- Email: [email protected]
Percutaneous radiofrequency lumbar sympathectomy
Percutaneous Radiofrequency Lumbar Sympathectomy John W. Nelson, MD
Lumbar sympathectomy has been employed for over 75 years for the treatment of a variety of painful and circulatory conditions in the lower extremities. Chemical sympathectomy decreased the need for open surgical sympathectomy with less morbidity and mortality but still has risks and complications that can be catastrophic. The development of precise neurolysis with radiofrequency lesioning significantly decreased the risks of sympathectomy with results comparable to chemical and surgical neuroablation. Radiofrequency sympathectomy also allows repeat procedures without the risk of distorting the original anatomy. © 2004 Elsevier Inc. All rights reserved.
he history of lumbar sympathectomy dates back to the early 20th century when Norman Dawson Royle and John Irvine Hunter in Sydney, Australia explored the relationship between the function of the sympathetic nerves and the clinical phenomenon observed in spastic paralysis. On September 1, 1923 via a posterior lateral approach, they performed a sympathetic denervation on a 30-year-old World War I veteran with spastic paralysis of the lower extremities following a gunshot wound to the head. The results were satisfactory. The results of the “lumbar ramisection” in 42 patients with spastic paralysis were reported at the Clinical Congress of the American College of Surgeons in New York in 1924. Before that meeting, William Mayo had visited Sydney, Australia in 1924 and heard details of the procedure as well as the observation of vascular changes noticed in the skin of the leg on the side of the lumbar sympathectomy. These observations of vasomotor changes and capillary dilation were passed on by William Mayo to Arthur Adson and George Brown at the Mayo Clinic, who explored the potential of sympathectomy in the treatment of vasospastic disorders of the lower limb. They measured a 5- to 8-fold increase in skin and subcutaneous tissue blood flow in the limb following sympathectomy and performed a lumbar sympathectomy on March 19, 1925 on a 16-year-old girl with Raynaud’s phenomenon (with intractable pain and ulcers) with striking success. Independent of Adson and Brown’s work and preceding them was the work of Jules Diez in Buenos Aires, Argentina, who had performed lumbar sympathectomy for peripheral vascular disease. His first two patients had thrombangiitis obliterans and underwent surgery on July 24, 1924 with dramatic results. As the technique spread, it was used to treat complex regional pain syndromes, frostbite, herpes zoster, hyperhidrosis, renal colic, phantom limb pain, and trench foot. Lindenauer and Cronen-
T
Address reprint requests to John W. Nelson, MD, 1625 Medical Center Point, Suite 240, Colorado Springs, CO 80907-5798. Email: [email protected]. © 2004 Elsevier Inc. All rights reserved. 1084-208X/04/0801-0010$30.00/0 doi:10.1053/j.trap.2003.11.010
wett in a literature review in 1982 quoted a 6.5% mortality with open sympathectomy. Complications included infection, bleeding, neuralgia, ejaculatory dysfunction, sympathalgia, or “overshoot syndrome” with the limb becoming too dry, edematous and painful. Incomplete sympathectomy could be blamed on poor technique, crossover of sympathetic fibers from the contralateral side, centralization of pain, and in some complex regional pain syndromes (with involvement of the foot and ankle), failure to denervate the sympathetic chain at L4 and L5 (the surgeon avoided dissection at these levels because of increased vascularity). Paralysis has been reported due to injury of the lumbar radicular arteries or artery of Adamkiewicz, with subsequent infarction of the spinal cord. Percutaneous neurolytic blockade of the lumbar sympathetic chain was first performed with alcohol by White in 1935, reported by Mandel in 1947, and improved by Reid with the addition of X-ray control in 1970. CT guidance has also been used, as has phenol, as a neurolytic agent. The results seem to be comparable to open techniques with less mortality, especially in patients with coexisting cerebrovascular and cardiopulmonary disease. Complications have included ureteral and kidney injury, genitofemoral neuritis (6-40%), lumbar plexus injury with leg numbness and weakness, ejaculatory dysfunction (from bilateral spread of neurolytic agents), chylous pleural effusion, infection, bleeding, paralysis (from spinal canal injection or spasm/injury to lumbar radicular arteries or the artery of Adamkiewicz), Horner’s syndrome, retroperitoneal hematoma, lymphatic injection, necrosis of the psoas muscle, postdural puncture headache, and disc injection/infection. One of the detractors of percutaneous neurolytic lumbar sympathectomy has been scarring and vascularization of the tissue plains around the sympathetic chain, such that the need to perform repeat neurolytic injections may be more hazardous due to altered anatomy. Injury to radicular arteries with sharp needles or even with