Lumbar Sympathetic Block

[GatorCHOMPions]

I've had an orthopedic surgeon in my community suggest LSB frequently for "possible CRPS". Some of these are highly questionable but on occasion CRPS seems remotely possible. Who still does these? I did a couple in training but not since then. If I did proceed, should I have any special monitoring or meds handy? Would you recommend an SCS trial instead if CRPS is possible, and they've failed a couple traditional meds?

How would you politely tell the surgeon you don't think it's CRPS, or that an LSB is not warranted?

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[willabeast]

Warning! Do not discuss with the surgeon. Simply very gratefully see all the referrals and then perhaps suggest to the patients a LSB is not going to help much. If you want to go further, send the surgeon a review article on the subject. This is based on personal experience. YMMV!

 

[Baron Samedi]

We do a fair amount. It only works in combination with a good Physical Therapist. We try and do ours early in the morning and have them go to PT right after.

No special monitoring, though I do get IV access beforehand. I use 8cc of 0.50% ropivicaine.

 

[MitchLevi]

Did one this AM.

Valium 5mg, no IV, no monitoring.

Sympathetic blocks are field blocks at the end of the day. If it is post op neuralgia, do the procedure. CRPS, do the procedure.

 

[RoloTomassi]

They are probably the least effective procedure I do

 

[MitchLevi]

They are probably the least effective procedure I do

Stellates work great in my hands, while lumbars don't

 

[interjectionreflection]

We do a fair amount. It only works in combination with a good Physical Therapist. We try and do ours early in the morning and have them go to PT right after.

This is the way

 

[Laryngospasm]

If they don’t meet Budapest criteria don’t even bother.. I have since started referring to the hot shot Interventional radiologists who can and do inject anything and do with multi axial imaging.. due to the risk and piss poor reimbursement.

 

[CleanUp]

I’m surprised people say the LSB is ineffective. I’m selective in who gets it. Usually people have failed multiple epidurals from another pain physician or been told the only option is a SCS. I will start gabapentin/lyrica, TCA and SNRI to make sure we make some progress however minimal. For patients who can afford it I go with a compounded cream. Then they can trial a LSB. I put ketamine and ropi or bupi and tell them I am buying them a window to engage in PT. This takes awhile to go over but I feel it is a complete plan. Just my two cents.

 

[bedrock]

If they don’t meet Budapest criteria don’t even bother.. I have since started referring to the hot shot Interventional radiologists who can and do inject anything and do with multi axial imaging.. due to the risk and piss poor reimbursement.

Interesting. I can understand part of the rationale. However, many CRPS patients also eventually require SCS. Do you care about losing out on those stims?

 

[Ducttape]

However, many CRPS patients also eventually require SCS.

that seems population dependent.

to wit, more often than not patients have resolution over time and overall most CRPS patients do not require neuromodulation.

now the ones that we typically see with chronic disease, i agree they may benefit from neuromodulation.


if i am seeing an acute CRPS, i am not discussing neuromodulation with them. im doing bisphophonates, possibly steroids, and primarily complementary therapy such as PT and if interested psychology.

 

[CleanUp]

that seems population dependent.

to wit, more often than not patients have resolution over time and overall most CRPS patients do not require neuromodulation.

now the ones that we typically see with chronic disease, i agree they may benefit from neuromodulation.


if i am seeing an acute CRPS, i am not discussing neuromodulation with them. im doing bisphophonates, possibly steroids, and primarily complementary therapy such as PT and if interested psychology.

What is your bisphosphonate and dosing?

 

[pastafan]

that seems population dependent.

to wit, more often than not patients have resolution over time and overall most CRPS patients do not require neuromodulation.

now the ones that we typically see with chronic disease, i agree they may benefit from neuromodulation.


if i am seeing an acute CRPS, i am not discussing neuromodulation with them. im doing bisphophonates, possibly steroids, and primarily complementary therapy such as PT and if interested psychology.

In acute cases mirror therapy is worthwhile: Using Mirror Therapy to Reduce Pain and Improve Movement

 

[Ducttape]

alendronate 10 mg daily for 2 months.

of note, not all insurances approve for crps.

and some data suggests IV works better, but wait to get in to see endocrine in this area is months, so thats why i tried it.

 

[agolden1]

Interesting. I can understand part of the rationale. However, many CRPS patients also eventually require SCS. Do you care about losing out on those stims?

Most patients I discuss stim with don’t want any part of an implantable device. They seem to prefer going down a pathway of injection, or failing that medication.

I’ve revised my SCS pitch a couple times over and still most of my patient population wants nothing to do with them.

That being said, my current shop does a fair amount of LSB + PT for lower extremity issues or regional block + PT for upper extremity issues. Probably 50% improve, 50% no better.

 

[Laryngospasm]

Interesting. I can understand part of the rationale. However, many CRPS patients also eventually require SCS. Do you care about losing out on those stims?

I don’t do scs anymore. I offer to refer them to someone who does. I really am not a huge fan of it anymore.

 

[bedrock]

Most patients I discuss stim with don’t want any part of an implantable device. They seem to prefer going down a pathway of injection, or failing that medication.

I’ve revised my SCS pitch a couple times over and still most of my patient population wants nothing to do with them.

That being said, my current shop does a fair amount of LSB + PT for lower extremity issues or regional block + PT for upper extremity issues. Probably 50% improve, 50% no better.

