Lumbar Sympathetic Blockade Research Articles

Retrospective Evaluation of the Effect of Lumbar Sympathetic Blockade on Pain Scores, Fontaine Classification, and Collateral Perfusion Status in Patients with Lower Extremity Peripheral Arterial Disease.

Background and Objectives: The aim of this retrospective study was to evaluate the effect of lumbar sympathetic block (LSB) on pain scores, Fontaine Classification, and collateral perfusion status in patients with lower extremity peripheral artery disease (PAD), in whom revascularization is impossible. Material and Methods: Medical records of 21 patients with PAD who underwent LSB with a combination of local anesthetics, steroids, and patient follow-up forms containing six-month follow-ups between January 2020 and March 2021 were retrospectively reviewed. Numeric Rating Scale (NRS), Pain Detect Questionnaire (PDQ) scores, Fontaine Classification Stages, and collateral perfusion status (collateral diameter and/or development of neovascularization) evaluated by arterial color Doppler Ultrasound (US) from the medical records and follow-up forms of the patients were reviewed. Results: NRS and PDQ scores were significantly lower, and regression of the Fontaine Classification Stages was significantly better after the procedure at the first, third, and sixth month than at the baseline values (p < 0.001). Only four patients (19%) had collaterals before the procedure. An increase in the collateral diameter after LSB was noted in three out of four patients. Before the procedure, 17 patients had no prominent collateral. However, in thirteen of these patients, after LSB, neovascularization was detected during the six-month follow-up period (three patients in the first month, seven patients in the third month, and thirteen patients in the sixth month). The number of patients evolving neovascularization after LSB was found to be statistically significant at the third and sixth months compared to the initial examination (p < 0.001). Conclusions: LSB with the use of local anesthetic and steroids in patients with lower extremity PAD not only led to lower NRS and PDQ scores, but also resulted in regressed Fontaine Classification Stages and better collateral perfusion status.

Human lumbar sympathetic blockade: An anatomical study to address potential block failure.

The lumbar sympathetic block is often used to treat complex regional pain syndrome, but it seems to have a high failure rate. This study seeks anatomical explanations for this apparent failure in order to refine our block procedure. Two simulated sympathetic trunk blocks were carried out on four fresh, cryopreserved unembalmed human cadavers under fluoroscopic control at the L2 vertebral body level, followed by two further simulated blocks at the L4 vertebral body level on the other side. Dye was injected, and the areas were dissected following a specific protocol. We then describe the anatomy and the spread of the dye compared to the spread of the contrast medium on fluoroscopy. The ganglia were differently located at different vertebral levels, and differed among the cadavers. Following this anatomical clarification, we now prefer to perform lumbar sympathetic blocks at the fourth lumbar vertebra level, using an extraforaminal approach at the caudal end of ​​the vertebra, avoiding the anterolateral margin of the vertebral body at the midpoint.

Continuous Lumbar Sympathetic Blockade Enhances the Effect of Lumbar Sympatholysis on Refractory Diabetic Neuropathy: A Randomized Controlled Trial

IntroductionThere are a number of options for the symptomatic treatment of peripheral neuropathy, but the overall treatment outcomes remain unsatisfactory.MethodsA total of 60 patients with refractory diabetic neuropathy were randomly assigned to two groups. Patients in Group A were treated with computed tomography (CT)-guided sympathetic neurolysis with alcohol, and patients in Group B were treated with a combined therapy of CT-guided catheterization to achieve continuous lumbar block for 4 weeks followed by neurolysis with alcohol administered via the catheter. The outcomes of these two treatment strategies were then analyzed in terms of pain relief, blood flow in the lower limb microcirculation, plasma levels of inflammatory mediators, and complications.ResultsThe visual analog scale (VAS) pain scores of all patients after treatment decreased significantly at the different evaluation time points compared with pre-treatment values, with the intergroup analysis revealing that the VAS scores were lower in Group B patients than in Group A patients at all post-treatment time points. Skin temperature, capillary filling time, and blood oxygen saturation level were significantly improved in all patients at the 1- and 7-day post-treatment assessment compared to pre-treatment values, but patients in Group B showed a greater improvement. The plasma levels of inflammatory mediators were lower in all patients at the 7-day post-treatment assessment compared to pre-treatment values, with those of patients in Group B being statistically significantly lower than those of patients in Group A.ConclusionCombined treatment with continuous lumbar sympathetic block followed by neurolysis with alcohol provided more benefit in all assessed outcomes than sympathetic alcohol neurolysis alone. The results show that the procedures were associated with satisfactory safety outcomes and sustained analgesic effects, thereby providing clinical evidence supporting the use of this novel treatment for patients with painful diabetic neuropathy.