nonvascular injections of neurolytic agents may put the patient at risk for ischemic injury to the spinal cord. Although rare, such a disastrous complication (especially in a patient with nonmalignant pain) is terribly tragic. The development of percutaneous radiofrequency lumbar sympathectomy with blunt, curved needles significantly decreased the incidence and risk of complications. The procedure requires proper patient selection based on the efficacy of diagnostic lumbar sympathetic blocks, patient education, informed consent, and absence of contraindications, such as local, systemic, or retroperitoneal infection, coagulopathy, severe allergy to contrast agent, and lack of patient cooperation. Radiographic imaging is mandatory and mild sedation often necessary, but the patient must be alert and cooperative to assess response to sensory and motor stimulation and pain with thermal lesions. Bilateral lumbar sympathectomy in males is probably not advisable due to the risk of sexual dysfunction, and spinal cord stimulation may be a better option for patients with more diffuse disease.
Techniques in Regional Anesthesia and Pain Management, Vol 8, No 1 (January), 2004: pp 53-56
53
Fig 1. Anatomy of lumbar sympathetic chain.
Fig 3. Lateral view of radiofrequency electrode at L2 to 4 sympathetics. (Courtesy of Dr. Way Yin)
Technique A thorough understanding of the relevant anatomy and imaging techniques is required (Fig 1). The sympathetic ganglia may be variable in number, location, and size and often there are no ganglia at L1. The ganglia are not visible with X-ray or CT (even with contrast) so the procedure is more accurately a denervation of the sympathetic chain rather than specific ganglia. Anatomical studies tend to show the L2 ganglion at the caudal one-fourth of the vertebral body near the anterior border, the L3 ganglion a mirror image at the cephlad one-fourth of L3, and L4 and L5 variable (Fig 5). Their location in relation to the anterior vertebral body on lateral fluoroscopic view may vary and the one absolute certainty is that they are ventral to the psoas muscle, so contrast injection is important to prove that the active electrode tip is ventral to the psoas. For peripheral vascular disease and complex regional pain syndromes, the author targets the sympathetic chain at L2, L3, and L4. For patients with complex regional pain syndrome involving the foot and ankle pain, L5 is also targeted.
The patient is placed in a prone position with intravenous access and appropriate monitoring with blood pressure, EKG, and pulse oxymetry. Resuscitative equipment must be immediately available. The patient should be NPO for 8 hours and mild sedation is given as needed. The lumbar spine is prepped with disinfectant with sterile towels and drapes applied and the injectionist adheres to meticulous sterile technique. The correct side to be lesioned is reconfirmed and the consent form is checked before any sedation is given. For each level, the C-arm is rotated cephalocaudad to square off the end plate of the disc space above the targeted level, ie, the L1 to 2 end plate for the L2 needle placement. The C-arm is rotated to the ipsilateral side with an increasing oblique view until the tip of the transverse process becomes flush with the lateral vertebral body thus eliminating the transverse process as an obstacle to radiofrequency needle placement. The skin and subcutaneous tissues are infiltrated with 1% lidocaine and a 16-gauge introducer needle and plastic cannula are inserted
Fig 2. Oblique view of radiofrequency electrode at L2 to 4 sympathetics. (Courtesy of Dr. Way Yin)
Fig 4. Anterior–posterior view of radiofrequency electrodes at L2 to 4 sympathetics. (Courtesy of Dr. Way Yin)
54
J. W. NELSON
electrode back before creating a second lesion, as you may pull the active tip into the psoas muscle or adjacent to the genitofemoral nerve. When completed, sterile dressings are applied and the patient is monitored for any complications. One should document the patient’s neurovascular status before and after the procedure and discharge with appropriate instructions, including the ability of the patient to reach you to discuss any problems or concerns. Keep hard copy images of the needle and probe placements, dye spread, stimulation and lesion parameters, and all drugs used. The advantages of percutaneous radiofrequency lumbar sympathectomy are: 1. The lesion is controllable, discreet, and can be repeated without the potential risk of liquid neurolytic agents. 2. Less hypotension then other sympatholytic techniques. 3. Risk of visceral, ureteral, or neurovascular injury are rare with the blunt needle. 4. Less overshoot sympathectomy or sympathalgia. 5. Duration of sympathectomy similar to surgical and chemical sympathectomy. One is able to target the L4 and L5 sympathetic chain if needed with a blunt needle (even in a vascular area). 6. Incidence of genitofemoral neuralgia should be minimal with appropriate stimulation guidelines and technique. Fig 5. Lesion zones for L2 to 4 sympathetics.
