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Lumbar sympatholysis can be an effective treatment for individuals suffering from chronic pain in the lower extremities as a result of various causes. Sympathectomy can be performed by chemical neurolysis, radiofrequency ablation, or surgically with variations in technique. The most common indications for this procedure include lower extremity complex regional pain syndrome (formally known as RSD and Causalgia), vascular insufficiency in the leg, phantom limb pain, erythromelalgia (a rare condition causing episodic burning pain and redness usually in the feet, less commonly in the upper extremities and face or ears likely due to postganglionic sympathetic dysfunction as well as hypersensitivity of C-fibers resulting in abnormal skin perfusion and arteriovenous shunting), post-herpetic neuralgia, and hyperhidrosis. This activity reviews the lumbar sympatholysis technique, anatomy, and associated clinical considerations. It also highlights the role of the healthcare team in improving outcomes for patients who undergo lumbar sympatholysis. Objectives: Identify the indications for lumbar sympatholysis. Determine the common techniques in regards to lumbar sympatholysis. Apply the appropriate evaluation of the potential complications of lumbar sympatholysis. Communicate interprofessional team strategies for improving care coordination and communication to ensure the appropriate selection of candidates for lumbar sympatholysis and to improve outcomes in patients undergoing lumbar sympatholysis. Access free multiple choice questions on this topic.

Lumbar sympathetic blocks that result in a sympathectomy have been described as an effective pain management treatment strategy for several causes of chronic pain since the early 1900s. The first reports of a lumbar sympathetic block technique and sympatholysis were initially documented in the 1920s. The conditions for which this treatment has been effectively implemented include lower extremity complex regional pain syndrome (CRPS, formally known as RSD or causalgia) as well as various painful conditions resulting in circulatory insufficiency in the lower extremity such as Buerger's disease, embolic occlusions, frostbite, vasospastic disease, and peripheral arterial disease. Other possible indications may include phantom limb pain, hyperhidrosis,  and postherpetic neuralgia. Procedural techniques have evolved with fluoroscopy, chemical neurolysis, and radiofrequency thermocoagulation approaches.[1] Surgical procedures (although not performed as often) have also been documented. An overview of interventional procedural anatomy, physiology, indications, contraindications, complications, and interventional techniques is provided for practitioners to help improve understanding and outcomes and minimize mortality and other adverse effects. It is important to distinguish lumbar sympatholysis from lumbar sympathetic block in that this procedure specifically seeks to accomplish a more long-term or permanent disruption of the sympathetic chain output to the lower extremity, whereas the lumbar sympathetic block typically utilizes only local anesthetics. However, the lumbar sympathetic block is often useful for diagnostic purposes on a potential candidate before performing more long-term treatment with lumbar sympatholysis.

Complications of performing lumbar sympatholytic can include bleeding, infection, neuraxial injection, intravascular injection, genitofemoral neuralgia, injury to nerve roots, and rarely injury to pelviureteric structures.[1] Genitofemoral neuralgia is the most common complication, with a 5 to 7% incidence following chemical lumbar sympathectomy. Some data suggest a higher incidence when using alcohol instead of phenol. The groin dysesthesia symptoms of genitofemoral neuralgia are usually transient and often resolve within 4 to 6 weeks.[10][11] The risk of genitofemoral neuralgia is reducible by avoiding injection of medications into the psoas muscle, especially at levels L3 and L4, where the intramuscular injection is more common.[9] There are also reports of post-sympathectomy neuralgia, which presents more as a dull ache, and its mechanism remains unclear. An inadvertent neuraxial injection can have devastating consequences such as total spinal and even death.[12][13] Intrathecal injection of chemical neurolytic medications reportedly causes transient weakness and paralysis, with reports of permanent cases as well.[14][15] Unintentional intravascular injection of neurolytic agents can occur, given the proximity of the lumbar sympathetic chain to major vessels such as the aorta and inferior vena cava, as described in the anatomy section. Variations in lumbar vessel anatomy, such as the artery of Adamkiewicz, may also be a factor in inadvertent intravascular injection, resulting in direct toxic or ischemic injury to the spinal cord.[16] These risks highlight the importance of aspiration before injection to avoid accidental intravascular injection of medication.

Lumbar sympatholysis is an invasive procedure and can be associated with serious complications such as paralysis or even death.[12][13] Thus, determining if a patient would be an ideal candidate is critical. Interdisciplinary communication between different medical specialties is often needed to evaluate the patient properly pre-procedure. It is also imperative for the performing provider to understand the anatomy, physiology, and various approaches of the technique to produce improved outcomes and minimize complications and for these ideas to be clearly explained to the patient as well.