|Year : 2014 | Volume
| Issue : 1 | Page : 24-28
Chemical lumbar sympathetic plexus block in Buerger's disease: Current scenario
Rampal Singh1, Aparna Shukla2, Lakhwinder Singh Kang1, Anand Prakash Verma1
1 Department of Anesthesiology, Rohilkhand Medical College and Hospital, Bareilly, Uttar Pradesh, India
2 Department of Anesthesiology, Integral Institute of Medical Sciences and Research, Lucknow, Uttar Pradesh, India
|Date of Web Publication||15-Mar-2014|
Department of Anesthesiology, Integral Institute of Medical Sciences and Research, Lucknow, Uttar Pradesh - 226 026
Source of Support: None, Conflict of Interest: None
Introduction: High incidences of Buerger's disease (43-62%) in India draw our attention towards available treatment modalities in such patients. Patients with this disease are in severe pain and agony. Pain relief by any means remains first and foremost priority in such patients and if patient is able to sleep even one pain free night it is a boon for the patients. The purpose of study was to test the hypothesis that lumber sympathetic block relieves the pain of ischemic limb in Buerger's disease. Aims and Objectives: To study the effect of chemical lumber sympathetic block on visual analog score (VAS) score and walking distance of the patients. Materials and Methods: Lumber sympathetic block was given under C-arm guidance with 17.5 cm long 22 G spinal needle at L3 and L4 level. Diagnostic block was given initially with plain bupivacaine 0.25% with two needle technique. Total seven blocks series were given in all patients. Final block was given with phenol 8%, 8 ml at L3 and L4 level. In postoperative period, VAS score was observed. Effect of block on walking distance was assessed on 3 rd day before giving next block. Statistical analysis: Software Statistical Package for Social Sciences (SPSS) version 11.5 was used for statistical analysis. Data were analyzed by paired t-test and P-value < 0.05 was considered as significant. Results: Both VAS and walking distance improved significantly after each successive block. Healing of ulcers of foot is also noted. Conclusion: Despite advances in treatment modalities in such patients, lumber sympathetic block is still very cost-effective, safe, and least-invasive technique in treating painful ischemic legs.
Keywords: Buergers′ disease, phenol, sympathectomy
|How to cite this article:|
Singh R, Shukla A, Kang LS, Verma AP. Chemical lumbar sympathetic plexus block in Buerger's disease: Current scenario. Indian J Pain 2014;28:24-8
|How to cite this URL:|
Singh R, Shukla A, Kang LS, Verma AP. Chemical lumbar sympathetic plexus block in Buerger's disease: Current scenario. Indian J Pain [serial online] 2014 [cited 2019 Aug 20];28:24-8. Available from: http://www.indianjpain.org/text.asp?2014/28/1/24/128888
| Introduction|| |
The outstanding symptom that occurs when the circulation to an extremity is impaired is pain. Thromboangiitis obliterans or Buerger's disease principally affects the young male smokers and is mainly a disease of medium sized and small limb arteries. , Smoking is very common in India and so the incidence of Buerger's disease. Although extensive experimentation has been done in this field and today various surgical and nonsurgical management options are available for managing ischemic limb ulcers. But, the results are inconsistent, controversial, and often unsatisfactory. Moreover, these techniques are costly and success depends on operator's expertise and comfort level. It has been a hypotheses that lumber sympathetic block relieves pain of ischemic limb. This study was conducted to study the beneficial effects of lumber sympathetic block on visual analog score (VAS) score and walking distance of affected patients.
| Materials and Methods|| |
The study was conducted in our Department of Anesthesiology during January 2011-June 2013 on 15 adult male patients. Inclusion criteria were:
- Patients having peripheral vascular disease,
- History of chronic smoking,
- Redness, shining, swelling, and increased temperature of the affected extremity,
- Necrosis of great toe,
- Absence of dorsalispedis artery in involved limb, and
- Color Doppler studies showed partial thrombosis of major vessels in lower limb like popliteal, posterior and anterior tibial artery.