parallel to the X-ray beam (using “tunnel vision”) for 1-2 inches, depending on the patient’s size. A 15-cm, 22-gauge, Racz-Finch blunt, curved radiofrequency needle (Radionics) with a 10- to 15-mm active tip is slowly advanced under tunnel vision until the tip is hugging bone at the anterior border of the vertebral body as seen on lateral view, and at the level of the facet joint on an anterior posterior view. Often one will feel a pop as the blunt needle goes through the psoas fascia. The blunt needle markedly decreases the risk of injury to neurovascular structures and the curved tip allows one to “steer” the needle optimizing placement at the bottom one-fourth of L2 and the upper one-fourth of L3, with the curved tip rotated medially, hugging the vertebral body at its anterior border. After negative aspiration, 1-2 mL of myelographic safe dye, such as Omnipaque 180 or 240 or Isovue M300, is injected to document absence of psoas or vascular spread and appropriate prevertebral spread on AP and lateral view. After all the radiofrequency needles have been placed (see Figs 2, 3 and 4) stimulation is then performed at 50 Hz for sensory and 2 Hz for motor stimulation. Some practitioners feel one must reproduce the patient’s pain at low-level sensory stimulation (less then 0.5 V), while others use stimulation at 1-1.5 V to document absence of stimulation of the ventral root, lumbar plexus, or genitofemoral nerve before creating a thermal lesion. Stimulation is done at each level before the injection of local anesthetic (1 mL to 2% preservative-free lidocaine). After replacing the radiofrequency probe, the position on lateral view is rechecked to be sure the needle has not moved with the injection of the local anesthetic. If the impedance is greater than 300 OHMS, an additional 1-2 mL of local anesthetic or saline may be injected to decrease the impedance. A lesion is then made at each level at 80-85°C for 60 seconds with the patient alert and cooperative. If there is any pain radiating to the groin, thigh, or leg, the lesion is discontinued. The advantage of the curved tip is that two additional lesions can be made by rotating the tip cephlad and then caudad to increase the size of the lesion. It is inadvisable to pull the PERCUTANEOUS RADIOFREQUENCY LUMBAR SYMPATHECTOMY
References 1. Adson AW, Brown GE: The treatment of Raynaud’s disease by resection of the upper thoracic and lumbar sympathetic ganglia and trunks. Surg Gynecol Obstet 48:577-603, 1929 2. Adson AW, Craig WM, Brown GE: Essential hyperhidrosis cured by sympathetic ganglionectomy and trunk resection. Arch Surg 31:793806, 1935 3. Dondelinger R, Kurdziel JC: Percutaneous phenol neurolysis of the lumbar sympathetic chain with computed tomography control. Ann Radiol 27:376-379, 1984 4. Haxton HA: Chemical sympathectomy. Br Med J 1:1026-1028, 1949 5. Koikkalainen K, Luosto R, Jokinin T: Lumbar sympathectomy in the treatment of severe lower limb ischaemia in old people. Ann Chirur Gynecol 69:92-96, 1980 6. Lindenauer SM, Cronenwett JL: What is the place of lumbar sympathectomy? Br J Surg 29:532-533, 1982 7. Moore PJ: Chemical and operative lumbar sympathectomy. Br J Clin Pract 35:283-284and 237, 1981 8. Patman D: Sympathectomy in the treatment of chronic venous leg ulcers. Arch Surg 117:1561-1565, 1982 9. Quayle JB: Sexual function after bilateral lumbar sympathectomy and aorto-iliac by-pass surgery. J Cardiovasc Surg 21:215-218, 1980 10. Reid W, Watt JK, Gray TG: Phenol injection of sympathetic chain. Br J Surg 57:45-50, 1970 