Continuing Education Activity

The autonomic nervous system consists of the sympathetic and parasympathetic divisions. As the name implies, the lumbar sympathetic block can be utilized to disrupt the nerve supply from the sympathetic chain to the lower extremities. This is useful in treating sympathetic mediators of pain. This activity reviews the indications, contraindications of lumbar sympathetic block and highlights the role of the interprofessional team in the management of patients with chronic pain syndrome.

Objectives:

• Describe the indications of a lumbar sympathetic block.
• Review the technique of a lumbar sympathetic block.
• Summarize the complications of a lumbar sympathetic block.
• Outline the importance of improving care coordination among interprofessional team members to improve outcomes for patients undergoing a lumbar sympathetic block.

Introduction

The autonomic nervous system consists of the sympathetic and parasympathetic divisions. As the name implies, the lumbar sympathetic block can be utilized to disrupt the nerve supply from the sympathetic chain to the lower extremities. This is useful in treating sympathetic mediators of pain. Specifically, lumbar sympathetic blocks can be used for the treatment of painful conditions such as complex regional pain syndrome, phantom limb pain, hyperhidrosis, painful vascular insufficiencies, and pain from herpes zoster/shingles.[1][2]

Anatomy and Physiology

The sympathetic trunk is comprised of a nerve bundle that runs from the skull base to the coccyx. Its main function is to mediate the body's "fight or flight" response, and it also plays an integral role in maintaining homeostasis in conjunction with the parasympathetic nervous system. The lumbar sympathetic trunk is located along the anterolateral aspect of the first through fourth lumbar vertebra. The preganglionic neurons exit the spinal cord via white rami of the ventral roots of spinal nerves L1 to L4 and then synapse at the appropriate lumbar sympathetic ganglion. From there, the postganglionic neurons extend distally and innervate specific sites. The densest portion of lumbar sympathetic ganglia resides in L2 and L3, therefore, lumbar sympathetic blocks are most commonly performed along with the lower third of L2 or the upper third of L3 levels.[3][4]

Indications

According to the practice guidelines for chronic pain management by the American Society of Anesthesiologists, lumbar sympathetic blocks are indicated for the treatment of a multitude of sympathetic-mediated pain disorders.

• Complex regional pain syndrome, formerly referred to as reflex sympathetic dystrophy, is characterized by dysregulation of the central and autonomic nervous system causing unregulated pain and temperature control on the affected extremity.[5] It is most commonly seen in patients who sustain an injury to the soft tissue or peripheral nerves of an extremity. Clinical features include vasomotor dysfunction, swelling, allodynia, and hyperalgesia. Affected limbs are often swollen, edematous, and may display trophic changes of the skin due to aberrant vasomotor activity.[6][7]
• Lower limb painful ischemia - The National Institute for Health and Clinical Excellence states that approximately 20% of the patients with painful ischemia of the lower limbs secondary to vascular disease are not candidates for surgical intervention due to either the pattern of their disease or medical co-morbidities. In these patients, lumbar sympathetic blocks may be utilized to reduce pain, improve wound healing, and potentially delay or avoid limb amputation. In these cases, the lumbar sympathetic block serves to disrupt the sympathetic innervation to the vascular supply of the lower extremity, thus causing vasodilation and subsequently improved blood flow to the limb.[8][9]
• Phantom limb pain - A phenomenon in which pain is perceived from a limb that is no longer present. Although the mechanism is poorly understood, studies report an incidence of phantom limb pain in amputee patients between 42% to 78%. Case studies have found lumbar sympathetic blocks to be safe and effective for the alleviation of phantom limb pain.[10][11][12]
• Neuropathic pain - sustained pain relief in a patient with intractable diabetic neuropathy.[1][13][14]
• Postherpetic neuralgia secondary to zoster. There is improvement in pain, function, and quality of life after lumbar sympathetic block in patients with postherpetic neuralgia secondary to zoster (Shingles).[15][16][17]
• Hyperhidrosis[18][19][20]
• Raynaud disease [21][22]
• Cancer pain[23]

Contraindications

• Anticoagulant therapy that can not be stopped
• Conditions with altered coagulation parameters
• Allergies to any of the medications that are injected
• Uncontrolled diabetes
• Poorly controlled heart disease
• Patient refusal

Equipment

Required equipment includes a mobile fluoroscopic C-arm x-ray. Additionally, the physician will need epidural spinal needles, sterile gloves, medications, contrast, sterile drapes, and betadine solution. Cardiac monitors and pulse oximeters are needed to monitor the patient's vitals.