After taking ethical committee consent, all patients were instructed nil by mouth night before procedure. After wheeling patients in operation theater table, 20 G intravenous (IV) line was secured and baseline monitors attached. Patients were positioned prone and one pillow was kept under abdomen to reduce lumbar lordosis. Under all aseptic precautions L3 and L4 vertebral level was identified with the help of image intensifier and a 17.5 cm long 22 G spinal needle was passed below the transverse process of vertebral body [Figure 1]. Needle is then advanced slowly to its lateral border so that it ultimately rested on the anterolateral margin of the vertebral body. After confirming the needle tip at the level of anterolateral border of vertebrae, 2 ml of nonionic water soluble dye (Iohexol, Omnipaque 300) mixed with the 1 ml of 2% lignocaine was instilled through needle and spread of dye was visualized [Figure 2]. Spread of dye just anterolateral to the vertebral body in cranial and caudal direction confirmed the correct needle placement. After careful aspiration for blood or cerebrospinal fluid, 10 ml of 0.25% bupivacaine mixed with 1 ml contrast dye injected at L3 and L4 level. In all patients, first diagnostic block was given with plain bupivacaine 10 ml, 0.25% at L3 and L4 level. Then five therapeutic blocks were given with same concentration of bupivacaine to obtain maximum vasodilatation of vessels. After first block, every successive block was repeated on 3 rd day. Relief of rest pain was indicative of successful block. Final (seventh) block was given with 8 ml of 8% phenol at L3 and L4 level. After each block VAS was assessed in immediate postoperative period and walking distance was assessed by a blind observer 3 rd day after giving block. Necrotic tissues were removed surgically. Dressing was done regularly. Each patient received antibiotics, analgesics, and antiplatelet drugs (cilostazole 100 mg twice a day and ecosprin 75 mg once a day) for 16-20 weeks.
|Figure 1: Showing the spinal needle at L3 vertebral level in end on position in anteroposterior view|
Click here to view
|Figure 2: Showing spinal needle in lateral position at anterolateral border and craniocaudal spread of dye at L3 and L4 vertebral level|
Click here to view
Statistical Package for Social Sciences (SPSS) 11.5 version software was used for data calculations and data was analyzed by paired t-test. P-value considered significant when it was less than 0.05.
Sample size was calculated with the help of following formula:
Z = Z value (e.g., 1.96 for 95% confidence level), p = percentage picking a choice, expressed as decimal (0.5 used for sample size needed), c = confidence interval, expressed as decimal, (e.g., 0.04 = ± 4)
| Results|| |
All patients were male and they were between age group of 30 and 50 years (mean 37.8 years). History of smoking was positive in all patients and they were in severe pain (VAS between 9 and 10).
There was involvement of great toe in all cases with involvement of fingers in some [Table 1].
Effect of block on Vas
Effect of each successive block on pain score was compared with base line pain score (a) i.e. before giving chemical lumbar sympathetic plexus block. Baseline pain score was 9.73 ± 0.46 (mean ± standard deviation (SD)). After giving the first block (b), VAS score improved to 6.93 ± 0.26. Difference was significant statistically, P < 0.0001. It was observed that with each block VAS was improved significantly.
Seventh block (g) was given with 8 ml of 8% phenol with Iohexol 300. When compared with preblock (a), the mean of VAS was 9.73 ± 0.46 vs 1.00 ± 0.00 (a vs g), P < 0.0001 [Table 2].
Effect of block on walking distance
Effect of block was also observed on walking distance. Relock (wd-a) data were compared with successive sympathetic plexus block. When preblock walking distance (wd-a) was compared with walking distance after first block (wd-b), the difference was statistically significant. Mean of walking distance (wd-a vs wd-b, mean ± SD) was 22.3 ± 15.91 vs 36.00 ± 20.28, P < 0.0001.
In same way when group wd-a was compared with group wd-b, wd-c, wd-d, wd-f, wd-g, wd-h, the mean ± SD between different groups was 22.3 ± 15.91 vs 46.20.28, 22.3 ± 15.91 vs 66.67 ± 20.93, 22.3 ± 15.91 vs 236.67 ± 76.69, 22.3 ± 15.91 vs 426 ± 109.98, 22.3 ± 15.91 vs 620 ± 101.42, 22.3 ± 15.91 vs 823.33 ± 108.34, respectively. P-value was highly significant for all the comparable groups [Table 3].
| Discussion|| |
In Buerger's disease, pain in the extremities is a local manifestation of a generalized pathological process leading to thrombosis in both the arteries and veins, associated with a certain degree of perivascular inflammation and there is formation of ischemic limb ulcers. Patients with ischemic limb ulcers are not only disabled by pain, but are frequently socially neglected; and when pain becomes unbearable, patient himself requests for amputation of affected extremity. ,
Various treatment modalities are now available for symptomatic pain relief in these patients. ,,, People have even tried substituting smokeless tobacco for cigarette.  It has been hypothesis that blocking the lumber sympathetic chain effectively reduces pain of ischemic limb and improves circulation by producing vasodilatation.