The Use of L2 and L3 Lumbar Sympathetic Blockade for Cancer-Related Pain, an Experience and Recommendation in the Oncologic Population.

The sympathetic nervous system has a recognized role in transmission of pain, and the lumbar sympathetic blockade is intended to provide analgesia. We share our experiences of lumbar sympathetic blockade in the treatment of cancer-related pain. We performed a retrospective analysis of patients with cancer-related pain in the back, abdomen, pelvis, or legs treated at Memorial Sloan Kettering Cancer Center between 2000 and 2018 undergoing lumbar sympathetic blockade at L2 or L3. Blocks were accomplished by injection of local anesthetic or local anesthetic with steroid under fluoroscopy. We measured numerical rating scale scores, percent relief, and relief time. The primary end point was defined as "effective" or "ineffective" pain relief. Effective pain relief was defined as ≥30% relief for at least one day. We identified 124 data points of lumbar sympathetic blockade at L2 or L3, of which 57 were with complete data and used for analysis. Peri-injection, 42 data points had active disease whereas 15 were in remission. Lumbar sympathetic blockade was 67% effective in the back pain cohort, 82% effective in the abdominopelvic pain cohort, and 75% effective in the leg pain cohort. Seventeen data points went on to neurolysis, two to neuromodulation, and eight to intrathecal pump implantation. Lumbar sympathetic blockade is effective for back, abdominopelvic, and leg pain related to cancer and its treatments. Future research should be aimed at refining its role within multimodal pain management.

TCTAP C-222 Successful Limb Salvage Case of Critical Limb Ischemia Patient with Systemic Sclerosis Treated by Endovascular Therapy in Combination with Lumbar Sympathetic Nerve Blockade

### Patient initials or identifier number E.S ### Relevant clinical history and physical exam A 87 years-old woman suffers from coldness of her each finger every winter. This ambulatory woman had rest pain in her right foot 2 months ago, and referred to our hospital with a deeply erythematous on

Erythromelalgia in the pediatric patient: role of computed-tomography-guided lumbar sympathetic blockade.

Erythromelalgia (EM) is an uncommon condition characterized by erythema, increased skin temperature, and burning pain, most frequently occurring in the lower extremities. The pain is generally very severe and treatment can be extremely challenging, especially in the pediatric and adolescent population. We report a series of three cases of primary EM in pediatric patients involving the lower extremities, refractory to medical treatment that responded favorably to computed-tomography-guided lumbar sympathetic blockade. There was a significant improvement in pain scores, quality of life, and overall function as well as decreased analgesic requirements. Lumbar sympathetic blockade should be considered as a therapeutic modality in pediatric and adolescent patients with EM who are refractory to other treatments.

Clinical efficacy of "Shamrock" ultrasound images-guided lumbar sympathetic ganglion blockade

