"%ance" stages o& the "isease( 'n such late stages, the ner%ous system has
lost its )lasticity an" cannot res)on" )ro)erly to surgical sym)athectomy(3=,3>)( More o%er, the "isease s)rea"s
(1,3=,3B:<<) to other )arts o& the *o"yJ hence a regional sym)athectomy 2ill not *e o& any *ene&it to the )atient(
&utcome7 'T' sho2e" &ailure o& sym)athectomy to relie%e the %ascular "ys&unction( Thermal imaging "one in )atients
2ho un"er2ent surgical or chemical sym)athectomy sho2e" a high )ercentage o& surgical &ailure(<5,<4)(
P'&*&THE'APY A,# A'TI+(*A' 3A+ET 8*&+;S
Articular &acet +oint *loc6s an" )rolothera)y (in+ection o& sclerotic agents to ligament surroun"ing the +oints) act as ne2
sources o& trauma an" )ain originating &rom the in+ure" %erte*ral &acet +oint( 'n contrast, s)inal e)i"ural an"
)ara%erte*ral *loc6s "o not cause chemical (sclerotic) "amage "ue to in+ection o& hy)ertonic glucose or )henol as in the
case 2ith )rolothera)y( These *loc6s shoul" not *e mista6en &or articular &acet in+ections( The &acet in+ections shoul" *e
a%oi"e" to )re%ent harm&ul &acet +oint "amage(

Ta"le -. Stages of +'PS
Stage I: #ysfunction$ !ith thermal changes% neuroinflammation% neuro&ascular instability% neuropathic pain%
&asomotor and fle'ion spasm.
Stage II: #ystrophy$ hair% nail% and s(in trophic changes) bouts of hair loss% alopecia% s(in rash% spontaneous
subcutaneous bleeding% ulcerati&e lesions% edema% and entrapment neuropathy.
Stage III: Atrophy$ as !ell as fluctuating &ital signs% &isceral neuroinflammation% chest pain% neuro&ascular
instability.
11A

Accor"ing to Cheema (<=), )ara%erte*ral ner%e *loc6 )ro%i"es e&&ecti%e )ain relie& &or *oth sym)athetically maintaine"
)ain an" sym)athetically in"e)en"ent )ain( This is in contrast to articular &acet (7ygoa)o)hyseal) *loc6s 2hich are
&raught 2ith )ain&ul +oint in+uries ("ue to nee"le traumati7ing the +oint)( og"u6 et al (<>) ha%e re)orte" only <0C )ain
relie& &rom ra"io&re.uency treatment o& the &acet +oints( The same a))lies to )rolothera)y 2hich is "one *y in+ection o&
sclerosing agents (such as )henol) into the ligaments surroun"ing articular &acet +oints(

Ta"le 5. ,eurohysiologic tests for neuroathic ain and somatic ain.
