Lumbar/Pelvic Somatic & Sympathetic Nerve Block

Lumbar Sympathetic Nerve Block

The sympathetic and parasympathetic divisions of the autonomic nervous system have both their advantages and disadvantages.
For example, parasympathetic drugs are often less effective for treating pain than sympathetic drugs, but they can be used to treat conditions such as complex regional pain syndrome and phantom limb pain.

Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) is a chronic pain disorder marked by spontaneous and localized pain that is disproportionately severe or long-lasting compared to the typical pain pattern following comparable tissue trauma.
The sympathetic nervous system (SNS), a component of the autonomic nervous system that regulates the majority of the body's involuntary functions, has been linked to neuropathic, vascular, and visceral pain.
To evaluate the involvement of the SNS in pain transmission, sympathetic ganglia have been the target of local anesthetic blockade.

Relevant Anatomy

White ramus leave the spinal cord in the ventral roots and develop into sympathetic ramus.
These sympathetic ramus then meet at the coccygeal level to form the terminal unpaired node of the sympathetic chain known as the ganglion Impar.
Sympathetic trunk is made up of 20-24 paired and linked ganglionic nodes that meet at the coccygeal level to produce the terminal unpaired node of the sympathetic chain (Impar node)

S1 Foramen

Indications

Visceral, vascular, and neuropathic pain can all be treated with sympathetic blocks.

Hyperhidrosis
Post-traumatic Stress Disorder
Electrical storms
Complex regional pain syndrome
Lower limb painful ischemia
Phantom limb pain
Postherpetic neuralgia secondary to zoster
Cancer pain

Contraindications

Allergy
Infection
Coagulopathy
Patient refusal

Articles on Sympathetic Blocks

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

Spiegel MA, Hingula L, Chen GH, Legler A, Puttanniah V, Gulati A. The Use of L2 and L3 Lumbar Sympathetic Blockade for Cancer-Related Pain, an Experience and Recommendation in the Oncologic Population. Pain Med. 2020 Jan 1;21(1):176-184. doi: 10.1093/pm/pnz142. PMID: 31274168; PMCID: PMC7761528.

"Lumbar Sympathetic Plexus Block as a Treatment for Postamputation Pain: Methodology for a Randomized Controlled Trial"

Zachary L McCormick, MD, Andrew Hendrix, MD, David Dayanim, MD, MS, MHA, Bryan Clay, MD, Amy Kirsling, MPA, Norman Harden, MD, Lumbar Sympathetic Plexus Block as a Treatment for Postamputation Pain: Methodology for a Randomized Controlled Trial, Pain Medicine, Volume 19, Issue 12, December 2018, Pages 2496–2503, https://doi.org/10.1093/pm/pny041

"Spinal afferent nerve endings in visceral organs: recent advances"

Spencer NJ, Zagorodnyuk V, Brookes SJ, Hibberd T. Spinal afferent nerve endings in visceral organs: recent advances. Am J Physiol Gastrointest Liver Physiol. 2016 Dec 1;311(6):G1056-G1063. doi: 10.1152/ajpgi.00319.2016. Epub 2016 Nov 17. PMID: 27856418.

"A visceral pain pathway in the dorsal column of the spinal cord"

Willis WD, Al-Chaer ED, Quast MJ, Westlund KN. A visceral pain pathway in the dorsal column of the spinal cord. Proc Natl Acad Sci U S A. 1999 Jul 6;96(14):7675-9. doi: 10.1073/pnas.96.14.7675. PMID: 10393879; PMCID: PMC33600.

"Lumbar Sympathetic Neurolysis: How to and When to Use?"

Zechlinski JJ, Hieb RA. Lumbar Sympathetic Neurolysis: How to and When to Use? Tech Vasc Interv Radiol. 2016 Jun;19(2):163-8. doi: 10.1053/j.tvir.2016.04.008. Epub 2016 Apr 27. PMID: 27423998.

"Review of Sympathetic Blocks: Anatomy, Sonoanatomy, Evidence, and Techniques"

Baig S, Moon JY, Shankar H. Review of Sympathetic Blocks: Anatomy, Sonoanatomy, Evidence, and Techniques. Reg Anesth Pain Med. 2017 May/Jun;42(3):377-391. doi: 10.1097/AAP.0000000000000591. PMID: 28272291.

References

and Intersting Articles

Alexander CE, De Jesus O, Varacallo M. Lumbar Sympathetic Block. [Updated 2022 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431107/
Doroshenko M, Turkot O, Horn DB. Sympathetic Nerve Block. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557637/
Abramov R. Lumbar sympathetic treatment in the management of lower limb pain. Curr Pain Headache Rep. 2014 Apr;18(4):403. doi: 10.1007/s11916-014-0403-x. PMID: 24643353.
Awal S, Madabushi R, Agarwal A, Singla V. CRPS: Early Lumbar Sympathetic Block is Better Compared to Other Interventions. Pain Physician. 2016 Feb;19(2):E363. PMID: 26815268.

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