Objective To evaluate the clinical efficacy of Shamrock ultrasound images-guided lumbar sympathetic ganglion blockade (LSGB). Methods Sixty patients of both sexes, aged 18-60 yr, weighing 50-70 kg, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, undergoing unilateral LSGB, were divided into groupⅠ(n=30) and group Ⅱ (n=30) using a random number table.In group Ⅰ, unilateral LSGB was performed at the L2 level under ultrasound guidance with paramedian transverse scanning.In group Ⅱ, unilateral LSGB was performed at the L2 level under ultrasound guidance with Shamrock ultrasound images.After final needle position was confirmed, 2% lidocaine 6.0 ml was administered in each patient.At 20 min before and after LSGB, the visual analogue scale scores and skin temperature of the big toe of the affected foot were recorded, and the successful blockade and visibility of important paravertebral structures on ultrasound images were recorded during puncture. Results The visual analogue scale scores were significantly lower, and the skin temperature on the affected side was significantly higher after LSGB than before LSGB in both groups (P<0.05). The important paravertebral structures such as erector spinae, quadratus lumborum, psoas major, transverse process of L2 vertebrae, and the curved edge of L2 vertebrae were visible in both groups.The visibility rate of the inferior vena cava or abdominal aorta on ultrasound images and the success rate of blockade were significantly lower in group Ⅰ than in group Ⅱ (P<0.01). Conclusion Compared with paramedian transverse scanning, LSGB has some advantages such as real-time monitoring, higher success rate of blockade, better efficacy and avoiding damage to great vessels when performed under Shamrock ultrasound image guidance. Key words: Ultrasonography; Ganglia, sympathetic; Nerve block

Ultrasound-Guided Lumbar Sympathetic Ganglion Blockade Using Shamrock Method: A Prospective Case Series

Background: Lumbar sympathetic ganglion blockade (LSGB) is traditionally performed using x-ray in either the fluoroscopy suite, or CT in the radiology department. This case series evaluated the feasibility of using the‘Shamrock method’ to perform LSGB under ultrasound guidance in patients.Methods: A total of 16 patients with postherpetic neuralgia received a real-time LSGB under the guidance of Shamrock ultra-sonogram for pain management. The blocks were performed using the in-plane needle insertion. Ultrasound visibility of the lumbar paravertebral structures was assessed in real time during the scout scan. Sympathetic block after LSGB was considered successful when changes in ipsilateral skin temperature between preblock and postblock were >2℃.Results: The lumbar paravertebral region was successfully visualized in all patients with a median ultrasound visibility score of 15 (range, 8-18). The skin temperature of the big toe before LSGB was significantly lower than that 20 minutes after LSGB. Additionally, the changes in skin temperature between preblock and postblock were >2℃ in 15 (93.8%) of 16 patients.Conclusions: Ultrasound-guided LSGB can be reliably accomplished using the Shamrock method. Citation: Dan-Xu Ma, Yun Wang, Meng-Meng Bao, Chen Zhang, Xue-Yang Li, An-Shi Wu, et al. Ultrasound-guided lumbar sympathetic ganglion blockade using shamrock method: a prospective case series. J Anesth Perioper Med 2016; 3: 114-118. doi: 10.24015/JAPM.2016.0015This is an open-access article, published by Evidence Based Communications (EBC). This work is licensed under the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium or format for any lawful purpose. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

Continuous peripheral nerve catheters in pediatric complex regional pain syndrome.

Continuous peripheral nerve catheters in pediatric complex regional pain syndrome.

Bortezomib Induced Peripheral Neuropathy in the Treatment of Renal Allograft Antibody Mediated Rejection.

Introduction: Treatment modalities for AMR and the development of DSA often prove inadequate with an observed failure rate, substantial cost, and unknown durability. The first-in-class novel therapeutic bortezomib has been shown to produce a clinically significant reduction in alloantibody and allograft stabilization. Despite a reported low incidence of adverse effects in transplantation, our center has observed a direct correlation with the use of bortezomib and the development of severe polyneuropathy. Methods: Selected cases were based upon inclusion in a pre-operative desensitization protocol or development of post-transplant AMR refractory to traditional treatment modalities for which bortezomib was initiated (4 IV doses at 1.3 mg/m2). Presence of bortezomib induced peripheral neuropathy (BIPN) was assessed by treating physicians in accordance to the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) Version 4.0. Results: Demographics are reported in Table 1.Table: No Caption available.Table 2 contains treatment information and observed degree of BIPN. Patient 1's symptoms led to prolonged immobility and the need for a lumbar sympathetic blockade. Patient 2 developed severe abdominal pain with paralytic ileus requiring hospitalization. Patient 4 remains ambulatory with assistance secondary to ataxia. Only Patients 2 and 5 were able to fully recover.Table: No Caption available.Discussion: Although bortezomib is used in an increasing number of transplant centers, BIPN has been infrequently documented. In our series, severe motor and sensory neuropathy symptoms were shown to negatively impact the quality of life, impair ADL's, and placed additional burdens on caregivers. As bortezomib based therapy is used in broader applications, detailed evaluations of its efficacy, durability, and safety profile in the transplant population should be an expectation.