Tests Somatic Symathetic ParaSymathetic
,er:e 3i"er
Tye
+linical
alication
*imitations Ad:antage
,M-J NCV
] - -
$omatic,
myelinate"
ner%es
$tu"y o& e&&erent
s)ino:thalamic
ner%es
't cannot
stu"y the
thermo:
rece)tor or
%asomotor
&unction
Neuro:muscular
an" myelinate"
somatic ner%e
stu"y
'n&rare" Thermal
'maging ('T')
- ] -
Micro: %ascular
an" C:thermo:
rece)tors
$ym)athetic
&unction
$ho2s ol"
an" ne2
)athologies
in"iscrim:
inately
A total *o"y
regional stu"y
Gaser ,%o6e"
Potential (G,P)
- ] -
Poorly
myelinate" C:
&i*resJ A
$tu"y o&
)eri)heral an"
central
neuro)athic )ain
Mainly
research
$tu"y o& C,
A^, an"
A &i*res
Microneurogra)hy
(MCN-)
- ] -
Post ganglionic
sym)athetic
e&&erent C:&i*res
1esearch on
sym)athetic
e&&erents
'n%asi%e,
time ta6ing,
an" )ain&ul
A research tool
/uantitati%e
$ensory Test
(/$T)
- ] -
C: thermo:
rece)tors %s
s)ino:thalamic
tactile ner%es
Accurate test &or
thermorece)tors
%s tactile
somatosensory
ner%es
$tu"ies a
limite" area
$ensiti%e stu"y
o& C:
thermorece)tors
%s somatic &i*res
/uantitati%e
$u"omotor A0on
1e&le0 Test
(/$A1T)
- - ]
Parasym)atheticJ
cholinergic,
su"omotor
ner%es
$2eat &unction
$tu"ies a
limite" area(
't cannot
stu"y the
thermal
&unction
$u"omotor
&unction
$omato:sensory
,%o6e" Potential
($$,P)
] - -
$omatosensory
ner%e &i*res
'"enti&ies
sensory ner%e
trac6s
Not an
autonomic
test
9armless
$cinti:gra)hic
Tri)hasic one
$can ($$)
] - -
?ee)
chemorece)tors
&i*res
'n&ormati%e in
early stages
Only
"iagnostic in
25:55C o&
)atients
9armless
120

&utcome7 Thirty:si0 )atients ha" un"ergone Prolothera)y *e&ore they 2ere re&erre" to our Clinic( 'T'
sho2e" &ocal hy)erthermia in the area o& Prolothera)y( None ha" e&&ecti%e long:term relie& &rom this
)rolothera)y(
#ISTA* EBT'EMITY ,EE#*E I,SE'TI&,
'n the area o& original ner%e "amage, the hy)erthermia )oints to "amage an" )aralysis o& %asoconstricti%e
&unction o& sym)athetic system (1)( The hy)erthermia area surroun"e" *y hy)othermia usually )oints to the
a)e0 o& "amage" thermosensory ner%e resulting in heat lea6age, as 2ell as accumulation o& su*stance P (<B:
51), an" nitric o0i"e(52,53)( This is an im)ortant thera)eutic clue to hel) a%oi"ing &urther trauma( Traumatic
)roce"ures such as surgical e0)loration, ner%e *loc6s, *otulinum to0in in+ection, ca)saicin, or ,M- nee"le
insertion shoul" not *e a))lie" to the "amage" hy)erthermic area in the e0tremity 2hich may lea" to &urther
"amage an" aggra%ation o& the con"ition (5<:54)(
AMP(TATI&,
'& at all )ossi*le, am)utation shoul" *e a%oi"e" (5=)( All 11 )ain&ul am)utee )atients in our series (Ta*le 1)
2ho 2ere re&erre" to us a&ter they ha" un"ergone am)utation sho2e" mar6e" "eterioration )ost:o)( The
surgical stum) 2as the source o& multi)le neuromas 2ith se%ere causalgic an" e)ha)tic (11) C1P$ '' ty)e o&
intracta*le )ain( Am)utation change" the C1P$ &rom ty)e ' to ty)e '' *y &orming innumera*le neuromas an"
ner%e im)ingements in the surgical stum)( Am)utation shoul" *e a%oi"e" *y all means "ue to its si"e e&&ects