11. Royle ND: The treatment of spastic paralysis by sympathetic ramisection. Experimental bases and clinical results. Surg Gynecol Obstet 39:701, 1924 12. Walker PM, Key JA, MacKay IM, et al: Phenol sympathectomy for vascular occlusive disease. Surg Gyn Obstet 146:741-744, 1978 13. Wilkinson HA: Radiofrequency percutaneous upper thoracic sympathectomy. N Engl J Med 311:34-36, 1984 14. Zagzag D, Fields S, Romanoff H, et al: Percutaneous 15. Adson AW, Brown GE: Treatment of Raynaud’s disease by lumbar ramisection and ganglionectomy and perivascular sympathectneurectomy of the common iliacs. JAMA 84:1908, 1925 16. Brown GE, Adson AW: Calorimetric studies of extremities following lumbar sympathetic ramisection and ganglionectomy. Am J Med Sci 170:232, 1925 17. Diez J: Un nuero metodo de simpatrectomia perifrica para el tratamiento de las afeccioners troficas y gangrenosas de los miembros: La disociacin fascicular. Bol Soc Cir B Aires 8:792, 1924 18. Royle ND: New operative procedure in treatment of spastic paralysis and its experimental basis. Med J Aust 1:77, 1924
55
19. Royle ND: Operations of sympathetic ramisection. Med J Aust 1:587, 1924 20. Royle ND: New operative procedure in the treatment of spastic paralysis and its experimental basis. Med J Aust 1:77-86, 1924 21. Ewing M: The history of lumbar sympathectomy. Surgery 70:790796, 1971 22. Mandl F: Die Paravertebrale Injections. Vienna, Springer Verlag, 1926 23. Barnes RW, Baker WH, Shanik G, et al: Value of concomitant sympathectomy in aortoiliac reconstruction: Results of a prospective, randomized study. Arch Surg 112:1325-1330, 1977 24. Haimovici H, Steinman C, Karson IH: Evaluation of lumbar sympathectomy, advanced occlusive arterial disease. Arch Surg 89:10891095, 1964 25. Kim GE, Ibrahim IM, Imparato A: Lumbar sympathectomy in end stage arterial occlusive disease. Am Surg 183:157-160, 1976 26. Reid W, Watt JK, Gray TG: Phenol injection of the sympathetic chain. Br J Surg 57:45, 1970
56
27. Janoff KA, Phinney ES, Porter JM: Lumbar sympathectomy for lower extremity vasospasm. Am J Surg V 150:147-152, 1985 28. Boas R, Hatangdi V, Richards E: Lumbar sympathectomy: A percutaneous chemical technique. Adv Pain Res Ther 1:685-689, 1976 29. Smith C, Davidson N, Ruckley C: Hazard of chemical sympathectomy. Br Med J 1:552-553, 1978 30. Artuso J, Stevens R, Lineberry P: Post dural puncture headache after lumbar sympathetic block: A report of two cases. Reg Anesth 16: 288-291, 1991 31. Kumarov I, MacIssac S, Sioufi J: Latrogenic ureteral injury secondary to lumbar sympathetic ganglion blockade. Urology 16:617-619, 1980 32. Haynsworth R, Noe C, Fassy L: Intralymphatic injection: Another complication of lumbar sympathetic block. Anesthesiology 80:460462, 1994 33. Collucci J, Derasari M, Kirkpatrick A: Complications of blinded lumbar sympathetic blocks. Reg Anesth 17:114-115, 1992
J. W. NELSON
Lumbar sympathectomy has been employed for over 75 years for the treatment of a variety of painful and circulatory conditions in the lower extremities. Chemical sympathectomy decreased the need for open surgical sympathectomy with less morbidity and mortality but still has risks and complications that can be catastrophic. The development of precise neurolysis with radiofrequency lesioning significantly decreased the risks of sympathectomy with results comparable to chemical and surgical neuroablation. Radiofrequency sympathectomy also allows repeat procedures without the risk of distorting the original anatomy. © 2004 Elsevier Inc. All rights reserved.