Photoplethysmographic signals to predict the success of lumbar sympathetic blockade for lower extremity pain.

A prospective, observational study to investigate how photoplethysmography (PPG) signals change during lumbar sympathetic blockade (LSB), and whether these changes can predict sympathetically mediated pain (SMP). Patients with unilateral lower extremity pain and self-reported cold hyperalgesia underwent LSB. Bilateral temperature and PPG signals (AC and DC) were recorded. Power spectrum analysis (PSA) was performed. Of the total patient cohort (n = 38), eight patients (22.1%) had excellent pain-relief after LSB and were determined to have SMP. In all patients, the PPG AC signal changed immediately after drug administration, before any temperature change. DC signals decreased slowly in a linear fashion. PSA of DC signals showed significantly lower low-frequency/high-frequency (LF/HF) ratios in the SMP group than the sympathetically independent pain group, both before and after LSB. A cut-off value of 2.92 for LF/HF resulted in sensitivity, specificity and positive predictive values for SMP of 75.0%, 76.7% and 3.21 [1.5, 6.9], respectively. PPG may be used as an early indicator of a successful LSB and could also be helpful in diagnosing SMP.

The Use of Lumbar Sympathetic Blockade at L4 for Management of Malignancy-Related Bladder Spasms

Background: Cancer-related bladder spasms may be a rare but severe symptom of bladder or metastatic cancer or its related treatments. Various treatments described in the literature include systemic medications, intravesical or epidural medications, or even sacral neurolectomies. Objective: We present 3 patients who have suffered from bladder spasm either from invasion of the bladder wall by tumor (2 patients) or from intravesical chemotherapeutic treatment. Design: Case Report. Setting: Cancer pain management hospital. Methods: For each patient, we describe the use of lumbar sympathetic block to successfully treat the bladder spasms. Sympathetic blockade was performed at the left anterolateral border of lumbar vertebra L4. We used 10 mL of local anesthetic (0.25% bupivacaine) delivered in 2 mL aliquots, each given after negative aspiration for heme. Each procedure was performed with fluoroscopic guidance (both AP and lateral views) with the use of iodine contrast (Omnipaque-180) to confirm the location of the medication and its resulting spread. Results: All 3 patients had a reduction in the frequency and intensity of spasms, with 2 out of 3 patients not having a recurrence of the spasms for up to 2 months post procedure and follow up. Limitations: Case Report. Conclusion: Lumbar sympathetic blockade could be a useful treatment for recurrent bladder spasm in the oncologic population. Based on these findings, we feel that the branches of the sympathetic nerve set at L4 may be a good target for neurolytic procedures, such as radiofrequency ablation, for long term treatment of bladder spasms. Further research is necessary to determine the efficacy of this technique for the treatment of bladder spasms in the oncologic population. Key words: Bladder spasm, cancer pain, splanchnic nerve, lumbar sympathetic block