o& aggra%ation o& )ain an" ten"ency &or s)rea" o& C1P$( ?ielissen et al (5>) re)orte" the results o&
am)utation in 2> 1$? )atients 2ho ha" un"ergone 3< am)utations in 31 lim*s( Only 2 o& 2> )atients
re)orte" )artial )ain relie&( 'n 24 o& 2> )atients, stum) in%ol%ement 2ith 1$? ma"e it im)ossi*le to 2ear a
)rosthesis (5=)( 'T' can i"enti&y the )ro)er le%el o& the e0tremity un"ergoing am)utation (5B)( This s)ares
the )atient &rom losing any e0cess tissue in the am)utee stum) (5B)(
&utcome7 'T' )ro%i"e" in&ormation that )re%ente" am)utation in 5 o& 4 )atients re&erre" to us &or
e%aluation an" &or consi"eration o& am)utation( O& the 5 )atients, < sho2e" enough 2armth an" intact
circulation to )re%ent am)utation( The 5
th
)atient 2as &oun" to su&&er &rom "ia*etic neuro)athy 2ith multi)le
)athologic right &oot &ractures aggra%ate" *y 2 years o& non:2eight *earing( #n"er )ro)er analgesia, the
)atient 2as instructe" to start 2eight *earing( A&ter 3 months, the &ractures heale" enough to a%oi" the
necessity &or am)utation(
,E+; A,# 8A+; PAI,
The 1B=0Es an" 1B>0Es literature re&lects con&using re)orts on "iagnostic %alue o& 'T' in cer%ical an" lum*ar
ra"iculo)athies, *ac6 )ain, "isc herniation, an" sciatica (5<,54,40:44)( More recent literature has re)orte"
that 'T' has no consistent "iagnostic %alue &or the nec6 an" *ac6 in+uries (4=:=1)( One reason may *e the
inconsistent "elta:T measure" *y li.ui" crystal contact thermogra)hy (=2) ma6ing it "i&&icult to arri%e at
accurate 8normal8 %alues(
'n the )resent stu"y, the 'T' "one in )atients su&&ering &rom &aile" s)ine, nec6 or *ac6 )ain, an" )ain in the
e0tremities re%eale" con&licting results : es)ecially 2hen com)are" 2ith the thermal imaging tests "one on
the same )atients in other la*oratories( The con&usion has its roots in technical limitations, an" im)ro)er
clinical a))lications o& the test(4=,4>)( 9ar)er (=3) an" Cha&et7 (=<) ha%e successi%ely re)orte" 54C an"
<0C a*normal 'T' o& s)ine in the 8normal8 controls( 'n our "aily li%es, the s)ine un"ergoes minor in+uries(
$uch )ree0isting minor in+uries may sho2 )ersistent minor a*normalities on 'T', contaminating the control
stu"ies( Gac6 o& a consistent control stan"ar" han"ica)s the %alue o& 'T' in "iagnosis o& s)ine )athology(
There ha%e *een re)eate" attem)ts to com)are the )hysiological test o& 'T' 2ith anatomical tests such as
M1' an" CT (=5)( This is an illogical com)arison( 'T' cannot *e e0)ecte" to "iagnose "isc herniation
*ecause "isc *ulging an" herniation cannot *e clearly re)resente" on 'T'( Con%ersely, M1' cannot *e
e0)ecte" to i"enti&y micro neurosensory )athology(
&utcome7 'n the )resent stu"y, the 'T' "one in )atients su&&ering &rom &aile" s)ine, nec6 or *ac6 )ain, an"
)ain in the e0tremities re%eale" con&licting results : es)ecially 2hen com)are" 2ith the thermal imaging
tests "one on the same )atients in other la*oratories( The con&usion has its roots in technical limitations, an"
im)ro)er clinical a))lications o& the test (4=,4>)(
121

+&MP*EB 'E2I&,A* PAI, SY,#'&ME >+'PS, 'S#?