he history of lumbar sympathectomy dates back to the early 20th century when Norman Dawson Royle and John Irvine Hunter in Sydney, Australia explored the relationship between the function of the sympathetic nerves and the clinical phenomenon observed in spastic paralysis. On September 1, 1923 via a posterior lateral approach, they performed a sympathetic denervation on a 30-year-old World War I veteran with spastic paralysis of the lower extremities following a gunshot wound to the head. The results were satisfactory. The results of the “lumbar ramisection” in 42 patients with spastic paralysis were reported at the Clinical Congress of the American College of Surgeons in New York in 1924. Before that meeting, William Mayo had visited Sydney, Australia in 1924 and heard details of the procedure as well as the observation of vascular changes noticed in the skin of the leg on the side of the lumbar sympathectomy. These observations of vasomotor changes and capillary dilation were passed on by William Mayo to Arthur Adson and George Brown at the Mayo Clinic, who explored the potential of sympathectomy in the treatment of vasospastic disorders of the lower limb. They measured a 5- to 8-fold increase in skin and subcutaneous tissue blood flow in the limb following sympathectomy and performed a lumbar sympathectomy on March 19, 1925 on a 16-year-old girl with Raynaud’s phenomenon (with intractable pain and ulcers) with striking success. Independent of Adson and Brown’s work and preceding them was the work of Jules Diez in Buenos Aires, Argentina, who had performed lumbar sympathectomy for peripheral vascular disease. His first two patients had thrombangiitis obliterans and underwent surgery on July 24, 1924 with dramatic results. As the technique spread, it was used to treat complex regional pain syndromes, frostbite, herpes zoster, hyperhidrosis, renal colic, phantom limb pain, and trench foot. Lindenauer and Cronen-
T
Address reprint requests to John W. Nelson, MD, 1625 Medical Center Point, Suite 240, Colorado Springs, CO 80907-5798. Email: [email protected]. © 2004 Elsevier Inc. All rights reserved. 1084-208X/04/0801-0010$30.00/0 doi:10.1053/j.trap.2003.11.010
wett in a literature review in 1982 quoted a 6.5% mortality with open sympathectomy. Complications included infection, bleeding, neuralgia, ejaculatory dysfunction, sympathalgia, or “overshoot syndrome” with the limb becoming too dry, edematous and painful. Incomplete sympathectomy could be blamed on poor technique, crossover of sympathetic fibers from the contralateral side, centralization of pain, and in some complex regional pain syndromes (with involvement of the foot and ankle), failure to denervate the sympathetic chain at L4 and L5 (the surgeon avoided dissection at these levels because of increased vascularity). Paralysis has been reported due to injury of the lumbar radicular arteries or artery of Adamkiewicz, with subsequent infarction of the spinal cord. Percutaneous neurolytic blockade of the lumbar sympathetic chain was first performed with alcohol by White in 1935, reported by Mandel in 1947, and improved by Reid with the addition of X-ray control in 1970. CT guidance has also been used, as has phenol, as a neurolytic agent. The results seem to be comparable to open techniques with less mortality, especially in patients with coexisting cerebrovascular and cardiopulmonary disease. Complications have included ureteral and kidney injury, genitofemoral neuritis (6-40%), lumbar plexus injury with leg numbness and weakness, ejaculatory dysfunction (from bilateral spread of neurolytic agents), chylous pleural effusion, infection, bleeding, paralysis (from spinal canal injection or spasm/injury to lumbar radicular arteries or the artery of Adamkiewicz), Horner’s syndrome, retroperitoneal hematoma, lymphatic injection, necrosis of the psoas muscle, postdural puncture headache, and disc injection/infection. One of the detractors of percutaneous neurolytic lumbar sympathectomy has been scarring and vascularization of the tissue plains around the sympathetic chain, such that the need to perform repeat neurolytic injections may be more hazardous due to altered anatomy. Injury to radicular arteries with sharp needles or even with nonvascular injections of neurolytic agents may put the patient at risk for ischemic injury to the spinal cord. Although rare, such a disastrous complication (especially in a patient with nonmalignant pain) is terribly tragic. The development of percutaneous radiofrequency lumbar sympathectomy with blunt, curved needles significantly decreased the incidence and risk of complications. The procedure requires proper patient selection based on the efficacy of diagnostic lumbar sympathetic blocks, patient education, informed consent, and absence of contraindications, such as local, systemic, or retroperitoneal infection, coagulopathy, severe allergy to contrast agent, and lack of patient cooperation. Radiographic imaging is mandatory and mild sedation often necessary, but the patient must be alert and cooperative to assess response to sensory and motor stimulation and pain with thermal lesions. Bilateral lumbar sympathectomy in males is probably not advisable due to the risk of sexual dysfunction, and spinal cord stimulation may be a better option for patients with more diffuse disease.