Lumbar Sympathetic Blockade in Children with Complex Regional Pain Syndromes

Sympathetic blockade is used in the management of complex regional pain syndromes in children, but there are no data on the efficacy or mechanism(s) by which it produces pain relief. The purpose of this study is to compare the efficacy of lidocaine administered by lumbar sympathetic to IV route. Under general anesthesia, children with unilateral lower limb complex regional pain syndromes received catheters along the lumbar sympathetic chain. In a double-blind placebo-controlled crossover design, patients received IV lidocaine and lumbar sympathetic saline or lumbar sympathetic lidocaine and IV saline. Spontaneous and evoked pain ratings and sensory thresholds were assessed before and after these two lidocaine/saline doses and between routes of lumbar sympathetic blockade and IV. Twenty-three patients, ages 10-18 yr, were enrolled. There was evidence for reduction of mean pain intensity of allodynia to brush (mean -1.4, 95% confidence interval [CI] -2.5 to -0.3) and to pinprick temporal summation (mean -1.3, 95% CI -2.5 to -0.2) with lidocaine treatment via the lumbar sympathetic blockade compared to IV route. Lumbar sympathetic blockade also produced significant reduction in pain intensity compared to pretreatment values of allodynia to brush, pinprick and pinprick temporal summation and verbal pain scores. IV lidocaine did not produce significant changes in spontaneous and evoked pain intensity measurements compared to pretreatment values. There were no carryover effects as assessed by route-by-period interaction. Under the conditions of this study, the results provide some direct evidence that a component of pain may be mediated by abnormal sympathetic efferent activity.

The influence of new antithrombotic drugs on regional anesthesia

Antithrombotic drugs are known to increase the risk of spinal epidural hematoma after neuraxial blockade. During the last few years, several new anticoagulants have been introduced, some of them more potent than the drugs currently available. More potency, however, may also indicate a higher risk of bleeding. Case series from the last few years indicate that spinal epidural hematoma is more common then previously estimated, with a prevalence from 1: 100,000 in obstetric patients to as high as 1: 3,600 in female orthopedic patients. In order to diminish this risk, most national societies have issued guidelines in which time intervals were established between administration of antithrombotic drugs and performance of neuraxial blockade. Guidelines are perceived to be capable of reducing the incidence of spinal epidural hematoma with the inherent risk of permanent paraplegia. These guidelines, however, will only be a valuable aid for clinicians if they are constantly updated and newer antithrombotic drugs are included. Although the resurge of peripheral nerve blocks may diminish patient hazards, deep nerve blocks such as lumbar sympathetic blockade are not devoid of serious complications and should probably be handled in the same way as neuraxial blockade.

Non-opioid analgesics: other: Intrathecal ziconotide (Prialt™T) relieves idiopathic peripheral neuropathic pain: A case report

Patient CJM, a 40-year-old man, was referred for treatment of burning pain in his lower extremities. His diagnosis by exclusion was idiopathic peripheral neuropathy. On presentation to the pain clinic in 1997, CJM described burning pain in a stocking distribution over both feet to his ankles. He also described intermittent swelling, but physical exam revealed no sympathetic changes. Conventional pain therapy provided only mild relief. Lumbar sympathetic blockade provided no benefit. A 7-day spinal cord stimulation trial was quite successful; the patient reported adequate analgesia but no reduction in medication usage. Unfortunately, due to lead migration, the generator had to be explanted. Intraspinal opioids provided substantial relief but were associated with problematic edema. An intraspinal opioid rotation was performed, placing the patient on hydromorphone. When the patient was reexamined on July 11, 2002, he had significant edema of the lower extremities causing 2+ pitting and skin fissures. His overall body habitus had changed with weight gain of over 150 lbs. Intraspinal opioids were slowly weaned to prepare for ziconotide infusion, a new non-opioid N-type calcium channel blocker. Ziconotide was initiated on December 11, 2002 at 2.4 mcg/d increased to 2.6 mcg/d using a slow titration schedule. The patient reported decreased sleep and increased energy; his analgesia was profound compared with his earlier modalities. Another dosage escalation was associated with mild sedation. The patient asked for another escalation and the infusion was increased to 6.0 mcg/d. As well as excellent pain relief, CJM reported some side effects, including word-finding difficulty, sleeplessness, dry mouth, mild agitation, and nystagmus. These events resolved with dosage reduction. CJM has remained at 3.1 mcg/d since September 17, 2003 with no recurrence of adverse effects. Medication regimen was simplified to oxycodone CR 20 mg BID with adjunctive bupropion. Ziconotide was effective with a purely neuropathic pain disorder.