'T' can &acilitate early "iagnosis o& Com)le0 1egional Pain $yn"rome (C1P$) (=4), an" can achie%e a
higher reco%ery rate among C1P$ )atients (10,11,3<,==) *y %irtue o& early "iagnosis o& the "isease( C1P$
cannot *e accurately "iagnose" *y a single test( C1P$ is a clinical "iagnosis 2hen the &ollo2ing &our
)rinci)les are met;
1( Neuro)athic, hy)er)athic, or causalgic )ainJ
2( Vasomotor "istur*ance, &le0or s)asm, or tremorJ
3( 'n&lammation at some )oint in the course o& the "iseaseJ an"
<( Gim*ic system "ys&unction in &orm o& insomnia, agitation, "e)ression, an" )oor memory (3=,=>)(
Tests such as 'T' are mainly hel)&ul to o*tain in&ormation regar"ing the nature an" e0tent o& the "isease, an"
to gui"e the clinician in )ro)er management o& )ain (11)( 'T' has the a"%antage o& )ro%i"ing a
com)rehensi%e )icture o& the entire *o"y tem)erature (=B)( 'n acute stage, the e)icenter o& the "amage" area
is usually hy)erthermic (11,>0)( A&ter a &e2 2ee6s, the hy)erthermic area shrin6s( 'n some cases (>0) the
hy)erthermia )ersists "ue to )ermanent "amage to sym)athetic ner%e &i*ers (1)( This is a har*inger o& )oor
)rognosis( The hy)othermic area surroun"ing the hy)erthermic e)icenter o& the "amage" ner%e re&lects u):
regulation an" su)ersensiti%ity o& sensory ner%es to nore)ine)hrine (>1:><)(
'n chronic stages (>5), the "isease is mani&este" *y a "ys&unctional rather than an u):regulate" sym)athetic
system (11,>4:B0)( The neuro%ascular insta*ility contri*utes to con&usion an" misun"erstan"ing o& 'T'
changes in C1P$( !or e0am)le, s)rea" o& %asoconstriction to other e0tremities may*e mista6en &or other
"iseases such as 1aynau"Hs Phenomenon (B0)( The 'T', li6e any other test, cannot *e e0)ecte" to sho2 100C
"iagnostic sensiti%ity( ,%en 2ith the col" 2ater stress 'T' testing (=4,>B), it is sensiti%e in B3 C o& the
)atients, s)eci&ic in >B C, )ositi%e )re"icti%e %alue (PPV) o& B0C, an" negati%e )re"icti%e %alue (NPV) o&
B<C (=4)( 1ecently, 9erric6 et al (B0), ha%e &oun" col" stress 'T' use&ul to "iagnose )atients su&&ering &rom
&racture 2ho are at ris6 &or C1P$(
&THE' #IA2,&STI+ TESTS I, +'PS
Gee an" Aee6s (B1), in their meta:analysis o& scintigra)hic *one scan ($$) (B1)sho2e" this test to *e
)ositi%e in no more than 55C o& C1P$ )atients (=1,B1)( ,M- an" NCV (B2,B3), or CT an" M1' cannot *e
e0)ecte" to "etect the microsco)ic )eri%ascular ner%e "ys&unction in C1P$( ,%en i& a coinci"ental "isc
*ulging is seen on M1', surgical )roce"ure in the in&lame" region is a)t to se%erely aggra%ate the C1P$ (B<:
B=)( /uantitati%e su"omotor a0on re&le0 test (/$A1T) (B>) (Ta*le 3) stu"ies the )ost: ganglionic cholinergic
su"omotor &unction o& the sym)athetic system (B<,B5,BB,100),not the thermoregulatory &unction( Gaser
e%o6e" )otential (G,P) (Ta*le 3) is a sensiti%e test &or the stu"y o& ca)illary circulation (<<,101:103)( 't
stu"ies a small area o& the *o"y there*y limiting its o%erall e0tent o& in&ormation( /uantitati%e thermal
sensory e%o6e" res)onse test (/$T) (<<,10<,105) (Ta*le 3) is sensiti%e an" use&ul in stu"ying the &unctions
o& c:thermorece)tors an" A:*eta mechanorece)tors in C1P$ (10<)( This test i"enti&ies the threshol" o&
somatic (s)inothalamic)col" or heat touch sensation : %ersus neuro)athic (sym)athetic) col" or heat )ain
sensation(
8I*ATE'A* TEMPE'AT('E +HA,2ES I, +'PS
The tem)erature "i&&erence *et2een the t2o e0tremities ("elta:T) shoul" not normally e0cee" more than 0(<