Techniques in Regional Anesthesia and Pain Management, Vol 8, No 1 (January), 2004: pp 53-56
53
Fig 1. Anatomy of lumbar sympathetic chain.
Fig 3. Lateral view of radiofrequency electrode at L2 to 4 sympathetics. (Courtesy of Dr. Way Yin)
Technique A thorough understanding of the relevant anatomy and imaging techniques is required (Fig 1). The sympathetic ganglia may be variable in number, location, and size and often there are no ganglia at L1. The ganglia are not visible with X-ray or CT (even with contrast) so the procedure is more accurately a denervation of the sympathetic chain rather than specific ganglia. Anatomical studies tend to show the L2 ganglion at the caudal one-fourth of the vertebral body near the anterior border, the L3 ganglion a mirror image at the cephlad one-fourth of L3, and L4 and L5 variable (Fig 5). Their location in relation to the anterior vertebral body on lateral fluoroscopic view may vary and the one absolute certainty is that they are ventral to the psoas muscle, so contrast injection is important to prove that the active electrode tip is ventral to the psoas. For peripheral vascular disease and complex regional pain syndromes, the author targets the sympathetic chain at L2, L3, and L4. For patients with complex regional pain syndrome involving the foot and ankle pain, L5 is also targeted.
The patient is placed in a prone position with intravenous access and appropriate monitoring with blood pressure, EKG, and pulse oxymetry. Resuscitative equipment must be immediately available. The patient should be NPO for 8 hours and mild sedation is given as needed. The lumbar spine is prepped with disinfectant with sterile towels and drapes applied and the injectionist adheres to meticulous sterile technique. The correct side to be lesioned is reconfirmed and the consent form is checked before any sedation is given. For each level, the C-arm is rotated cephalocaudad to square off the end plate of the disc space above the targeted level, ie, the L1 to 2 end plate for the L2 needle placement. The C-arm is rotated to the ipsilateral side with an increasing oblique view until the tip of the transverse process becomes flush with the lateral vertebral body thus eliminating the transverse process as an obstacle to radiofrequency needle placement. The skin and subcutaneous tissues are infiltrated with 1% lidocaine and a 16-gauge introducer needle and plastic cannula are inserted
Fig 2. Oblique view of radiofrequency electrode at L2 to 4 sympathetics. (Courtesy of Dr. Way Yin)
Fig 4. Anterior–posterior view of radiofrequency electrodes at L2 to 4 sympathetics. (Courtesy of Dr. Way Yin)
54
J. W. NELSON
electrode back before creating a second lesion, as you may pull the active tip into the psoas muscle or adjacent to the genitofemoral nerve. When completed, sterile dressings are applied and the patient is monitored for any complications. One should document the patient’s neurovascular status before and after the procedure and discharge with appropriate instructions, including the ability of the patient to reach you to discuss any problems or concerns. Keep hard copy images of the needle and probe placements, dye spread, stimulation and lesion parameters, and all drugs used. The advantages of percutaneous radiofrequency lumbar sympathectomy are: 1. The lesion is controllable, discreet, and can be repeated without the potential risk of liquid neurolytic agents. 2. Less hypotension then other sympatholytic techniques. 3. Risk of visceral, ureteral, or neurovascular injury are rare with the blunt needle. 4. Less overshoot sympathectomy or sympathalgia. 5. Duration of sympathectomy similar to surgical and chemical sympathectomy. One is able to target the L4 and L5 sympathetic chain if needed with a blunt needle (even in a vascular area). 6. Incidence of genitofemoral neuralgia should be minimal with appropriate stimulation guidelines and technique. Fig 5. Lesion zones for L2 to 4 sympathetics.