Sympathetic ganglion blockade with phenol in patients with low-back syndromes

Abstract Objectives: To evaluate the long-term efficacy of lumbar sympathetic ganglion blockade with phenol for low-back syndromes and to identify factors which may enhance the long-term success of this procedure. Study-design: Survival analysis of the period of pain relief following a successful lumbar sympathetic ganglion blockade with phenol for low-back syndromes. Patients and methods: A total of 90 consecutive patients were screened, who were treated with blockade of the lumbar sympathetic ganglion for low-back syndromes. In patients responding to a diagnostic blockade of the lumbar sympathetic ganglion, neurolysis of this structure with phenol was performed. Patients who were considered to have had clinical benefit from lumbar sympathetic ganglion blockade with phenol and who did not experience a relapse of their complaints in the follow-up period were included for an assessment by questionnaire. Results: Two months following therapy, 49% of the patients undergoing lumbar sympathetic ganglion blocka...

Lumber sympathetic blockade

Lumbar sympathetic blockade is indicated for diagnosis, prognosis, and therapy of painful and other conditions presumably associated with sympathetic nervous system dysfunction. Anatomy of the lumbar sympathetic chain and the rationale for the block are essential to know before performing the block. Different techniques have been described for the lumbar sympathetic blockade, with efficacy ranging from 13% to 80%, which varies according to the initial patient pathology. Genito-femoral neuralgia occurs in about 5% of patients after neurolytic block. Other potential complications are infection, hematomas, and somatic nerve damage. Copyright © 2001 by W.B. Saunders Company

Chronic Pain: Management Strategies That Work

Chronic Pain: Management Strategies That Work

Comparison of lower extremity cutaneous temperature changes in patients receiving lumbar sympathetic ganglion blocks versus epidural anesthesia

Study Objective: To investigate if paravertebral lumbar sympathetic ganglion block and lumbar epidural anesthesia result in comparable cutaneous temperature changes in the lower extremity. Design: Nonrandomized comparison study. Setting: Operating rooms and pain clinic procedure rooms in a tertiary care hospital. Patients and Interventions: 18 patients undergoing lumbar sympathetic ganglion blocks for the diagnosis and/or treatment of chronic pain, and 13 patients undergoing lumbar epidural anesthesia for radical prostatectomy. Measurements: Cutaneous temperatures were measured over the great toe, calf, and thigh in all patients. Mean maximum temperature (Tmax), rate of change of skin temperature (from 5% to 95% of maximum temperature change), and mean time to 1°C increase, and 50% and 95% of maximum temperature change for each group were compared. Temperature changes for the epidural and lumbar sympathetic block patients were compared. Main Results: Epidural and lumbar sympathetic block resulted in similar Tmax (34.1 ± 0.2 and 33.8 ± 0.9°C, respectively, mean ± SEM; p = 0.18) and rate of temperature change (0.64 ± 0.09 and 0.49 ± 0.07°C/min; p = 0.2) in the great toe. The onset of cutaneous temperature change after lumbar sympathetic block was slower than after epidural anesthesia (1°C increase: 17 and 11 min, respectively, 50% of Tmax: 25 and 17 min, respectively, and 95% of Tmax: 40 and 31 min, respectively; p < 0.05 for each). Conclusions: The similar rate and magnitude of cutaneous temperature change in the distal lower extremity suggests the degree of sympathetic blockade is similar with lumbar sympathetic blockade and epidural anesthesia. Either technique should provide adequate sympathectomy for treating sympathetically maintained pain once the diagnosis has been confirmed using selective sympathetic blockade.

Calciphylaxis treated with neurolytic lumbar sympathetic block: Case report and review of the literature

Background and Objective: Calciphylaxis is a painful complication of end-stage renal disease and secondary hyperparathyroidism. Calcification most commonly affects skin and soft tissue of the lower extremities resulting in excruciatingly painful skin ulcers. Treatment involves correction of hypercalcemia and hyperphosphatemia, parathyroidectomy, and supportive measures. Methods: The literature and the merits of neurolytic lumbar sympathetic blockade (LSB) for the treatment of pain associated with calciphylaxis are reviewed. Conclusions: The neurolytic LSB provided pain relief and is a treatment modality to be considered in managing the pain associated with calciphylaxis. Reg Anesth Pain Med 2000;25:310–312.