:0(4K C (5<,54)( 'n early stages o& C1P$, the 'T' sho2s more than 0(50K C "i&&erence( 'n later stages, the
tem)erature "i&&erence gra"ually "isa))ears( The "elta T *et2een the t2o e0tremities is not statistically
signi&icant in C1P$ )atients( 'n contrast, com)aring the same C1P$ )atients 2ith non:C1P$ grou), the
C1P$ e0tremities 2ere signi&icantly col"er than the control grou) (104)( The cut o&& line to "iscriminate the
)atient &rom the control grou) 2as 0(41K C &or accurate )re"icta*ility o& C1P$ "iagnosis (104)( The
e.uali7ation o& &unction is "ue to symmetrical re)resentation o& autonomic changes at hy)othalamic an"
s)inal cor" le%els (10=)( Other )athologic changes such as asymmetrical &oci o& hy)erthermia i"enti&y the
site o& the in+ury( These hy)erthermic &oci are usually a sign o& "amage to the ner%e &i*res causing
hy)erthermic e)ha)tic (in contrast to syna)tic)(10>) electrical "ischarges *et2een the a"+acent sensory ner%e
&i*res( !re.uently, the in+ure" si"e may sho2 a hy)erthermic &ocus, com)ensate" *y the contralateral normal
si"e un"ergoing mo"erate hy)othermia(10B)(
122

1e%ie2
ITI 3I,#I,2S I, +'PS SP'EA#
'n a))ro0imately 1/3 o& C1P$ )atients, the com)le0 regional )ain an" in&lammation s)rea"s to other
e0tremities mani&este" on 'T' test (B>,110:11<)(The s)rea" through )ara%erte*ral chain o& sym)athetic
ganglia may *e %ertical, hori7ontal, or *oth (110,111,115,114)(
+'Y&THE'APY 3&' +'PS
1e)etiti%e ice a))lication may result in chil*lains (or )erniosis) "ue to in&lammatory areas o& hy)erthermia
secon"ary to long term &rost *ite ty)e o& ner%e "amage *y a))lication o& ice( The 'T' hel)s "iagnose this
con"ition to "iscontinue the "estructi%e cryothera)y( as*aum (11=), an" others (11>:121) ha%e
"emonstrate" lesions a&&ecting large myelinate" a0ons secon"ary to ice e0)osure( These lesions are in the
&orm o& Valerian "egeneration an" segmental "emyelination (11=,11>,121)( The cryothera)y causes
iatrogenic hy)othermia 2ith islan"s o& )ermanent hy)erthermia "ue to &rost*ite ner%e "amage mentione"
a*o%e(
&utcome7 'T' 2as hel)&ul in i"enti&ying the areas o& thermosensory ner%e "amage, an" as 2ell as
"iagnosing the )henomenon o& C1P$ s)rea"(
#IA8ETI+ ,E('&PATHY A,# #IA8ETI+ 3&&T
'n a"%ance" stages o& "ia*etic neuro)athy, the "isease is com)licate" *y neuroin&lammatory changes,
&ractures (CharcotHs &oot), an" *y &oot ulcers (122:125)( The 'T' changes in these )atients are the
)rototy)ical e0am)les o& ner%e "amage causing irre%ersi*le hy)erthermia in "i&&erent "egrees( Armstrong et
al (122) ha%e utili7e" 'T' as the )re"ictor o& early sign o& "eterioration o& ulcers an" tro)hic &racture( They
ha%e use" the high "elta:T o& 2K C *et2een the in%ol%e" an" contralateral e0tremities to initiate thera)eutic
inter%ention(
&utcome7 'n our stu"ies, in all 11 "ia*etic &oot )atients hy)erthermic &oci 2ere o*ser%e"( These 11
)atients 2ere re&erre" to us &or a secon" o)inion *e&ore am)utation( None o& these )atient en"e" u) 2ith
am)utation( 'T' )laye" a )i%otal role in s)aring these )atientsH e0tremities( The recognition o&
neuroin&lammatory )henomenon (101) in these )atients le" us to treat them 2ith 2eight:*earing,
mo*ili7ation, ner%e *loc6s, '(V( Mannitol, )hysical thera)y, etc(, s)aring these )atients &rom am)utation as
2ell as relie%ing neuroin&lammation an" )ain 2ith ner%e *loc6s an" '(V( Mannitol (100gm/500cc ?5A
treatment)(124,12=)(
TE,,IS E*8&.
