lumbar sympathetic blocks

[smarterchild]

hi everyone. when doing lumbar sympathetic blocks, do you prefer to use a single needle approach at L3 or a multi-needle approach? I was trained and have been doing the procedure using the former but one of my colleagues stated a multi-needle approach at L2, L3, and L4 would be more effective. I looked for any research on this but didn't come up with much. Any insight on whether I should update my technique?

Thanks!

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[emd123]

hi everyone. when doing lumbar sympathetic blocks, do you prefer to use a single needle approach at L3 or a multi-needle approach? I was trained and have been doing the procedure using the former but one of my colleagues stated a multi-needle approach at L2, L3, and L4 would be more effective. I looked for any research on this but didn't come up with much. Any insight on whether I should update my technique?

Thanks!

I don't do a ton of these, but when I do, it's a single needle at L3. If done right, you should easily see contrast spread one level above and 1 level below. You're injecting into a potential space that spreads easily. I'm not sure what you gain by doing two more needles.

 

[SommeRiver]

One needle at L3. I do 10cc of dex 10mg, bupi 0.25% 7cc, and NS 2cc. In training we did it with Toradol, Clonidine, dex, and bupi.

 

[Taus]

I do 1 needle at L3. 10cc spreads to cover 2 and 4. If spread wasn’t great maybe I would add another needle. Haven’t had to do that.

 

[Ferrismonk]

I do L2 and L3 but only bill for the single block obviously. If contrast flow isn't great on one of them, I don't get bent out of shape though and just inject at the one level with good contrast spread. I use Bupi and Dex.

 

[willabeast]

Every once in a while your contrast will be blocked usually at a lower level in someone who has scar tissue there. This happened to me once every 10 years or so. In that situation try another level. But 99% of the time a single level is going to work well. I usually took bilateral temperature readings off of the big toes as proof of my block. I would use 2% lidocaine (for speed) bupivicaine (for longevity) and some kenalog (because steroid suppresses neuronal discharges) and some epinephrine (to detect an IV injection). If i could find some Mepvicaine I would use that instead for local. I always measure and record the distance between the needle insertion site and the middle of the spine, makes it easier for future injections. usually #22 gauge 5-7 inch .

 

[painfree23]

how often are you doing these? and for anything else other than CRPS?

 

[smarterchild]

thank you all for the replies! always learn a lot from you all!

 

[vpl2909]

Currently a fellow. We do single level usually L3 and use 1cc of 10mg dex, 8cc bupi with epi, and 1cc contrast. Not all attendings use the 1cc contrast with the block itself.

 

[painfree23]

Why epi?

 

[Ducttape]

from an academic standpoint, i think the epi is used as another indicator that the injection might be intravascular.

 

[vpl2909]

from an academic standpoint, i think the epi is used as another indicator that the injection might be intravascular.

Yep- We usually inject 2cc at a time, listen for any increase in HR, and check spread.

 

[painfree23]

Yep- We usually inject 2cc at a time, listen for any increase in HR, and check spread.

Has it ever happened? What do you if the hr goes up? Withdraw the needle and then inject or push it in further and then inject?

 

[emd123]

Yep- We usually inject 2cc at a time, listen for any increase in HR, and check spread.

Why not just inject 1 or 2 cc of contrast, by itself, first?
It should be obvious as hell if you inject 1 or 2 cc of contrast into the IVC which is huge. I'm not sure why you'd need to also inject epi, directly into the biggest vein of the body which tracks directly to the heart. If anything, I'd be worried about triggering an arrhythmia or coronary vasospasm. Pretty much the only situation you want to inject epi directly IV is in cardiac arrests or shock. Even in anaphylaxis it's recommend you give it subcu or IM, not IV.

Maybe your dose is small enough, but personally, I don't like the idea of injecting cardiotoxic epi IV, as a way to determine if you've accidentally given cardiotoxic bupivicane IV, when it's so easy to determine the same thing with omnipaque which is cardio-inert.

Safety of epinephrine for anaphylaxis in the emergency setting
"When is IV dosing of epinephrine in anaphylaxis appropriate?
While guidelines recommend that epinephrine be given via IM injection for the initial treatment of anaphylaxis,[8] IV delivery should be considered in special circumstances such as severely hypotensive patients, patients in cardiac or respiratory arrest, or those who have failed to respond to multiple IM injections of epinephrine.

 

[Biohazard685]

Why not just inject 1 or 2 cc of contrast, by itself, first?
It should be obvious as hell if you inject 1 or 2 cc of contrast into the IVC which is huge. I'm not sure why you'd need to also inject epi, directly into the biggest vein of the body which tracks directly to the heart. If anything, I'd be worried about triggering an arrhythmia or coronary vasospasm. Pretty much the only situation you want to inject epi directly IV is in cardiac arrests or shock. Even in anaphylaxis it's recommend you give it subcu or IM, not IV.

Maybe your dose is small enough, but personally, I don't like the idea of injecting cardiotoxic epi IV, as a way to determine if you've accidentally given cardiotoxic bupivicane IV, when it's so easy to determine the same thing with omnipaque which is cardio-inert.

Safety of epinephrine for anaphylaxis in the emergency setting
"When is IV dosing of epinephrine in anaphylaxis appropriate?
While guidelines recommend that epinephrine be given via IM injection for the initial treatment of anaphylaxis,[8] IV delivery should be considered in special circumstances such as severely hypotensive patients, patients in cardiac or respiratory arrest, or those who have failed to respond to multiple IM injections of epinephrine.

For conventional labor epidurals, it was common in our residency to give a test dose from the kit to make sure the catheter wasn't IT or IV.

Test dose from the kit is usually 3 mL of lidocaine 1.5% and epi 1:200,000. Comes out to I think 15 mcg of epi.

Only seen a catheter go vascular maybe once or twice. The 15 mcg is a small dose and the highest I've seen the HR go was maybe 120s. Probably a confounding response since the patient is also somewhat anxious for the procedure.

 

[Ducttape]

yes but...

your typical labor parturient can reasonably tolerate an increased cardiac stimulation for 10-15 minutes. not so sure about your elderly spinal stenosis patient.

 

[SommeRiver]

Why would anyone put epi in a LSB? I just don't see any reason for it. Use contrast. Put the needle where it's supposed to go.