parallel to the X-ray beam (using “tunnel vision”) for 1-2 inches, depending on the patient’s size. A 15-cm, 22-gauge, Racz-Finch blunt, curved radiofrequency needle (Radionics) with a 10- to 15-mm active tip is slowly advanced under tunnel vision until the tip is hugging bone at the anterior border of the vertebral body as seen on lateral view, and at the level of the facet joint on an anterior posterior view. Often one will feel a pop as the blunt needle goes through the psoas fascia. The blunt needle markedly decreases the risk of injury to neurovascular structures and the curved tip allows one to “steer” the needle optimizing placement at the bottom one-fourth of L2 and the upper one-fourth of L3, with the curved tip rotated medially, hugging the vertebral body at its anterior border. After negative aspiration, 1-2 mL of myelographic safe dye, such as Omnipaque 180 or 240 or Isovue M300, is injected to document absence of psoas or vascular spread and appropriate prevertebral spread on AP and lateral view. After all the radiofrequency needles have been placed (see Figs 2, 3 and 4) stimulation is then performed at 50 Hz for sensory and 2 Hz for motor stimulation. Some practitioners feel one must reproduce the patient’s pain at low-level sensory stimulation (less then 0.5 V), while others use stimulation at 1-1.5 V to document absence of stimulation of the ventral root, lumbar plexus, or genitofemoral nerve before creating a thermal lesion. Stimulation is done at each level before the injection of local anesthetic (1 mL to 2% preservative-free lidocaine). After replacing the radiofrequency probe, the position on lateral view is rechecked to be sure the needle has not moved with the injection of the local anesthetic. If the impedance is greater than 300 OHMS, an additional 1-2 mL of local anesthetic or saline may be injected to decrease the impedance. A lesion is then made at each level at 80-85°C for 60 seconds with the patient alert and cooperative. If there is any pain radiating to the groin, thigh, or leg, the lesion is discontinued. The advantage of the curved tip is that two additional lesions can be made by rotating the tip cephlad and then caudad to increase the size of the lesion. It is inadvisable to pull the PERCUTANEOUS RADIOFREQUENCY LUMBAR SYMPATHECTOMY
References 1. Adson AW, Brown GE: The treatment of Raynaud’s disease by resection of the upper thoracic and lumbar sympathetic ganglia and trunks. Surg Gynecol Obstet 48:577-603, 1929 2. Adson AW, Craig WM, Brown GE: Essential hyperhidrosis cured by sympathetic ganglionectomy and trunk resection. Arch Surg 31:793806, 1935 3. Dondelinger R, Kurdziel JC: Percutaneous phenol neurolysis of the lumbar sympathetic chain with computed tomography control. Ann Radiol 27:376-379, 1984 4. Haxton HA: Chemical sympathectomy. Br Med J 1:1026-1028, 1949 5. Koikkalainen K, Luosto R, Jokinin T: Lumbar sympathectomy in the treatment of severe lower limb ischaemia in old people. Ann Chirur Gynecol 69:92-96, 1980 6. Lindenauer SM, Cronenwett JL: What is the place of lumbar sympathectomy? Br J Surg 29:532-533, 1982 7. Moore PJ: Chemical and operative lumbar sympathectomy. Br J Clin Pract 35:283-284and 237, 1981 