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

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

3. 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.

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

5. Contra indications
Anticoagulant therapy
Infection at the site

6. 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

8. 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

9. 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 ??

11. 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

12. 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

14. 1. Radiographic control
Especially in neurolytic
blocks

15. 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.

16. 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 )

17. 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

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

19. Complications

20. 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)

21. 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.

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

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

24. 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

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

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

28. Red triangle

29. Complications

30. 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

31. 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

33. 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-

34. 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 ?

37. 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.

38. 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

39. Thank you all