Lumbar sympathetic block Dr S. Parthasarathy MD DA DNB PhD FICA , Dip software based statistics

Definition and indications Injection of a local anesthetic or neurolytic in the sympathetic ganglia of the lumbar sympathetic trunk. Vascular Neuropathic Visceral

Indications Peripheral vascular disease- acute Chronic vasospastic conditions: Raynaud’s syndrome, acrocyanosis, livedo reticularis, and sequelae of spinal cord injury or polio. Chronic obliterative arterial diseases: TAO Perioperative: micro-vascular surgery, arteriovenous fistula formation.

Indications Neuropathic pain Reflexive sympathetic dystrophies Urogenic/Pelvic pain Cancer pain Phantom pain Herpes Zoster involving the lower extremities

Contra indications Anticoagulant therapy Infection at the site

Sympathetic chain ?? From T12, it descends to abdominal cavity – anterolateral portion of vertebra Psoas separates somatic and sympathetic Takes and gives off branches to viscera and other plexus Close to aorta

Procedure Experienced anesthetist All resuscitative equipment Prone position: support with a pillow in the mid-abdomen (to eliminate lumbar lordosis). The patient’s arms should be dangling. Relaxed patient Lateral decubitus the flank is supported with a pillow. The side being blocked should be uppermost

Approx 7 cm from midline of spinous process Intercristal line is L4 Perpendiculr to highest point of iliac crest – hit the rib edge go transverse That’s L2 Where do we want to block ??

Introduce the needle at 30 degrees Hit transverse process at 3-4 cm Withdraw go more step cranially Hit the periosteum of the body Turn the bevel and slide anterior

1. Loss-of-resistance technique with 0. 9 % saline or air 1. Loss-of-resistance technique with 0.9 % saline or air. Perforation of the psoas fascia is similar to the sensation experienced when carrying out an epidural

1. Radiographic control Especially in neurolytic blocks

Clinical pearls The lumbar sympathetic trunk lies about twice as deep as the distance between the skin and the transverse process. The distance from the transverse process and the ganglia of the lumbar sympathetic trunk is 3.8–5 cm and is relatively constant. The distance from the skin to the transverse process depends on the anatomy and is rather more variable.

10 ml local anesthetic per needle (in the two- needle or three-needle technique)—e.g., 0.2–0.375 % ropivacaine, 0.25 % bupivacaine (0.25 % levobupivacaine). Injection of neurolytics—45–95 % ethanol, 7 % phenol in water, or 7–10 % phenol in Conray (iothalamate meglumine)—at the lumbar sympathetic ganglia. (3 ml/segment )

How do we know it has worked ?? Increase in skin temperature (skin thermocouple) Hyperthermia and anhidrosis Loss of the sympathogalvanic reflex (SCR) ECG leads in both legs and record changes of decreased sweat) Reduced pain or absence of pain No signs of sensory or motor block

Sweat tests Ninhydrin test – Cobalt blue filter paper test Starch iodine tests

Complications

Common, less common , rare ) Transient motor weakness due to block of the lumbar somatic nerves. Hypotension Intravascular injection (aorta, vena cava) with toxic reactions Epidural or subarachnoid injection Retroperitoneal hemorhage , renal injury, ejaculation problem (bilateral)

Superior hypogastric plexus The superior hypogastric plexus represents the pelvic extension of the abdominal sympathetic nervous system. Its (preganglionic) cells of origin are located chiefly in the lower thoracic and upper two lumbar levels of intermedio lateral column of the spinal cord.

Sup. Hypo is bilateral but can block -- inferior hypo - ?? Celiac plexus Sup. Hypo Inferior hypo

Painful !! Cancer and non-cancer pelvic pain Visceral trauma, bladder, rectal pain erectile dysfunction

Position: prone The L4/5 interspace is identified and bilateral needle entry points are marked 5–7 cm lateral to the midline at that level. With image intensifier guidance, the two needles are inserted to lie anterolateral to the L5/S1 interspace

L4 L5 interspace – 7 cm from the midline Bilateral needles Transverse process Cranial Body – walk off to see in the radiograph Get beyond psoas !!

Image guided Complications Intravascular injection (proximity of the bifurcation of the common iliac vessels) . Epidural or subarachnoid injection (less likely)

Red triangle

Complications

Ganglion of walther The ganglion impar is an irregularly shaped terminal ganglion of the sympathetic chain that is usually located close to the midline. The variably shaped ganglion is approximately 4 mm long. It may be located anywhere from the anterior surface of the sacrococcygeal junction to the lower coccygeal vertebral bodies

Ganglion Impar (Walther Ganglion) Block Injection of a local anesthetic or neurolytic into the region of the most inferior (unpaired) ganglion of the sympathetic trunk, on the ventral side of the sacrococcygeal joint

GIB is indicated for sympathetically mediated pain in the region of the anus, distal part of the rectum, urethra, and vagina. Coccygodynia following trauma, infection, degenerative changes, and subluxation has also been relieved temporarily with this block-

Procedure Prone May be dangling legs Tip of coccyx and anus midpoint Prick and go inside to pierce sacrococcygeal ligament 30 degre angulation needle Enter the ventral surface of the SC joint Inject 8 ml Image guided Beware rectum ?

Complications Rectal perforation with tracking of contaminants back to the rectum. Infection and fistula formation, especially in patients who are immunocompromised or who underwent prior radiation therapy to the perineum. Epidural spread within the caudal canal. Periosteal injection.

Summary Anatomy – sympathetic Indications – vascular, Ne, visceral Position and procedure Tests of block CI – infection and anticoagulants Complications – vascular, somatic nerve blockade, hematoma and viscera injury

Thank you all