LUMBAR SYMPATHETIC BLOCK

 

Anatomy:

The lumbar sympathetic nerves extend from the first to the fifth lumbar vertebrae. The lumbar sympathetic nerves run down either side of the spinal column. These nerves supply sensation of the lower extremities.

 

Preparation for a Lumbar Sympathetic Block:

…       You must not have eaten for at least 6 hours prior to your scheduled appointment.

…       You must be accompanied by a person who can drive you home. You may be given sedation, which alters your driving abilities. You may experience leg weakness after the procedure.

…       The nurse will start an IV and place a blood pressure cuff on you.  Also, EKG leads will be put on your chest.  The nurse will monitor your blood pressure and pulse.  A temperature pad will be placed on your affected foot.

…       You may be given sedation through your IV to help you relax.

…       You will read and sign a consent form for the procedure.

…       You will be positioned on your stomach with a pillow under your abdomen.  This makes the lumbar area easier to reach.

…       You will feel the doctor pressing and marking the landmarks (certain bony areas) on your lower back.

…       The area to be blocked will be cleaned and anesthetized (numbed) before the procedure starts.

 

Indications for a Lumbar Sympathetic Block:

…       Causalgia or other sympathetic dystrophy's.

…       Pain due to peripheral vascular disease.

…       Phantom limb pain.

…       Acute herpes zoster.

…       Post herpetic neuralgia.

 

Benefits:

…       Pain relief and improved healing of skin lesions.

…       Improved blood flow to lower extremities.

 

Possible Risks:

Lumbar sympathetic blocks can be safely done as an outpatient at the Pain Control Center. There is a potential risk of complications.  However, with this block these are rare. They include puncture of blood vessel, seizures, backache, headache, neuralgia, chronic back pain, temporary spinal block or disc perforation.  Although the complications are rare, there are experienced doctors and nurses close at hand to handle these problems.

 

Frequency of Treatment:

Lumbar sympathetic blocks are usually repeated at 2 to4 week intervals.  A series of 4-6 blocks is the average number done to obtain prolonged relief.

 

What to Expect after a Block:

…       You will feel increased warmth due to increased blood flow to the lower extremities.

…       You may feel some numbness and tingling in the affected extremity, as well as leg weakness. These symptoms usually go away in 4-6 hours.

…       There may be some backache from needle insertion. This can usually be relieved by sleeping on a heating pad and one or two Tylenol tablets, or using ice on this area.

…       The desired effect is a decrease in your pain. You will need to tell your doctor if the pain stops, slows down or in any way changes and how long this lasted.

 

Frequently Asked Questions

 

What is a Lumbar Sympathetic Block?

Lumbar Sympathetic Block is an injection of local anesthetic in the "sympathetic nerve tissue" ñ the nerves which are a part of Sympathetic Nervous System. The nerves are located on the either side of spine, in the back.

 

What is the purpose of it?

The injection blocks the Sympathetic Nerves. This may in turn reduce pain, swelling, color, and sweating changes in the lower extremity and may improve mobility. It is done as a part of the treatment of Reflex Sympathetic Dystrophy (RSD), Sympathetic Maintained Pain, Complex Regional Pain Syndrome, and Herpes Zoster (shingles) involving lower extremity.

 

How long does the injection take?

The actual procedure may take only 15 to 20 minutes. Nevertheless, you need to allow sufficient time for the legal paperwork, the pre-procedure nursing assessment, the procedure preparation, as well as the recovery period. On the average, you should plan to spend 2 to 3 hours in the facility.

 

What is actually injected?

The injection consists of a local anesthetic (like lidocaine or bupivacaine). Epinephrine (adrenaline) or Clonidine may be added to prolong the effects of the injection. Occasionally steroids are also injected.

 

Will the injection hurt?

The procedure involves inserting a needle through skin and deeper tissues (like a "tetanus shot"). So, there is some discomfort involved. However, we may numb the skin and deeper tissues with a local anesthetic using a very thin needle before inserting the actual block needle. Most of the patients also receive intravenous sedation and analgesia, which makes the procedure easy to tolerate.

 

Will I be "put out" for this procedure?

No. This procedure is done under local anesthesia. If you feel extremely nervous about this procedure, an IV may be placed to give a medication to help you relax. However, physicians frequently try to limit the amount of medication you receive so that you may go home as soon as possible. Let your doctor know how you feel; extra time must be allowed for patients who receive IV medications, sometimes referred to as "conscious sedation." For "conscious sedation" many doctors use Versed, a fast-acting anti-anxiety medication that helps patients relax, yet remain awake. Patients frequently report partial amnesia (memory loss) regarding the procedure, but do not feel drugged or high afterward. All patients receiving Versed are monitored closely, because the drug can cause a serious drop in blood pressure, heart rate, and breathing in some individuals. Putting a patient to sleep, or even oversedating the patient, may be unsafe, since you loose the ability to monitor correct needle placement, risking the possibility of permanent nerve damage.

 

How is the injection performed?