Personnel

Staff typically consists of a nurse or assistant, a fluoroscopic C-arm operator, and a physician.

Preparation

A time-out should be performed at which time the staff identify the patient, discuss which procedure will be performed, and verify the side of the body to be treated. The patient should be placed on the fluoroscopy table in the prone position. Some clinicians choose to provide the patient with intravenous sedation at this time. Once the target area has been identified, the area should be cleaned thoroughly with a betadine solution and then covered with a sterile draping. After the patient has been positioned appropriately and the skin has been sterilized, the clinician may proceed.

Technique or Treatment

The fluoroscope's C-arm imaging projector should be positioned such that the L2 and L3 vertebrae are easily visualized, and the superior endplates are aligned. Occasionally, the procedure is done under computed tomography guidance. The C-arm is placed in the oblique plane until the end of the transverse process is aligned with the anterior aspect of the vertebral body to avoid the transverse process during the insertion of the needle. The needle should be aimed towards the anterior aspect of the vertebral bodies of L2 or L3.[23] Sometimes, the block is done at both levels. Local anesthesia is injected at the planned entry point. Once the trajectory has been confirmed, the C-arm should be returned to an anteroposterior view. From here, the needle is introduced and advanced. It should approach the target vertebral body in the mid pedicular position. The needle should be in contact with the vertebra and "walked along" the vertebral body to ensure correct placement. The great vessels are located ventral to the vertebral bodies. A lateral image should be obtained to verify the depth of the needle. The needle should be adjusted so that it is three to five millimeters dorsal to the most ventral portion of the vertebral body.

Once in the correct position, and aspiration was negative for air, blood, or cerebrospinal fluid, 1 mL of contrast is injected to ensure adequate flow and proper location. The clinician should be able to visualize the contrast covering the anterior portion of the vertebral body with an inferior and superior spread at L1 to L3. After adequate location and craniocaudal spread, the medication (anesthetic bupivacaine 0.5%, ethanol 96%, or botulinum toxin) is injected to complete the lumbar sympathetic blockade. The needle is removed and pressure is applied on the entry point and then covered with a bandage. The greatest indication of a successful lumbar sympathetic block is a two-three degree Celcius rise in the temperature of the affected limb. The patient might also note that the skin of the extremity on the injected side will become flushed as a result of blood vessel dilation.

Complications

The most common complications include bleeding, bruising, swelling, and soreness at the site of injection. This is usually self-limited and resolves within hours to days of having the procedure. Some patients have also reported dizziness, headache, and transient numbness, and weakness of the leg on the side that was injected.[24][25][26][27] More serious complications include infection, visceral injury, intravascular injection, intralymphatic injection, ureter injury, kidney injury, Horner's syndrome, an allergic reaction to the medication, although these occurrences are exceedingly rare.[28][29][30][31][32][33][34]. Anterior thigh pain, presumably from damage to the genitofemoral nerve and lateral femoral cutaneous nerve, may occur in some patients.[24][35]

Clinical Significance

Overall, the lumbar sympathetic block is a safe and effective procedure that can be used to alleviate pain in the appropriate patient population. This includes people with vascular insufficiency of the lower extremities, complex regional pain syndrome, phantom limb pain, postherpetic neuralgia, and other neuropathic pain syndromes that are refractory to medical management.[36][37]

Enhancing Healthcare Team Outcomes

The nurse and physician performing the procedure must be aware of the most common complications include bleeding, bruising, swelling, and soreness at the site of injection. The agent is usually prepared by the pharmacy; dosing and proper formulation fall to them to perform correctly and discuss any potential adverse effects with the team. The nurse must provide monitoring and report untoward events such as dizziness and transient numbness and weakness of the leg on the side that was injected. More serious complications including infection, intravascular injection, and allergic reaction to the medication may occur and the interprofessional healthcare team should be prepared to work together to respond. [Level 5] The collaboration of the interdisciplinary team helps to ensure good pain-free results and improve outcomes.

Review Questions

• Access free multiple choice questions on this topic.
• Comment on this article.

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Disclosure: Christopher Alexander declares no relevant financial relationships with ineligible companies.

Disclosure: Orlando De Jesus declares no relevant financial relationships with ineligible companies.

Disclosure: Matthew Varacallo declares no relevant financial relationships with ineligible companies.