&utcome7 'T' is use&ul in "iagnosing Traumatic lateral e)icon"ylitis (12>,12B), or tennis el*o2( The 'T'
sho2e" a &ocali7e" hy)erthermia at the lateral e)icon"yle in 53 o& 54 )atients (B5C)(12>)( $imilar &in"ing o&
hy)erthermia is also note" in tarsal tunnel entra)ment neuro)athy( These areas o& hy)erthermia shoul" not *e
aggra%ate" *y nee"le insertion( Any trigger )oint in+ection or ner%e *loc6 shoul" *e )er&orme" )ro0imal to
the hy)erthermic area( 'n+ections aime" at the &oot, an6le, han", or 2rist causes &urther trauma an" u):
regulation o& the sym)athetic system lea"ing to a source o& )ain, an" &urther thermal "ys&unction (3=)(
TH&'A+I+ &(T*ET SY,#'&ME>T&S?
&utcome7 Another &re.uently o%er:"iagnose" an" o%er: treate" syn"rome in neuro)athic )ain is Thoracic
Outlet $yn"rome (TO$)(130)( ?ue to the in&lammatory nature o& neuro)athic )ain, es)ecially in C1P$ in
u))er e0tremities, *rachial )le0itis is &re.uently mista6en &or TO$ an" is im)ro)erly manage" *y surgery(
The surgical )roce"ure *ecomes a ne2 source o& neuro)athetic )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 e0tremity
in &orm o& e)ha)tic hy)erthermia: )ointing to the original source o& )athology rather than the secon"ary
in&lammation o& *rachial )le0itis( 'T' s)are" such )atients &rom surgery &or TO$ in 1< o& >2< C1P$ )atients
2ith )resum)ti%e "iagnosis o& TO$ (3=)(
+E'4I+&2E,I+ HEA#A+HES
'T' can hel) "iagnose an" "i&&erentiate cer%icogenic hea"aches &rom migraine( The cer%icogenic hea"ache
sho2s areas o& hy)er : an" hy)othermia in the "istri*ution o& )osterior sensory ner%e *ranches o& C2 through
C< ner%e roots, an" occi)ital ner%es( Ner%e *loc6s in these areas )ro%i"e e0cellent relie& (11,3=)( On the
other han", ra"io&re.uency "amage to articular &acet (<>,132,133), or rhi7otomy (13<) generates a ne2
source o& algogenic )athology, hy)erthermia an" more se%ere )ain( $timulation o& the )eri)heral en"s o& the
cut "orsal roots "ilates cutaneus *loo" %essels (135)( The retrogra"e acti%ation o& cutaneous sensory ner%es
lea"s to &ocal %ascular changes causing neurogenic in&lammation (134,13=) "ue to the release o& )ro:
in&lammatory chemicals (50:53,114,13>:15B)(
123

This %aso"ilation an" in&lammation e0)lains the hy)erthermia in the area o& ner%e in+ury( The trigeminal
%ascular sym)athetic &unction is in&luence" *y many &actors inclu"ing, *ut not limite" to, chemical changes
in the *loo" (140), cranio%ascular circulatory changes (141,142), an" stimulation o& trigeminal nucleus *y
re&erre" )ain originating &rom the )osterior ner%e *ranches o& the C1 to C< ner%e roots (143)(
&utcome7 'T' hel)s i"enti&y the craniocer%ical hy)erthermic areas, an" "i&&erentiate this hea"ache &rom
migraine( Ahere as in migraine hea"aches thermal &luctuations are .uite unsta*le, in cer%icogenic hea"aches
the hy)erthermia is )resent in the occi)ital ner%e region an" the craniocer%ical +unction (11)( These t2o
ty)es o& hea"aches re.uire t2o o))osite &orms o& treatment( $umatri)tan aggra%ates cer%icogenic hea"achesJ
con%ersely ner%e *loc6s "o not usually relie%e the true migraine hea"aches(
MI2'AI,E HEA#A+HES
#n&ortunately the term migraine has *een relati%ely loosely a))lie" to any ty)e o& neuro%ascular hea"ache,
migraine or other2ise( This results in contamination o& stu"ies "one on this su*+ect( The 'T' has *een
re)orte" as ha%ing no %alue &or e%aluation o& true, generic migraine hea"aches (140,14<) e0clu"ing
cer%icogenic, TMD, an" Trigeminal ner%e in+ury hea"aches( The migraine hea"aches cause cranio&acial
thermal &luctuations 2hich are unsta*le an" change in "i&&erent stages o& the migraine attac6 (115)(
9y)othermia o%er the o)hthalmic *ranch o& the trigeminal ner%e has *een re)orte" on 'T' o& migraine
)atients (140)( 't is seen mainly "uring the acute attac6 as a transient )henomenon( Mathe2 et al (145), ha%e
re)orte" thermal symmetry in =>C o& hea"ache : &ree %olunteers( 9o2e%er, this symmetry can also *e
)resent in a high )ercentage o& migrainous )atients as 2ell(
&utcome7 More stu"ies are nee"e" regar"ing the role o& 'T' in true migraine(
TEMP&'&MA,#I8(*A' #YS3(,+TI&, >TM#?
