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CT GUIDED LUMBAR SYMPATHECTOMY
DR MADHUSUDHAN KSMD, FRCR, MAMS
ASSOCIATE PROFESSOR,
DEPARTMENT OF RADIODIAGNOSIS,
AIIMS, NEW DELHI 110029
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LUMBAR SYMPATHECTOMY (LS)
Disruption of lumbar sympathetic chain
Sympathectomy
Increase collateral perfusion (release of vascular tone)
Removes sympathetic pain component
Surgical
Invasive; morbidity / mortality (4-7%)
Risks due to cardiovascular morbidities
Image guidance –
CT / fluoroscopic
Minimally invasive, less complications
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INDICATIONS
Peripheral vascular disease
Not amenable to reconstruction
Symptoms –
rest pain, arterial ulcer, gangrene
Complex regional pain syndromes
Plantar hyperhidrosis
Contraindications (relative)
Coagulation abnormalities
Difficulty in pt positioning, aortic aneurysm, scoliosis
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CRITICAL LIMB ISCHEMIA
CLI -
chronic ischemic rest pain for >2 weeks, ulcers or gangrene
25% mortality –
1 year; 25% -
major amputation
Diagnosis of CLI -
poor prognosis for life and limb
Management
Revascularization
Aggressive lifestyle modification
Medications
Lumbar sympathectomy
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GUIDANCE
Fluoroscopy
20 –
30% psoas
injections; subarachnoid injection
Injury to genitofemoral
N, bowel, IVC, aorta, lumbar plexus
Spine abnormalities –
increases complications
CT
minimally invasive, safe and effective
success rates 30 –
87%; complications < 1%.
Little RP fat
Scoliosis
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PRE-PROCEDURE
Clinical evaluation
CT or MR angiography
Assess for revascularization
Hardware
Chiba needle (22G), 2% lignocaine, absolute alcohol, iodinated contrast
Patient position –
prone / decubitus
L3 level; unilateral / bilateral
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ANATOMYIVCCrus
Ureter
Psoas
Vertebral body
Aorta
Ureter
Psoas
Vertebral body
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TECHNIQUE –
BILATERAL
Preliminary scan
Grid marker
LA needles
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TECHNIQUE –
BILATERAL
Final needle position
Test injectionLA + contrast
Alcohol injection
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COMPLICATIONS & FOLLOW UP
Complications
< 1%
Pain
Neuralgia
Ureteric
injury –
stricture, necrosis
Infection –
retroperitoneal abscess
Follow up
Clinical evaluation
Rest pain
Claudication
distance
Ulcer healing
Every 3 –
6 months
? Ultrasonography
for KUB
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CASE 1
NPSPre CTLS –
83 weeks –
33 months
–
26 months –
11 year –
1
60-year-old male, smoker presenting with rest pain and ulcer for 8 months
6 months
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CASE 2
33-year-old male, smoker presenting with rest pain and ulcer for 1 year
NPSPre CTLS –
63 weeks –
13 months
–
1
3 months
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CONCLUSION
CTLS –
simple & safe palliative technique
L2 –
L3 level better
Bilateral procedures provide better results
Complications -
rare
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THANK YOU