8. Patman D: Sympathectomy in the treatment of chronic venous leg ulcers. Arch Surg 117:1561-1565, 1982 9. Quayle JB: Sexual function after bilateral lumbar sympathectomy and aorto-iliac by-pass surgery. J Cardiovasc Surg 21:215-218, 1980 10. Reid W, Watt JK, Gray TG: Phenol injection of sympathetic chain. Br J Surg 57:45-50, 1970 11. Royle ND: The treatment of spastic paralysis by sympathetic ramisection. Experimental bases and clinical results. Surg Gynecol Obstet 39:701, 1924 12. Walker PM, Key JA, MacKay IM, et al: Phenol sympathectomy for vascular occlusive disease. Surg Gyn Obstet 146:741-744, 1978 13. Wilkinson HA: Radiofrequency percutaneous upper thoracic sympathectomy. N Engl J Med 311:34-36, 1984 14. Zagzag D, Fields S, Romanoff H, et al: Percutaneous 15. Adson AW, Brown GE: Treatment of Raynaud’s disease by lumbar ramisection and ganglionectomy and perivascular sympathectneurectomy of the common iliacs. JAMA 84:1908, 1925 16. Brown GE, Adson AW: Calorimetric studies of extremities following lumbar sympathetic ramisection and ganglionectomy. Am J Med Sci 170:232, 1925 17. Diez J: Un nuero metodo de simpatrectomia perifrica para el tratamiento de las afeccioners troficas y gangrenosas de los miembros: La disociacin fascicular. Bol Soc Cir B Aires 8:792, 1924 18. Royle ND: New operative procedure in treatment of spastic paralysis and its experimental basis. Med J Aust 1:77, 1924
55
19. Royle ND: Operations of sympathetic ramisection. Med J Aust 1:587, 1924 20. Royle ND: New operative procedure in the treatment of spastic paralysis and its experimental basis. Med J Aust 1:77-86, 1924 21. Ewing M: The history of lumbar sympathectomy. Surgery 70:790796, 1971 22. Mandl F: Die Paravertebrale Injections. Vienna, Springer Verlag, 1926 23. Barnes RW, Baker WH, Shanik G, et al: Value of concomitant sympathectomy in aortoiliac reconstruction: Results of a prospective, randomized study. Arch Surg 112:1325-1330, 1977 24. Haimovici H, Steinman C, Karson IH: Evaluation of lumbar sympathectomy, advanced occlusive arterial disease. Arch Surg 89:10891095, 1964 25. Kim GE, Ibrahim IM, Imparato A: Lumbar sympathectomy in end stage arterial occlusive disease. Am Surg 183:157-160, 1976 26. Reid W, Watt JK, Gray TG: Phenol injection of the sympathetic chain. Br J Surg 57:45, 1970
56
27. Janoff KA, Phinney ES, Porter JM: Lumbar sympathectomy for lower extremity vasospasm. Am J Surg V 150:147-152, 1985 28. Boas R, Hatangdi V, Richards E: Lumbar sympathectomy: A percutaneous chemical technique. Adv Pain Res Ther 1:685-689, 1976 29. Smith C, Davidson N, Ruckley C: Hazard of chemical sympathectomy. Br Med J 1:552-553, 1978 30. Artuso J, Stevens R, Lineberry P: Post dural puncture headache after lumbar sympathetic block: A report of two cases. Reg Anesth 16: 288-291, 1991 31. Kumarov I, MacIssac S, Sioufi J: Latrogenic ureteral injury secondary to lumbar sympathetic ganglion blockade. Urology 16:617-619, 1980 32. Haynsworth R, Noe C, Fassy L: Intralymphatic injection: Another complication of lumbar sympathetic block. Anesthesiology 80:460462, 1994 33. Collucci J, Derasari M, Kirkpatrick A: Complications of blinded lumbar sympathetic blocks. Reg Anesth 17:114-115, 1992
J. W. NELSON