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Lumbar sympathetic block

If you are considering having a lumbar sympathetic block or have a procedure planned, it is important to know all you can about it. This includes:

 

  • why you need this procedure

  • what it will be like

  • how it will affect you

  • what risks are involved

  • any alternatives.

 

The information here is a guide to common medical practice. Each hospital and doctor will have slightly different ways of doing things, so you should follow their guidance where it is different from the information given here. Because all patients, conditions and treatments vary it cannot cover everything. Use this information when making your treatment choices with your doctors. You should mention any worries you have. Remember that you can ask for more information at any time.

 

 

What is the problem?

You have pain coming from your leg or foot, and perhaps your lower back. The pain involves the sympathetic nerves in this area. The sympathetic nerves control the things we do not need to think about, such as digestion, blood pressure and heart rate. This group of nerves does not normally send pain messages, but they become ‘switched-on’ in certain conditions. We do not know why this happens, but have learnt to recognise the times when it does. The sympathetic nerves to the legs, all come together on either side of the spine in the lower back. This is known as the lumbar area. Injecting local anaesthetic around the sympathetic nerves should reduce your pains.

Lumbar sympathetic block

Pain from the sympathetic nerves does not respond to the usual painkillers that we use for simple pain, like a headache. Neither does it respond well to stronger painkillers that we might use for a broken bone. Sympathetic pain seems to be there all the time, sometimes getting worse and sometimes easing off. The pain may be affected by heat or cold and may therefore change with the weather.

 

If the pain affects the leg, then the skin of the limb can be seen to go pale or even mottled. There may be loss of hairs and the skin may take on a smooth, featureless appearance. Sometimes the toenails look dry and brittle. Unfortunately, there is no exact test to confirm the diagnosis. The doctor recognises a pattern in the description of the pain (often sharp, stabbing or shooting) and by the appearance of the skin.

 

What is a lumbar sympathetic block?

A lumbar sympathetic block is an injection around a junction or ‘crossroads’ where many nerves meet. This crossroads can sometimes be responsible for sending pain messages to the brain. Pain from the leg, and occasionally the lower back, can send messages through this junction.

Lumbar sympathetic block 2

Injecting local anaesthetic around this nerve junction blocks the pain messages, causing the pain to be reduced.

 

An anti-inflammatory steroid may be injected with the local anaesthetic. If required, only a small amount of steroid is needed and it will not cause any of the side effects sometimes associated with taking steroid tablets. They are not the same kind of steroids that athletes may take.

 

Blocking the sympathetic nerves also causes the blood vessels in the legs to dilate, meaning they become wider. This will improve the blood supply in patients that are having pain because of poor circulation.

 

What has gone wrong?

Your sympathetic nerves have started sending pain messages. It is not at all clear why this happens. It is known that by blocking the activity of the sympathetic nerves the pain can be reduced.

 

Often the pain is related to poor circulation. When the blood vessels to the legs are narrowed or diseased, this pain can happen. The block helps by dilating the blood vessels in the legs, which improves blood circulation.

 

The aims

The aim of the procedure is to reduce the signals sent by the sympathetic nerves, which in turn reduces the pain. The procedure will also improve the circulation of the legs and may improve pain caused by ischaemia, which is a poor blood supply.

 

The benefits

Your pain should be reduced and you should be able to move around more easily. If successful, this treatment can reduce the need for tablet medications.  

 

Are there any alternatives?

By the time that you consider having a lumbar sympathetic block you should have already tried other more simple treatments. These include rest, both painkilling and anti-inflammatory tablets, and physiotherapy with exercise.

 

You may have also tried a transcutaneous electrical nerve stimulation (TENS) machine for the pain. This works by sending soothing pulses across the surface of the skin and along the nerve fibres. The pulses prevent pain signals from reaching the brain. They also stimulate your body to produce higher levels of its own natural painkillers, called endorphins.

           

Sometimes, even the strongest painkillers, like morphine, will have been tried.

 

What if you do nothing?

If you do nothing there are several things that may happen:

 

  • With time and rest the pain may settle on its own

  • The pain and difficulty in performing daily activities may remain the same

  • The pain may increase and spread

  • Your posture may get worse, making activities and even sleeping more difficult

  • If the pain is due to poor circulation, other treatments and maybe even operations may be needed

 

Who should have it done?

The following groups of patients should have the procedure done:

 

  • Patients with pain in the leg or lower back that has failed to respond to standard treatments

  • Patients with pain in the leg or lower back with symptoms suggesting that the sympathetic nerves are involved

  • Patients with poor blood circulation in the legs

 

Who should not have it done?

Each patient must make the final decision on whether to proceed or not. If you are unhappy about the procedure for any reason you should not continue.

 

There are specific medical situations when a lumbar sympathetic block should not be done and they are as follows:

 

  • When a patient is on medication that prevents blood from clotting, such as warfarin. This would lead to more bleeding than normal. It may be possible to stop the medication a few days before the procedure. This will need to be discussed with your doctor

  • When a patient is suffering from an illness that prevents blood from clotting, such as haemophilia. This would also lead to more bleeding than normal

  • When there is infection of the skin over the site where the needle needs to be put in. This could lead to infection in the deeper tissues

 

Author: Dr Sean White FRCA. Consultant in pain and anaesthesia.

© Dumas Ltd 2006

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