RSD and post-surgical onset: prevention strategies for surgeons
Reflex sympathetic dystrophy (RSD), now more often called complex regional pain syndrome (CRPS), is a chronic pain condition involving the nervous system. After an operation, it may cause persistent burning, swelling, extreme sensitivity, stiffness, or changes in skin temperature and colour.
Persistent postoperative pain is common, so timing alone cannot identify RSD. Injury to a nerve, infection, blood clots, scar problems, arthritis and other complications can resemble or coexist with it. A surgeon needs to distinguish these causes rather than assume that worsening pain is simply part of recovery.
No method guarantees prevention, and the evidence for preventing rare postoperative cases remains limited. A sensible approach combines careful tissue handling, individualised pain control, safe early movement and prompt review of unusual symptoms. Anxiety and mood may affect how pain is experienced, but they never make it imaginary or justify blaming a patient.
Why post-surgical RSD can develop
Surgery creates tissue injury, inflammation, altered nerve signalling and temporary immobility. In some people, these normal events may interact with an exaggerated neuroimmune response and pain sensitisation. The exact pathway is still being studied, so prevention focuses on reducing avoidable stress and detecting an atypical pattern early.
Redness, warmth and swelling may initially look like CRPS, yet infection or a clot must be excluded. Patients should never be told that pain is normal simply because an operation has occurred. Understanding why the burning occurs can help teams explain symptoms, while a thorough assessment remains necessary before labelling the condition RSD.
Assessing risk before surgery
Before surgery, the team should ask about previous CRPS, chronic unexplained pain, circulation problems, current medicines and expected mobility after the procedure. No preoperative test can reliably predict CRPS, and a past episode does not automatically rule out surgery. It does, however, justify documenting the history and planning extra support.
Shared decisions should cover the operation’s purpose, expected pain, alternatives, and who will manage problems afterward. Patients should tell the anaesthetist, physiotherapist and ward nurse about previous CRPS symptoms, using the familiar term “flare-up” when describing a worsening episode. Anxiety or low mood should prompt support, not assumptions that a person caused the outcome.
Protecting tissue during surgery
Theatre teams can reduce mechanical and tissue trauma through careful positioning, adequate padding, gentle retraction and avoidance of unnecessary pressure or repeated disturbance. Minimising incision and dissection when equally safe can reduce the injury burden. These measures support ordinary healing and may lower the chance of provoking an abnormal pain response, although they cannot remove every risk.
Infection prevention, accurate surgery and a review of unexpectedly severe pain before discharge are equally important. A patient whose pain is rapidly increasing or differs sharply from the agreed recovery pattern should receive an examination and explanation, not simply another dose of analgesia. Documentation of the pattern helps the GP and rehabilitation team respond consistently.
Managing pain without adding harm
Individualised multimodal analgesia can address different pain mechanisms without relying entirely on opioids. Paracetamol, anti-inflammatory medicines, local anaesthetic techniques or other agents may be considered when suitable for the operation and the person’s health. Because Australian prescribing is regulated through the TGA and many medicines are listed on the PBS, access and safety still depend on clinical assessment rather than subsidy alone.
Pain that is poorly controlled can sustain sensitisation and prevent sleep or movement, while heavy sedation and opioid-related nausea can delay rehabilitation. Anaesthetists, surgeons, pharmacists and ward staff should review the balance together, with a written plan for breakthrough pain. Any change should reflect the operation, existing conditions and recovery goals.
Mobilising early and supporting rehabilitation
Early movement within the surgical safety limits protects function and reduces prolonged immobility. Physiotherapy should use graded loading, protective positioning and gentle range-of-motion work rather than forcing painful exercise. A patient who has had CRPS may need slower progression and close monitoring, since ordinary postoperative stiffness can become a major trigger if ignored.
Access differs across Australia. Major private and public services in Melbourne and Sydney offer multidisciplinary pathways, while patients in regional NSW may depend on GP referrals, travelling to a public outpatient clinic or using telehealth for review. Some allied-health visits may receive Medicare support through an eligible chronic disease management plan; private rebates can also cover part of physiotherapy.
Recognising warning signs after discharge
Warning signs include escalating or disproportionate pain, burning beyond the wound, pain from light touch, increasing swelling, stiffness, unusual sweating, and a limb that feels markedly hotter or colder than usual. Symptoms spreading beyond the surgical area deserve review. Fever, wound changes, a swollen calf or sudden breathlessness require urgent assessment because they may indicate another emergency.
Patients should contact the surgical team or their GP promptly rather than wait for the next routine appointment. After hours, an after-hours GP, emergency department or 000 may be appropriate, depending on severity and location. Telehealth can support rural assessment, but a hands-on examination may still be needed. CRPS is a clinical diagnosis, and burning pain alone does not establish it.
Coordinating follow-up across the system
A strong recovery pathway names the responsible clinician, lists expected symptoms, explains medicine use and sets a review time. In Australia’s mixed Medicare and private-insurance system, discharge information should travel clearly between the surgeon, GP, pharmacist, physiotherapist and any public pain service. My Health Record can assist continuity, although consent and accurate updates remain essential.
Service planning also benefits from evidence about how patients move through care; broader patient pathway research can reveal gaps between private and public systems. Teams can audit whether high-risk patients receive earlier reviews, whether advice is understood, and whether a rapid escalation route exists. The focus is prevention and support, not retrospective blame.
Use this guide to build a written preoperative and discharge plan that covers pain control, early movement, warning signs and follow-up. Surgeons should involve patients and GPs in that plan, while patients can ask who will review unusual pain and how to reach them outside normal hours.
Readers seeking further general information about RSD can contact Brooks-County.org or share this article with a surgical team or patient support group. Share the guide, keep the warning signs accessible, and ensure that postoperative pain is reviewed promptly rather than dismissed.