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Chapter 47: Lumbar Sympathetic Block

Joshua P. Prager

SYMPATHETIC NERVE BLOCKS

Indications

Pain specialists use sympathetic nerve blocks for diagnostic, prognostic, prophylactic, and therapeutic purposes (Table 47-1). Sympathetic nerve blocks have been used to:

TABLE 47-1.Neural blockade as part of integrated pain management
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TABLE 47-1.Neural blockade as part of integrated pain management

Diagnostic blocks

  • Determine source of chronic pain.

  • Determine contribution of sympathetic nervous system to patient’s pain.

  • Differentiate peripheral from central pain.

  • Evaluate the patient’s reaction to treatment.

Prognostic blocks

  • Allow patients to experience pain relief of the nerve block.

  • Can predict the effect of spinal cord stimulation.

Prophylactic blocks

  • Delay onset of postoperative pain.

  • Prevent exacerbation of chronic pain syndromes, such as complex regional pain syndrome, when trauma (such as surgery) is anticipated.

Therapeutic blocks

  • Optimize short-term pain relief.

  • Provide pain relief that permits more effective physical therapy and rehabilitation.

  • Improve peripheral blood flow.

  • Gain patient’s cooperation in addressing physiologic and psychologic aspects of pain.

  • Diagnose sympathetically mediated pain

  • Control pain during surgery

  • Treat pain associated with complex regional pain syndrome (CRPS)

  • Treat herpes zoster infections

  • Treat Raynaud disease

  • Treat phantom limb pain

  • Treat scleroderma

  • Treat cancer pain

Sympathetic nerve blocks are used routinely to provide short-term regional analgesia, and their efficacy for this application is well established. Though the effect of local anesthetics can be prolonged by the addition of epinephrine, any resulting analgesia eventually diminishes. Thus, even successful therapeutic blockade is not curative. In the context of interdisciplinary pain management, however, sympathetic blocks can be used to facilitate rehabilitation in patients with chronic noncancer pain.

Although the popularity of sympathetic blocks has generally decreased, mainly due to the scarcity of evidence from randomized controlled trials, the procedure continues to be valuable in treating CRPS. An interdisciplinary treatment protocol for CRPS, developed under the aegis of the International Association for the Study of Pain, positions sympathetic blocks early to support physical rehabilitation (Figure 47-1). If blockade is not sustained or progressively longer with each injection, sympathetic blockade should be abandoned and a trial of spinal cord stimulation (SCS) initiated. Among the advantages of sympathetic blocks and SCS are that both are minimally invasive and neither involves neuroablation.

Figure 47-1.

Multidisciplinary care continuum for complex regional pain syndrome. This algorithm was developed by the International Association for the Study of Pain for the multidisciplinary treatment of complex regional pain syndrome. It emphasizes functional rehabilitation utilizing various forms of progressive physical therapy, with adjuvant interventional pain management techniques, including neuromodulation and behavioral therapy. (Adapted from Stanton-Hicks, et al. Pain Pract. 2002;2:1-16.)

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  • Sympathetically maintained pain requires a coupling of sympathetic noradrenergic neurons and primary afferent neurons in the periphery of the body.

  • The long-lasting pain relief achieved by temporary sympathetic blockade ...

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