Lumbar Sympathectomy:Lumbar Sympathectomy:Indications & TechniquesIndications & Techniques

Chapter 85Chapter 85

OverviewOverview

HistoryHistory

AnatomyAnatomy

PhysiologyPhysiology

Clinical FindingsClinical Findings

Techniques of BlocksTechniques of Blocks

Clinical IndicationsClinical Indications

Operative TechniqueOperative Technique

HistoryHistory

Concept of sympathetic denervation to treat occlusive Concept of sympathetic denervation to treat occlusive arterial diseasearterial disease– Jaboulay (1889): periarterial sympathectomy on femoral arteryJaboulay (1889): periarterial sympathectomy on femoral artery– Leriche (1921): results disappointing due to reinnervation and Leriche (1921): results disappointing due to reinnervation and

vasospasm within weeks of operationvasospasm within weeks of operation– Royle (1924): observed after lumbar sympathectomy that skin Royle (1924): observed after lumbar sympathectomy that skin

and toes of ipsilateral foot became warm and dryand toes of ipsilateral foot became warm and dry

1930s-1950s: widely used for occlusive arterial disease 1930s-1950s: widely used for occlusive arterial disease because it was often the only alternative to amputationbecause it was often the only alternative to amputation– Experience proved to provide only short-term palliationExperience proved to provide only short-term palliation

1960s: direct surgical revascularization supplanted 1960s: direct surgical revascularization supplanted sympathectomysympathectomy

Anatomy:Anatomy:Efferent PathwayEfferent Pathway

AnatomyAnatomy

Sympathetic outflow to lower extremities originates from Sympathetic outflow to lower extremities originates from spinal cord segments T10 to L3 and are conveyed spinal cord segments T10 to L3 and are conveyed primarily through L1 to L4 gangliaprimarily through L1 to L4 gangliaUsually 3 lumbar ganglia foundUsually 3 lumbar ganglia found– L1 and L2 fusedL1 and L2 fused– L2 and L3 ganglionectomy usually sufficientL2 and L3 ganglionectomy usually sufficient

Anatomic completeness of sympathectomy is essential Anatomic completeness of sympathectomy is essential to minimize regeneration (occurs 2-5 years post to minimize regeneration (occurs 2-5 years post operation)operation)– Most common causes of early failure of procedure due to poor Most common causes of early failure of procedure due to poor

patient selection and incomplete degenerationpatient selection and incomplete degeneration

PhysiologyPhysiology

Sympathetic denervation increases blood Sympathetic denervation increases blood flow to a normal limbflow to a normal limb

Impact on an extremity affected by Impact on an extremity affected by arterial occlusive disease less cleararterial occlusive disease less clear

1.1. Increase in blood flowIncrease in blood flow

2.2. Effect of collateral circulationEffect of collateral circulation

3.3. Nutritive value of blood flow increaseNutritive value of blood flow increase

4.4. Alteration of pain impulse transmissionAlteration of pain impulse transmission

PhysiologyPhysiology1. Increase in Blood Flow1. Increase in Blood Flow

Abolishing basal and reflex constriction of Abolishing basal and reflex constriction of arterioles and precapillary sphinctersarterioles and precapillary sphincters– Flow increases of 10-200% are observedFlow increases of 10-200% are observed

Depends on degree of occlusive diseaseDepends on degree of occlusive diseaseSevere, multilevel occlusions may derive no benefit due to Severe, multilevel occlusions may derive no benefit due to already being maximally dilated at restalready being maximally dilated at rest

– Alters distribution of blood flow by shunting through Alters distribution of blood flow by shunting through cutaneous arteriovenous anastomoses cutaneous arteriovenous anastomoses

Maximized by distributing to distal cutaneous circulationMaximized by distributing to distal cutaneous circulationLeads to characteristic warm, pink footLeads to characteristic warm, pink footNot necessarily an increase in tissue perfusionNot necessarily an increase in tissue perfusion

– Canine model (Rutherford ’71, Cronenwett ‘80) showed neither Canine model (Rutherford ’71, Cronenwett ‘80) showed neither resting or exertional muscle perfusion improved by resting or exertional muscle perfusion improved by sympathectomysympathectomy

– Explains why sympathectomy not useful for claudicationExplains why sympathectomy not useful for claudication

PhysiologyPhysiology1. Increase in Blood Flow1. Increase in Blood Flow

Maximal vasodilation noted Maximal vasodilation noted immediately after sympathectomyimmediately after sympathectomy– Tapers within 5-7 daysTapers within 5-7 days– Resting vasomotor tone returns to Resting vasomotor tone returns to

normal levels 2-6 months laternormal levels 2-6 months laterIncomplete denervationIncomplete denervation

Cross-over reinnervationCross-over reinnervation

Vascular hyperreactivity to circulating Vascular hyperreactivity to circulating catecholaminescatecholamines

PhysiologyPhysiology2. Effect on collateral circulation2. Effect on collateral circulation