At the time of your injection, you will be asked to put on a patient gown (opened towards the back), and sign a consent form. Your blood pressure, pulse rate and respiration will also be checked. You will be asked what medications you are presently taking and if you have any allergies to medication. Depending on your pain location and the facet joints to be treated, you will be positioned on your stomach with a pillow under your. Your blood pressure and heart rate will be constantly monitored. Prior to the procedure, your back will be cleansed with antiseptic solution and the physician will numb the area around the injection. A burning sensation lasting 2-3 seconds is to be expected. You may receive a small dose of Valium, or a similar agent, to help you relax. After that, your doctor will position a special needle into the facet joint. During placement of the needle, you can expect to momentarily feel your usual pain, which lets the doctor know the needle is positioned correctly. He/she will then inject the medication slowly. You can expect to feel pressure, but usually not much discomfort, during the injection. Lumbar sympathetic blocks are performed using a C-arm fluoroscope (X-Ray machine) to direct needles through the skin and muscles of the back to the path of the sympathetic nerves. At that point, we will inject the local anesthetic (like lidocaine or bupivacaine). Epinephrine (adrenaline) or Clonidine may be added to prolong the effects of the injection. Occasionally steroids are also injected. The Lumbar Sympathetic Block is temporary, since the medication is eventually absorbed into the body. After your injection, you will return to the recovery room for a 30-45 minute observation period. It is important that you have someone to drive you home afterward. In the follow-up visit the physician will inquire about the level of pain relief obtained from the procedure.

 

What should I expect after the injection?

Immediately after the injection, you may feel your lower extremity getting warm. In addition, immediately after the injection, you may feel that your pain may be gone or significantly reduced. You may also notice some weakness and/or numbness in the leg ñ which is temporary. This is due to the local anesthetic injected. This will last 4 to 6 hours. Leg numbness and weakness is rather common after the procedure. This should be self limiting and should wear off in 4 to 6 hours. Your pain will return and may actually feel worse than usual for 5 to 6 days. This is due to the mechanical process of needle insertion as well as initial irritation form the steroid itself. You should start noticing pain relief starting the 5th day or so. This is how long it takes for the steroids (if injected), to bring the swelling down to a point where the patient will be able to tell a difference.

 

What should I do after the procedure?

You should have a ride home. Do not plan on doing anything else for the rest of the day. You should not drive, since you may be under the influence of sedatives (drunk, for all practical purposes). You should avoid making any important decisions, since you may regret them later, as the sedation wears off. We advise the patients to take it easy for a day or so after the procedure. You may feel great, but we advise you against doing things that you were not been able to do while in pain. Remember that this feeling of wellbeing may be secondary to the sedation and the effects of the local anesthetics (numbing medicine), both of which will wear off. Remember to apply ice to the affected area, 15 minutes on and 15 minutes off. Remember to wrap the ice with a towel, to prevent burning the skin. Perform the activities as tolerated by you. Use common sense. Some of the patients may go for immediate physical therapy.

 

Can I go to work to work the next day?

Unless there are complications, you should be able to return to your work the next day. The most common thing you may feel is soreness in the neck at the injection site.

 

How long the effect of the medication lasts?

The local anesthetic wears off in a few hours. However, the blockade of sympathetic nerves may last for many more hours. Usually, the duration of relief gets longer after each injection.

 

How many injections do I need to have?

Possibilities include:

…       If the first injection does not relieve your symptoms in about a week to two weeks, you may be recommended to have one more injection. This is occasionally done, just to make sure that the lack of response was not secondary to a technical difficulty during the procedure (i.e. distorted anatomy secondary to prior surgeries).

…       If your response to the procedure is beneficial, but still have residual pain, you may be recommended to have one more injection. As long as you keep improving with each procedure.

…       If your pain completely goes away and does not seem to be returning, then there is no need for further treatments.

…       If you get excellent results, but they just do not last, we may recommend changing techniques (i.e. radiofrequency).

…       Usually, a series of such injections is needed to treat the problem. Some may need only 2 to 4 and some may need more that 10. The response to such injections varies from patient to patient.

 

Will the Lumbar Sympathetic Block help me?

It is very difficult to predict if the injection(s) will indeed help you or not. The patients who present early during their illness tend to respond better than those who have this treatment after about six months of symptoms do. Patients in the advanced stages of disease may not respond adequately. Remember that above all, this is a diagnostic procedure meant to help us find the cause of your pain. Even a procedure that does not provide you with relief of the pain, it will provide your physician with invaluable information about the mechanism of your pain, ultimately putting us one step closer to the solution of the problem.

 

What are the risks and side effects?

This procedure is relatively safe. However, with any procedure there are risks, side effects, and possibility of complications. The most common side effect is pain ñ which is temporary. The other risk involves bleeding, infection, spinal block, epidural block, and injection into blood vessels and surrounding organs. Fortunately, the serious side effects and complications are uncommon.

 

Who should not have this injection?

If you are allergic to any of the medications to be injected, if you are on blood thinning medications (e.g. CoumadinÆ, PlavixÆ, TiclidÆ), or if you have an active infection going on near the injection site, you should not have the injection.

 

What should I expect after the procedure?

You will be given specific instructions to take home. Most patients having a facet injection are pain-free on discharge. For some patients, the pain relief can be long-term; however, it is unusual for one block to completely relieve pain for a long period of time. Keep a pain diary between appointments so that your doctor can work with you more effectively. Your physician will need specific information about your response to treatment so that he can determine whether additional facet injections will help you. Help yourself by following instructions about medications, exercise, relaxation techniques, and sleep aids.

 

Remember
As with everything in medicine, results can vary; you may have complete pain relief, partial relief, or no change in your pain level after the facet block. As in all invasive procedures, there is a small chance of infection or bleeding. Numbness and /or loss of feeling in the back or extremities can last for several hours. Your physician will discuss the risks and benefits of facet blocks with you prior to treatment