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Lumbar Sympathetic Block 57 Sascha Qian, Vikram Sengupta, Ned Urbiztondo, and Nameer Haider

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Lumbar Sympathetic Block 57 Sascha Qian, Vikram Sengupta, Ned Urbiztondo, and Nameer Haider Lumbar Sympathetic Block 57 Sascha Qian, Vikram Sengupta, Ned Urbiztondo, and Nameer Haider Introduction Brown and Adson in 1925 who demonstrated the efficacy of lumbar sympathetic blockade for Raynaud’s and obliterative The lumbar sympathetic block targets the sympathetic chain arterial disease. into the lower extremities with the objective of disrupting the In 1924, Brunn and Mandl in Vienna described the first nerve supply. This has been useful for the treatment of sym- percutaneous lumbar sympathetic block, for which they ini- pathetically mediated pain pathologies such as complex tially used local anesthetic and later 70% alcohol. The origi- regional pain syndrome, peripheral vascular disease, vaso- nal description outlined a paravertebral approach: (1) the spastic syndrome, frostbite, phantom limb pain, hyperhidro- spinous processes of the second through fourth lumbar verte- sis, and postherpetic neuralgia. bra were palpated, and three needles were placed 5–6 cm laterally to the spinous processes with a needle at each level, and (2) the needles were then advanced in a medial direction Background and Historical Perspective until contact with the anterolateral aspect of the vertebral body. In 1949, Haxon applied the same paravertebral tech- While the anatomy of the sympathetic nervous system was nique in 220 patients with 1 important modification: he used delineated as early as the sixteenth century by Renaissance phenol for sympathetic neurolysis rather than alcohol. The physician Vesalius, the functions of the sympathetic nervous result was significant pain reduction for patients with hyper- system were not explored until the end of the nineteenth cen- hidrosis, frostbite, and peripheral vascular disease; one tury with a series of surgical sympathectomies. In 1917, patient even experienced 2 years of sympathetic denervation. Rene Leriche, a military surgeon, performed the first periar- Overall, the complications were noted to be minimal com- terial sympathectomy on a patient with chronic hand pain pared to the mortality and morbidity associated with open and numbness after a gunshot wound to the axilla. After not- sympathectomy. ing complete resolution of his patient’s pain, Leriche suc- During World War II, lumbar sympathetic blockade rose cessfully replicated his surgical technique for other in popularity as a treatment option for patients with lower syndromes with marked vasomotor dysregulation and con- extremity neuropathic pain and has continued to evolve over ceived of the term “sympathetic neuritis”—a concept that the past century as a commonly used interventional pain pro- emphasized the crucial role of the sympathetic nervous sys- cedure. With the advent of fluoroscopy, CT, and ultrasound tem in pathophysiology of neuropathic pain. With the goal of for visualization, lumbar sympathetic block has developed targeting the sympathetic ganglia, Royle and Hunter per- an improved safety profile, while the options for disrupting formed the world’s first lumbar sympathectomy in 1923 on a sympathetic innervations have expanded to include not only young World War I veteran with spastic paralysis. They surgical ligation and local anesthetic infiltration but also var- noted not only the anticipated result of reduced spasticity but ious forms of chemical neurolysis and radiofrequency also increased temperature and bright color of the affected lesioning. limb—a seminal milestone that was quickly followed by Uses and Indications S. Qian (*) · V. Sengupta · N. Urbiztondo · N. Haider Lumbar sympathetic blocks are indicated for a multitude of Spinal & Skeletal Pain Medicine, Utica, NY, USA sympathetically mediated pain disorder. These include the e-mail: [email protected]; [email protected] following (for full list, see Table 57.1): © Springer Nature Switzerland AG 2019 467 T. R. Deer et al. (eds.), Deer’s Treatment of Pain, https://doi.org/10.1007/978-3-030-12281-2_57 468 S. Qian et al. Table 57.1 Potential indications for lumbar sympathetic block II. Chronic obstructive arterial disease (COAD) is the Complex regional pain syndrome I and II reduction in blood flow in the arterial beds of the lower Chronic occlusive arterial disease (includes critical limb ischemia) extremities, often manifesting as intermittent claudica- Diabetic neuropathy tion when the obstruction of the vessel is greater than Phantom limb pain 50% and progressing onto severe persistent pain at rest Vasospastic disorders (Raynaud’s phenomenon, acrocyanosis, livedo reticularis) when the collateral flow becomes insufficient, such as Thromboangiitis obliterans when COAD developed into critical limb ischemia Erythromelalgia (CLI). Because CLI is often associated with ulcers and Cancer pain gangrene, interventions such as bypass, endarterectomy, Radiation neuritis and stenting have to be undertaken. Lumbar sympathetic Frostbite blockade is a viable treatment option for patients with Acute herpes zoster, postherpetic neuralgia painful COAD and CLI, for whom revascularization is Renal colic Hyperhidrosis not feasible, and should be considered prior to proceed- ing with amputation. Some vascular surgeons may even consider lumbar sympathetic neurolysis as a treatment I. Complex regional pain syndrome (CRPS) is a regional for ulcers or as a bridge to revascularization. Lumbar pain of complex pathophysiology involving disturbance sympathetic chemical neurolysis, a fairly safe and mini- of both central and autonomic nervous system. CRPS I is mally invasive procedure, has similar short-term success formerly known as reflex sympathetic dystrophy and rates compared to surgical sympathectomy and may be entails presence of initiating noxious event or a cause of an effective strategy in avoiding or delaying surgical immobilization, while CRPS II is formerly known as cau- trauma. salgia and entails the presence of continuing pain after The mechanism of pain control after sympathetic nerve injury. Patient typically endorses symptoms and blockade is likely related to the transient abolishment of exhibits signs of allodynia, hyperalgesia, vasomotor dys- basal and reflex constriction of arterioles and precapil- function, edema, and trophic changes of the affected limb. lary sphincters leading to increased flow through the The optimal management of CRPS involves early occluded vessel as well as increased perfusion through diagnosis and time-dependent, interdisciplinary treat- collateral circulation. The improvement in blood flow ment, which focuses on rehabilitation, pain manage- bears nutritive value for the capillary beds and may alle- ment, and psychological therapy. Any delay can viate further tissue damage. Furthermore, the sympa- adversely affect response to treatment. Therefore, a thetic blockade may directly interrupt or attenuate minimally invasive interventional pain procedure, such nociceptive transmission directly via decreasing tissue as lumbar sympathetic block, should be considered ear- norepinephrine levels, which would account for analge- lier in the treatment algorithm, especially when a patient sic relief in the patients with severe multilevel arterial has reached a plateau in progress after intensive reha- occlusions who are still able to experience pain relief bilitation and aggressive pharmacotherapy. In providing without improvement in distal perfusion. Clinically, an updated algorithm of the management of CRPS, a patients will typically demonstrate significant increase panel of experts meeting in 2002 recommended mini- in warmth of the affected extremity due to shunting mally invasive procedures such as sympathetic nerve through cutaneous arteriovenous anastomosis as well as block in conjunction with mainstay therapy within the increased filling of the veins and increase in arterial first 12–16 weeks—after which, failure to progress pulsations. should prompt consideration of more advanced tech- III. Vasospastic disorders, including Raynaud’s phenome- niques such as spinal cord stimulation and DRG stimu- non, acrocyanosis, and livedo reticularis, present with lation. Positive response to sympathetic nerve block the hallmark symptom of episodic cyanosis of the may also bode well for spinal cord stimulation; a study extremities. Excessive spasm of the peripheral blood in 2003 showed that patients with a good response to vessels in the lower extremities results in numbness as sympathetic blocks were more likely to have pain relief well as pain. Conservative treatment includes lifestyle during SCS trial and long-term pain relief after place- modification and calcium channel blockers, which may ment of permanent device. be effective in only two thirds of the patients; refractory While the sympathetic nervous system is traditionally cases of vasospasm can lead to unremitting pain as well implicated in the origin of CRPS, the terms sympatheti- as digital ulceration. While there is a paucity of data on cally maintained pain and sympathetically independent efficacy of lumbar sympathetic blockade in vasospastic pain have been employed to account for the inconsistent disorders, there exist case reports of successful bilateral response to sympathetic blocking procedures. lumbar sympathetic blockade performed on patients 57 Lumbar Sympathetic Block 469 with refractory Raynaud’s phenomenon. The benefit of and personally and professionally limiting. In patients lumbar sympathectomy is likely due to its reduction of who do not respond to conventional treatment, such as vasoconstrictor tone and improvement of circulation to topical agents and botulinum
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