Temporary but significant Temporary but significant increase in collateral blood increase in collateral blood flowflow– Studied in humans and dogsStudied in humans and dogs– 10% increase in distal 10% increase in distal

perfusion after perfusion after sympathectomy attributable sympathectomy attributable to collateral perfusionto collateral perfusion

PhysiologyPhysiology3. Nutritive value of blood flow increase3. Nutritive value of blood flow increase

Shunting through cutaneous arteriovenous Shunting through cutaneous arteriovenous anastomoses bypasses capillary perfusionanastomoses bypasses capillary perfusion– Presumably makes blood non-nutritivePresumably makes blood non-nutritive– Conflicting studies regarding clearance of Conflicting studies regarding clearance of

radio-labeled isotopesradio-labeled isotopes

Uncontrolled clinical series (Moore ’71) Uncontrolled clinical series (Moore ’71) reported ischemic ulcer healing in 40-67% reported ischemic ulcer healing in 40-67% of patients after sympathectomyof patients after sympathectomy

PhysiologyPhysiology4. Alteration of pain impulse transmission4. Alteration of pain impulse transmission

Relief of ischemic rest pain due to loss of Relief of ischemic rest pain due to loss of attenuation of painful stimulus attenuation of painful stimulus transmissiontransmissionRelationship between lumbar Relationship between lumbar sympathectomy and pain thresholdsympathectomy and pain threshold– Sympathectomy decreases noxious stimulus Sympathectomy decreases noxious stimulus

by decreasing tissue norepi levelsby decreasing tissue norepi levels– Explains why in clinical series that rest pain Explains why in clinical series that rest pain

improves without hemodynamic evidence of improves without hemodynamic evidence of improved tissue perfusionimproved tissue perfusion

Clinical FindingsClinical Findings

Lumbar sympathetic blockLumbar sympathetic block– Significant increase in warmth (subjective or objective)Significant increase in warmth (subjective or objective)– Increased filling of veinsIncreased filling of veins– Increase in arterial pulsations shown by oscillometry or Increase in arterial pulsations shown by oscillometry or

plethysmographyplethysmography– Abolished secretion of sweatAbolished secretion of sweat

Noninvasive LabNoninvasive Lab– ABI<0.3 indicates low likelihood to improve after sympathectomy ABI<0.3 indicates low likelihood to improve after sympathectomy

(Yao ’73)(Yao ’73)– Presence of sympathetic vasomotor tone assessed by noting Presence of sympathetic vasomotor tone assessed by noting

response of digit pulse amplitude to deep breathresponse of digit pulse amplitude to deep breathLoss of vasoconstrictive reflex in DM, surgical sympathectomy, or Loss of vasoconstrictive reflex in DM, surgical sympathectomy, or advanced ischemiaadvanced ischemia

– Ability of digit circulation to increase pulse amplitude by inducing Ability of digit circulation to increase pulse amplitude by inducing temporary ischemia using pneumatic cufftemporary ischemia using pneumatic cuff

Lumbar Sympathetic BlockLumbar Sympathetic Block

AnatomyAnatomy– L1: level of junction of 12L1: level of junction of 12thth rib rib

and erector spinae musclesand erector spinae muscles– L4-L5: level of line drawn L4-L5: level of line drawn

between posterior iliac crestsbetween posterior iliac crests– 19 gauge needle 12-18cm long19 gauge needle 12-18cm long– 15 mL Marcaine15 mL Marcaine

Chemical blockadeChemical blockade– 3mL of 6.5% to 7% phenol 3mL of 6.5% to 7% phenol

dissolved in waterdissolved in water– 3mL of absolute alcohol3mL of absolute alcohol

Clinical IndicationsClinical Indications

Review of the history of clinical papers regarding lumbar Review of the history of clinical papers regarding lumbar sympathectomy (Cross ’99)sympathectomy (Cross ’99)– Sympathectomy does not improve claudicationSympathectomy does not improve claudication– May improve ischemic rest painMay improve ischemic rest pain– Does not improve long-term patency of peripheral vascular Does not improve long-term patency of peripheral vascular

bypass graftsbypass grafts

Subjective and objective preoperative assessment of Subjective and objective preoperative assessment of response to sympathetic blockade greatly enhances response to sympathetic blockade greatly enhances probability of therapeutic successprobability of therapeutic successThree main indicationsThree main indications– CausalgiaCausalgia– Inoperative arterial occlusive disease with limb-threatening Inoperative arterial occlusive disease with limb-threatening

ischemia causing rest pain, limited ulceration, or superficial ischemia causing rest pain, limited ulceration, or superficial digital gangrenedigital gangrene

– Symptomatic vasospastic disordersSymptomatic vasospastic disorders

CausalgiaCausalgiaStage I-Acute (warmth, erythema, burning, edema)Stage I-Acute (warmth, erythema, burning, edema)– 40-60% respond to intensive medical therapy including 40-60% respond to intensive medical therapy including

mild analgesics, physiotherapy, TCAs, anticonvulsants, mild analgesics, physiotherapy, TCAs, anticonvulsants, adrenergic blockersadrenergic blockers

