Lumbar Sympathetic Block-efficacy

[kstarm]

Curious about others thoughts about this. I seem to always end up going to stim. Even though the blocks reduce pain I rarely get anything that lasts very long even with good PT and consistent HEP with my patients. What is everyone else noticing? What percentage of your patients go from LSB to stim? Do you see it as a prerequisite before stim. or are people just jumping right to stim? Thanks.

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[willabeast]

Curious about others thoughts about this. I seem to always end up going to stim. Even though the blocks reduce pain I rarely get anything that lasts very long even with good PT and consistent HEP with my patients. What is everyone else noticing? What percentage of your patients go from LSB to stim? Do you see it as a prerequisite before stim. or are people just jumping right to stim? Thanks.

I had a lot of chronic patients who would want a LSB to quiet down their CRPS when it was acting up. Would see them once or twice a year. used a mixture of epi, carbocaine, 1/2% bupivicaine and 40 mg of kenalog. The toughest CRPS patients are the ones that are formerly known as axis 2. Doubt a LSB would help them much but worth trying once anyway.

 

[Multimodal]

I usually end up going to stim too as long as they aren't workers comp in WA state. I have had such variable but usually short lived results with LSB that I cannot rely on them.

 

[TIVAndy]

agree. a lot of them go to stim

 

[paindoc007]

Agree w above. they don’t work well. To the point now where when I offer it for the right patient I say “in my experience this usually provides a very short lived response” caution to the patient.

 

[SommeRiver]

...hate them.

Rarely work in my experience and they don't alter the trajectory of CRPS.

They probably help with PT.

 

[callmeanesthesia]

I don’t like them and rarely do them. Mainly for acute CRPS to facilitate PT.

 

[Multimodal]

so glad I'm not alone in my distaste for LSB. this thread made me feel alot better about the ****tastic results from this procedure

 

[Ronin1]

However I think it reasonable to try sympathetic blocks before moving to implantable procedure. I have had many patients, anecdotally I know, have incredible results from 1-3 blocks in combination with aggressive PT.

 

[SommeRiver]

I work in a large ortho group (over 20 surgeons) and rarely see CRPS.

Positive Budapest = CRPS

Call me skeptical as to the abundance of these pts.

 

[paindoc007]

For some reason I’ve had significantly better results with stellates for UE crps than lsb for LE crps. Is this also what you guys see?

 

[SommeRiver]

For some reason I’ve had significantly better results with stellates for UE crps than lsb for LE crps. Is this also what you guys see?

Yes.

 

[Orin]

For some reason I’ve had significantly better results with stellates for UE crps than lsb for LE crps. Is this also what you guys see?

The sympathetic blocks just facilitate PT/rehab. It's a lot harder to break the fear/cycle of pain avoidance for LE as compared to UE pain. The difficult part is that local anesthetic just does not last very long.

I'm hoping to eventually be able to inject something better like botulinum or maybe some sweet cactus juice from Sorrento, resiniferatoxin.

Lumbar Sympathetic Block with Botulinum Toxin Type A and Type B for the Complex Regional Pain Syndrome

A lumbar sympathetic ganglion block (LSB) is a therapeutic method for complex regional pain syndrome (CRPS) affecting the lower limbs. Recently, LSB with botulinum toxin type A and B was introduced as a novel method to achieve longer duration of analgesia. ...

www.ncbi.nlm.nih.gov

Sorrento Releases Positive Results of Phase 1B Trial of Resiniferatoxin (RTX) In Reduction of OsteoArthritis (OA) Knee Pain

Phase 1b safety data at 6 month post-administration and Day 84 efficacy data available for all patients enrolled.No dose limiting toxicities at any of the...

www.globenewswire.com

 

[TIVAndy]

I work in a large ortho group (over 20 surgeons) and rarely see CRPS.

Positive Budapest = CRPS

Call me skeptical as to the abundance of these pts.

Im in a similar setting. I see a range of possible mild crps to severe rarely. If u look at the literature the crps rate after bone fracture is surprisingly high i think around 5-10%.

 

[Laryngospasm]

For acute crps and PT I have had success... series of three with PT and gabapentin. For anything non acute proceeding to scs is most likely going to happen.

 

[callmeanesthesia]

I work in a large ortho group (over 20 surgeons) and rarely see CRPS.

Positive Budapest = CRPS

Call me skeptical as to the abundance of these pts.

I don’t really trust the Budapest criteria either. Had a patient totally debilitated by bilateral CRPS after a minor injury (no fracture). Tried sympathetic block to facilitate PT, no significant result. Significant other was definitely an enabler. Never would have touched that patient with SCS in a million years. Technically did meet Budapest criteria, but her psychiatrist was pretty convinced it was a conversion disorder and I leaned that way myself.
I’m in an Ortho group. Most of the CRPS I see is acute and you can diagnose it from the door. Pretty simple - if they have work comp, they don’t get better. If they have any other insurer, and they quit smoking and do PT, they get better. Unless it’s Type 2 - I know the difference is supposed to be largely academic but I’ve seen the most persistent cases in people with a discrete nerve injury.

 

[painfree23]

any other indications other than crps? peripheral neuropathy perhaps?

 

[Ducttape]

lumbar sympathetic blocks for vascular insufficiency can be beneficial - of course, success in these cases is mostly preventing amputation.

i agree that LSBs are primarily so people can tolerate PT for acute cases, but i do have a cadre of patients who profess that they benefit from intermittent LSBs.

imo many cases of CRPS are really not and it gets overcalled by a lot of orthos. "it hurts like heck and is red and swollen doc! are you sure its not because of the (6 hour completely gratuitous) surgery you did 2 weeks ago? should these stitches be hanging out? theres no way i can ever go back to work at my desk!" "No. of course not. never happens after surgery. its got to be RSD."

 

[epidural man]

I don’t really trust the Budapest criteria either.

Why not? We need to hear more about this.

The whole point of the Budapest criteria was to try and make it more standardized, especially for science reproducibility.

 

[epidural man]

Curious about others thoughts about this. I seem to always end up going to stim. Even though the blocks reduce pain I rarely get anything that lasts very long even with good PT and consistent HEP with my patients. What is everyone else noticing? What percentage of your patients go from LSB to stim? Do you see it as a prerequisite before stim. or are people just jumping right to stim? Thanks.

If I didn’t work with fellows, I don’t think I would ever order one.

I know that sounds bad and that I only do them for educational benefit. So now after typing this, I realize perhaps there is liability with my statement out there.

So I changed my mind. I now love them.

 

[callmeanesthesia]

Why not? We need to hear more about this.

The whole point of the Budapest criteria was to try and make it more standardized, especially for science reproducibility.

Mainly because of the case I described - pretty sure it was conversion disorder but technically met criteria. And most of the time they aren’t needed for me because it’s obvious from across the room in the patient that had an ankle fracture 2 months ago and the surgeon’s note says the bones are all healed. Still, I do try to document and apply them where it may be relevant, like WC cases.