'T' she"s more light on the com)le0 su*+ect o& tem)oroman"i*ular "ys&unction (TM?); 'n )ain&ul, clic6ing
ty)e o& TM?, Mceth et al, sho2e" 'T' to ha%e a "iagnostic sensiti%ity o& >=C (144)( This 2as in contrast
2ith normal controls sho2ing normal s)eci&icity o& >4C (144)( 'T' an" li.ui" crystal thermogra)hies 2ere
usually normal in *et2een &lare u)s o& trigeminal neuralgia or trigemino%ascular &acial )ains (14=)( ?uring
the sym)tomatic attac6s 'T' sho2e" hot or col" s)ots in o%er >0 C o& )atients (><,14=)( The hot s)ots are
more li6ely "ue to TMD )athology (14>,14B) or &acial sinusitis (14B)(
Thirty:three )atients 2ho ha" un"ergone TMD surgery &ollo2e" *y )ersistence an" s)rea" o& neuro)athic
)ain 2ere re&erre" to us &or "iagnosis an" treatment in the )ast si0 years( T2o main &actors : care&ul history
ta6ing an" 'T' : sol%e" the )u77le, an" e0)laine" the reason &or )oor reco%ery(
&utcome7 The 'T' re%eale" an a*normal sym)athetic "ys&unction in the cer%ical (14 )atients), lum*ar (B
)atients), an" thoracic s)ine regions (= )atients)( Only one )atient ha" sho2n no s)inal in%ol%ement : instea"
the )atient 2as &oun" to su&&er &rom ma0illary *one osteonecrosis an" a*normal thermal changes in the
Trigeminal ner%e "istri*ution(
+&,+*(SI&,
A )ro)erly )er&orme" 'T', )ro%i"es "iagnostic thera)eutic in&ormation not o*taine" *y ,M-, NCV, CT, or
M1'( This in&ormation is in"is)ensa*le in hel)ing to arri%e at an accurate "iagnosis, an" in i"enti&ying the
)athologic areas( 't hel)s 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 as
su&&ering &rom con%ersion reaction(
AcCno%ledgment
Ae are most grate&ul to Mr( ,ric Philli)s &or his in"is)ensa*le, an" e0tensi%e research an" )re)aration o& this
re)ort(
#isclaimer
The authors ha%e no &i"uciary interest in any me"ical su))lies, or any me"ications "iscusse" in this )a)er(
12<

1e%ie2
'E3E'E,+ES
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125

<2( 1a"t P; ilateral re&le0 neuro%ascular "ystro)hy &ollo2ing a neurosurgical )roce"ure( Clinical )icture
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15 No 2(
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5=( 1o2*otham MC; Com)le0 regional )ain syn"rome ty)e ' (re&le0 sym)athetic "ystro)hy)( More than a
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5>( ?ielissen PA, Claassen AT, Vel"man P9, -oris 1D; Am)utation &or re&le0 sym)athetic "ystro)hy( D
one Doint $urg( 1BB5J ==;2=0:3(
5B( McCollum PT, $)encer VA, Aal6er A!; Am)utation &or )eri)heral %ascular "isease; the case &or le%el
selection( r D $urg( 1B>>J =5; 11B3:5(
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ai" in "iagnosis( Ortho) 1e%( 1B>=J 14; 541:4(
41( #ematsu $; Thermogra)hic imaging o& the sensory "ermatome, $ociety &or Neuroscience A*stracts(
1B>3J B; 32<(
