Transcript Lumbar sympathetic block mgmc 1

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
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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.
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.
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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).
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Injection of neurolytics—45–95 % ethanol, 7 %
phenol in water, or 7–10 % phenol in Conray
(iothalamate
meglumine)—at
sympathetic ganglia. (3 ml/segment )
the
lumbar
How do we know it has worked ??
1. Increase in skin temperature (skin
thermocouple)
2. Hyperthermia and anhidrosis
3. Loss of the sympathogalvanic reflex (SCR)
ECG leads in both legs and record changes of
decreased sweat)
4. Reduced pain or absence of pain
5. 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 !!
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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
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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
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• Complications
• Intravascular injection (proximity of the bifurcation of the
common iliac vessels)
• . Epidural or subarachnoid injection (less likely)
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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
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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
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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