– Surgical sympathectomy considered after 3 monthsSurgical sympathectomy considered after 3 months– Translumbar sympathetic blocks can be usedTranslumbar sympathetic blocks can be used

Stage 2-Dystrophic (coolness, mottling, cyanosisStage 2-Dystrophic (coolness, mottling, cyanosis– Sympathectomy should be applied as soon as there is Sympathectomy should be applied as soon as there is

relief from blockaderelief from blockade

Stage 3-AtrophicStage 3-Atrophic– Not indicatedNot indicated

Inoperable Arterial Occlusive Inoperable Arterial Occlusive DiseaseDisease

Lumbar sympathectomy can be considered prior Lumbar sympathectomy can be considered prior to amputationto amputation– ABI>0.3ABI>0.3– Absent neuropathyAbsent neuropathy– Symptomatic relief obtained by trial blockSymptomatic relief obtained by trial block

Relief of rest pain expected in 50-85% of Relief of rest pain expected in 50-85% of patients meeting these criteriapatients meeting these criteriaFor tissue loss patients, need to limit treatment For tissue loss patients, need to limit treatment to patients who only have limited ulceration or to patients who only have limited ulceration or single-digit gangrene and absence of major single-digit gangrene and absence of major deep infectiondeep infection– Healing seen in 35-65% of patientsHealing seen in 35-65% of patients

Lower Extremity VasospasmLower Extremity Vasospasm

Primarily affects patients with Raynaud’s Primarily affects patients with Raynaud’s phenomenon or frostbite victimsphenomenon or frostbite victims– Discomfort and typical color changes in response to Discomfort and typical color changes in response to

environmental coldenvironmental cold– Severe vasospasm can produce digital ulceration Severe vasospasm can produce digital ulceration

even with palpable pulseseven with palpable pulses

Maximal medical therapyMaximal medical therapy– CA channel blockersCA channel blockers– Cold avoidanceCold avoidance– Cessastion of smokingCessastion of smoking

Refractory vasospasm warrants surgeryRefractory vasospasm warrants surgery– 90% success rates90% success rates

Operative TechniqueOperative Technique

Retroperitoneal positioning on table on bean bagRetroperitoneal positioning on table on bean bagOblique incision from lateral edge of rectus towards Oblique incision from lateral edge of rectus towards middle of space between ribs and iliac crest ending at middle of space between ribs and iliac crest ending at anterior axillary lineanterior axillary lineLumbar sympathetic chain located medial to psoas Lumbar sympathetic chain located medial to psoas muscle overlying transverse processes of lumbar spinemuscle overlying transverse processes of lumbar spine– Left: adjacent and lateral to aortaLeft: adjacent and lateral to aorta– Right: beneath edge of IVCRight: beneath edge of IVC– Tactile identification by plucking the chain causes a “snap” Tactile identification by plucking the chain causes a “snap”

(genitofemoral nerve nearby is less taut)(genitofemoral nerve nearby is less taut)– Clips placed proximal and distal to proposed sites of transectionClips placed proximal and distal to proposed sites of transection

Send specimen to pathology to confirm sympathetic fibersSend specimen to pathology to confirm sympathetic fibers

ComplicationsComplications

Major complications result from failure to appreciate Major complications result from failure to appreciate normal anatomic relationshipsnormal anatomic relationshipsMost common complication is postsympathectomy Most common complication is postsympathectomy neuralgianeuralgia– 50% of patients 5-20 days post operation50% of patients 5-20 days post operation– Annoying “ache” in anterolateral thigh worse at night unaffected Annoying “ache” in anterolateral thigh worse at night unaffected

by activityby activity– Responds to analgesics and spontaneously resolves 8-12 Responds to analgesics and spontaneously resolves 8-12

weeksweeks

Sexual problems 25-50% of patients undergoing bilateral Sexual problems 25-50% of patients undergoing bilateral surgerysurgery22ndnd most common complication is failure to achieve most common complication is failure to achieve desired objectives of pain relief or tissue healingdesired objectives of pain relief or tissue healing

SummarySummary

Sympathectomy increases peripheral blood flow Sympathectomy increases peripheral blood flow by vasodilation of arterioles in cutaneous by vasodilation of arterioles in cutaneous vascular bedsvascular bedsSome patients may receive sufficient increases Some patients may receive sufficient increases to help heal superficial ischemic ulcers and to help heal superficial ischemic ulcers and relieve rest painrelieve rest painBlood flow effects are comparatively small in the Blood flow effects are comparatively small in the long runlong runProtection against an exaggerated Protection against an exaggerated vasoconstrictor response to cold, improvement vasoconstrictor response to cold, improvement against sympathetic pain, and suppression of against sympathetic pain, and suppression of sweating are long-lasting resultssweating are long-lasting results