Lumbar sympathetic blocks

[schmee90]

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Relatively new Attending, haven’t actually done a a lumbar sympathetic block or hypogastric blocks.

I looked up a bunch of sources on how to actually do the blocks and they actually look fairly technically straightforward in terms of obliquing until the transverse processes lines up with the VB touching os and then walking off from a lateral position until the needle is dorsal a few mm to the anterior edge of the vert body to stay away from great vessels. Go back to back AP and making sure you’re in mid pedicular period inject contrast make sure you’re not in muscle or vasculature

Hypogastric block I know you’re dealing with iliac crest which makes life a little harder but other then that any pearls from more seasoned docs? Thanks in advance.

 

[willabeast]

I like a stick on temperature probe on both legs with a digital readout, usually can tell quickly if got the sympathetics. Combine a short acting with a long acting local anesthetic.

 

[Logano2230]

I would recommend bending the needle further back than you normally would, around 1cm from the tip. Keep in mind you are crawling around 3 dimensional cylindrical structure. Aligning TP within the vertebral body usually means you’re touching os at about 40% depth on vertebral body. One move lateral gets around the apex, then advance with bend pointed medially until depth is just short of anterior cortex.

Contrast should look bubbly like an interlam and be medial to lateral cortex on AP. If it’s a dark vertical stripe you’re probably in muscle and not medial enough. Can always reset with a more oblique approach if it’s not working.

 

[pastafan]

Review Furman's atlas. Very easy block to perform.

 

[schmee90]

Thanks all appreciate it, the insights

 

[giddyup]

For hypogastric you’ll often times need a good bit of tilt to get the iliac crest out of the way, it’s not uncommon for me to go up to 30 degrees

 

[schmee90]

For hypogastric you’ll often times need a good bit of tilt to get the iliac crest out of the way, it’s not uncommon for me to go up to 30 degrees

Im assumig you add quite a big of cephalad tilt to go over the top ofthe crest?

 

[painfree23]

What do you bill for the hypogastrics?

 

[interjectionreflection]

For hypogastric you’ll often times need a good bit of tilt to get the iliac crest out of the way, it’s not uncommon for me to go up to 30 degrees

Do you do transdiscal approach or above TP?

 

[hopefulgasman]

What are y'all putting for the injectate for this block

 

[giddyup]

Im assumig you add quite a big of cephalad tilt to go over the top ofthe crest?

Yes, up to 30 degrees. Ferguson view

 

[giddyup]

What do you bill for the hypogastrics?

64517

 

[giddyup]

Do you do transdiscal approach or above TP?

Above TP

 

[giddyup]

What are y'all putting for the injectate for this block

20ml 0.5 bup, would use rop if I was hopd but too $$ for private practice

 

[painfree23]

20ml 0.5 bup, would use rop if I was hopd but too $$ for private practice

Wow, that’s a strong block. How hypotensive do they get?

 

[Ducttape]

not usually hypotensive but it is a risk.
not as much tissue to vasodilate as, say a celiac.

for hypogastric, i use 10 ml 0.25% bupiv.


there is another way...

 

[giddyup]

Wow, that’s a strong block. How hypotensive do they get?

i do 10ml each side. i give them IV fluids. in 15 years never had an episode of hypotension

 

[BobBarker]

I give around 15ml local. Mix of lido and ropi.

 

[schmee90]

Ive seen different info on this on the safety view or the lateral view most text say you should be just dorsal to the VB, another say on the anterior border of the VB. Of course vasculature is anteior to the VB but I have seen a few text say can be just beyond. What are others thoughts on this?

Also if any trouble shooting tips if you are not getting the contrast spread you are looking for (other then advancing farther)

 

[bubaghanush]

Ive seen different info on this on the safety view or the lateral view most text say you should be just dorsal to the VB, another say on the anterior border of the VB. Of course vasculature is anteior to the VB but I have seen a few text say can be just beyond. What are others thoughts on this?

Also if any trouble shooting tips if you are not getting the contrast spread you are looking for (other then advancing farther)

Look at your imaging before and see where the vasculature is and how much room you have.

You can start with some contrast a couple mm before the anterior border so you're comfortable. Advance until good spread, I won't go more than a couple of millimeters beyond the border, depending on imaging. The medial angle of your needle should help hug the vertebrae.

I suppose you could try a slightly different angle or different vertebral level if you don't get good spread, but generally I see good spread and don't need to redirect.

 

[Orin]

Ive seen different info on this on the safety view or the lateral view most text say you should be just dorsal to the VB, another say on the anterior border of the VB. Of course vasculature is anteior to the VB but I have seen a few text say can be just beyond. What are others thoughts on this?

Also if any trouble shooting tips if you are not getting the contrast spread you are looking for (other then advancing farther)

The goal is to be hugging the VB medially and as far anterior as you can safely go while not being in a vessel. The ganglia chain appears on dissections or MRI to be at that anterior border, but it's a cylindrical structure that you're working around.

If you get into the tissue plane and have spread anterior without being close, wonderful.
If you get muscle spread, you want to aim more medial and advance.
If you see it vascular going to the spinal canal, stay out of the waist of the body.
If you see it vascular going craniocaudal, back up and get more medial.

My only tip would be to get two views if the contrast spread looks weird before deciding what to do.

 

[schmee90]

Thanks so much for the detailed resposnes...somehow i only got like 2 of these in fellowship that were pretty straight forward got the contrast spread was looking for right away...didnt have to trouble shoot much