42( Pulst $M, 9aller P; Thermogra)hic assessment o& im)aire" sym)athetic &unction in )eri)heral ner%e
in+uries( D Neurol(1B>1J 224; 35:<2(
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Ortho $urg 1B>2J 3; =3:5(
4<( -ateless ?, -ilroy D; Tight:+eans meralgia; hot or col"( DAMA( 1B><J 252; <2:3(
45( Comstoc6 C, Marchettini P, Ochoa D; Thermogra)hic ma))ing o& s6in o& the human han" "uring
intra&ascicular ner%e microstimulation( Pa)er )resente" at the Peri)heral ner%e stu"y grou) meeting,
$2iterlan" ( $e)tem*er 1B>5(
44( rels&or" F, #ematsu $; Thermogra)hic )resentation o& cutaneous sensory an" %asomotor acti%ity in the
in+ure" )eri)heral ner%e( D Neurosurg( 1B>5J 42; =11:5(
4=( ?e%ul"er D, ?umoulin F, ?e Gaat M, 1olly -; 'n&ra:re" thermogra)hic e%aluation o& s)inal cor"
electrostimulation in )atients 2ith chronic )ain a&ter &aile" *ac6 surgery( r D Neurosurg( 1BB4J 10; 3=B:>3(
4>( McCulloch D, !rymoyer D, $teurer P, 1ia7 -, 9urst !; Thermogra)hy as a "iagnostic ai" in sciatica( D
$)inal ?isor"( 1BB3J 4; <2=:31(
4B( Aet7el !T, Ga1occa $9, An"inol&i M; The treatment o& chronic e0tremity in &aile" lum*ar surgery( The
role o& lum*ar sym)athectomy( $)ine( 1BB2J 1=; 1<42:>(
=0( $o QT, Olney 1F, Amino&& MD; A com)arison o& thermogra)hy an" electromyogra)hy in the "iagnosis
o& cer%ical ra"iculo)athy( Muscle Ner%e( 1BB0J 13; 1032:4(
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in%estigation o& ner%e root com)ression "ue to lum*osacral lateral s)inal stenosis( $)ine( 1B>4J 11; <2=:32(
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"iagnosis o& lum*osacral ra"iculo)athy( Neurology( 1BB1J <1; 1010:<(
=<( Cha&et7 N, Ae0ler C,, Faiser DA; Neuromuscular thermogra)hy o& the s)ine 2ith CT correlation(
$)ine( 1B>>J 13; B22:5(
124

1e%ie2
=5( Thomas ?, Cullum ?, $iahamis -, Ganglois $; 'n&rare" thermogra)hic imaging, magnetic resonance
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=>( enarroch ,,; The central autonomic net2or6; &unctional organi7ation, "ys&unction, an" )ers)ecti%e(
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=B( $tee" PA; The utili7ation o& contact li.ui" crystal thermogra)hy in the e%aluation o& tem)oroman"i*ular
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Allo"ynia( 1a%en Press, Ne2 Qor6( 1BB2J 5B:=B(
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1e%ie2
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Address for correspondence
9( 9ooshman", M(?(
Neurological Associates Pain Management Center
1255 3=
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$treet, $uite
Vero each, !lori"a, #$A(
(Manuscri)t recei%e" on =(3(2000( re%ision acce)te" 20(<(2001)

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Thermology internationa l 11 / 2 (2001) Original article

Infrared Thermal Imaging As A Tool In Pain

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