I understand that most patients would prefer an injection and meds over SCS. So would I.

As long as those meds aren’t COT.

I’m happy to try a sympathetic block and trial CRPS patients on multiple neuropathic meds.

But if they fail the pt, temp relief with block, and fail more than 3-4 different neuropathic meds, then I give them the option of living with it vs SCS.
I don’t give them the COT option. If they ask I say no.

 

[Orin]

LSBs are harder as the ganglia aren't as lumped up as the stellate is. 10-20 mL per side. Sometimes a multi-level injection to get better spread with L2 plus L4.

It's a poor man's stim trial in my opinion, but great to avoid the implant if they can get better with PT/desensitization.

 

[Ducttape]

the option they should choose is more PT and CBT and EAAT.

but that often isnt what they are seeking, because they'd rather have the quick fix.

 

[SC Tian]

I do some, but it's definitely not well-paid. I usually insert two needles at the L2 and L3 levels. The block has been reliable, but the relief is usually short-lived.

 

[RoloTomassi]

Question re: LSB for post surgical CRPS (~6mo).

What's everybody doing? 1 block vs series, how many, how far apart? Evidence?

 

[oreosandsake]

Not all CRPS is sympathetically mediated

Not all CRPS is sympathetically mediated

Not all CRPS is sympathetically mediated


IMO Regional blocks do better for crps and crps-like conditions. You get the sympathetic block as well as dense nociceptive block that can provide solid relief for weeks. Patients in unrelenting neuropathic pain welcome the quiet relief of the dense sensory block. Another pro is you Can also perform in office in minutes without fluoro

 

[MitchLevi]

Not all CRPS is sympathetically mediated

Not all CRPS is sympathetically mediated

Not all CRPS is sympathetically mediated


IMO Regional blocks do better for crps and crps-like conditions. You get the sympathetic block as well as dense nociceptive block that can provide solid relief for weeks. Patients in unrelenting neuropathic pain welcome the quiet relief of the dense sensory block. Another pro is you Can also perform in office in minutes without fluoro

I’m doing more and more of these instead of lumbar SB. Posterior tibial and superficial peroneal simultaneously is helpful for a lot of people. The superficial peroneal is hard to find sometimes.

 

[callmeanesthesia]

I’m doing more and more of these instead of lumbar SB. Posterior tibial and superficial peroneal simultaneously is helpful for a lot of people. The superficial peroneal is hard to find sometimes.

For foot and ankle pain, are you guys blocking the saphenous too? I hate doing sympathetic blocks so I’d love alternatives, plus I’ve always loved the immediate satisfaction of peripheral nerve blocks.
I’m interested in trying this for upper extremity too - I did have a patient I did some axillary blocks on that she said helped for about a month at a time. Ended up doing a stim though and she’s doing great with that.

 

[MitchLevi]

For foot and ankle pain, are you guys blocking the saphenous too? I hate doing sympathetic blocks so I’d love alternatives, plus I’ve always loved the immediate satisfaction of peripheral nerve blocks.
I’m interested in trying this for upper extremity too - I did have a patient I did some axillary blocks on that she said helped for about a month at a time. Ended up doing a stim though and she’s doing great with that.

I just do superficial peroneal and posterior tibial, but the SPN can be hard to visualize so I am often just doing a field block where the nerve should be. It sits in a small fascial compartment so it is really hard to get "lucky" on that nerve, but I'd say I find it clearly most of the time. There are free YouTube videos that demonstrate this technique. I have also done sural as well. These procedures do NOT pay anything, so I would not get clever trying to do too much at one time because they can be difficult to do.

It's really hit or miss with who it helps and who it doesn't help (like everything).

I've had some big wins and some outright failures.

Ropivacaine 0.5% and I don't use steroid on peripheral nerves other than the suprascapular.

I once had a massive amount of fat atrophy on a cubital tunnel injection and the pt had to have surgery because of it. I refused the procedure for nearly 6 months or so and finally gave in and did it.

 

[oreosandsake]

I’m doing more and more of these instead of lumbar SB. Posterior tibial and superficial peroneal simultaneously is helpful for a lot of people. The superficial peroneal is hard to find sometimes.

I go for big juicy nerves more proximal. Sciatic in the popliteal fossa is easy to find. Numb the whole leg. Motor block is the least of their worries just have a driver and someone help them to their car and on way home or a rolling walker.
Brachial plexus for upper extremity

Particulate steroids cause fat atrophy. Dex should be ok And prolongs the block

 

[MitchLevi]

I go for big juicy nerves more proximal. Sciatic in the popliteal fossa is easy to find. Numb the whole leg. Motor block is the least of their worries just have a driver and someone help them to their car and on way home or a rolling walker.
Brachial plexus for upper extremity

Particulate steroids cause fat atrophy. Dex should be ok And prolongs the block

I may start doing pop fossa blocks. Did a few in fellowship. Don’t remember them being difficult at all.

 

[oreosandsake]

I may start doing pop fossa blocks. Did a few in fellowship. Don’t remember them being difficult at all.

nysora has some great resources. find the pop artery, look lateral and superficial. find the nerve. trace up to make sure you have both together, not just one. otherwise, make sure you dont poke the peroneal as you enter trying to block the tibial. large volume block is fine. true crps, they'll be very grateful to have the pain silenced.