We carried out this study to assess the effectiveness of fluoroscopy-guided chemical lumbar sympathetic block on VAS score and walking distance. Eight milliliter of 8% phenol was used for chemical sympathectomy. We noticed that there was improvement in VAS score and walking distance with each successive block in all patients. VAS was 9.73 ± 0.46 after seventh block and it was significantly higher than preblock VAS which was 1.00 ± 0.00. The walking distance also improved significantly after seventh block 22.3 ± 15.91 vs 823.33 ± 108.34 before giving block. We also noticed healing of ulcers and color change in gangrenous limbs [Figure 3].
|Figure 3: Showing healing of ischemic ulcer on great toe and color change after successive block|
Click here to view
Similar to our study Mashiah et al., performed phenol lumber sympathetic block in patients with arteriosclerotic peripheral vascular disease and lower limb ischemia.  In over 24-120 months of follow-up, 219 patients (58.7%) experienced total relief from pain and healing of gangrenous ulcers, although the treatment was unsuccessful in 154 patients. A favorable result was marked in diabetic patients who had rest pain and in nondiabetic patients who had digital gangrene or digital ulcers. Age and sex did not affect the results but heavy smoking did. They opined that phenol sympathectomy should be considered as an alternative to surgical sympathectomy.
Cheng et al.,  tested the hypothesis that sympathetic nerve blocks significantly reduce pain in a patient with painful diabetic neuropathy who has failed multiple pharmacological treatments. A series of nine lumbar sympathetic blocks over a 26-month period provided sustained pain relief in his legs. They observed that lumbar and thoracic sympathetic nerve blocks significantly improved the circulations and reduced neuropathic pain in this patient with diabetic small fiber sensory neuropathy. The analgesic effects were reproducible upon repeated blocks and were long-lasting (sustained 2-4 months after each block).
Lumbar sympathetic blocks have been used widely by other workers also in treating patients with chronic pain conditions in the lower limbs such as complex regional pain syndromes and they were satisfied with the results. ,
| Conclusion|| |
Lumber sympathetic block is cost-effective, noninvasive, and less risky technique in relief of pain in Buerger's disease. Pain is relieved from the first block itself which is evident by improvement of VAS score. Eventually there is improvement in walking distance also and patient is able to do his routine work.
| References|| |
|1.||Piazza G, Creager MA. Thromboangiitis obliterans. Circulation 2010;121:1858-61. |
|2.||Dargon PT, Landry GJ. Buerger's disease. Ann Vasc Surg 2012;26:871-80. |
|3.||Espinoza LR. Buerger's disease: Thromboangiitis obliterans 100 years after the initial description. Am J Med Sci 2009;337:285-6. |
|4.||Malecki R, Zdrojowy K, Adamiec R. Thromboangiitis obliterans in the 21st century - a new face of disease. Atherosclerosis 2009;206:328-34. |
|5.||Bozkurt AK, Cengiz K, Arslan C, Mine DY, Oner S, Deniz DB, et al. A stable prostacyclin analogue (iloprost) in the treatment of Buerger's disease: A prospective analysis of 150 patients. Ann Thorac Cardiovasc Surg 2013;19:120-5. |
|6.||Idei N, Soga J, Hata T, Fujii Y, Fujimura N, Mikami S, et al. Autologous bone-marrow mononuclear cell implantation reduces long-term major amputation risk in patients with critical limb ischemia: A comparison of atherosclerotic peripheral arterial disease and Buerger disease. Circ Cardiovasc Interv 2011;4:15-25. |
|7.||Fadini GP, Agostini C, Avogaro A. Autologous stem cell therapy for peripheral arterial disease meta-analysis and systematic review of the literature. Atherosclerosis 2010;209:10-7. |
|8.||Tavakoli H, Salimi J, Rashidi A. Reply: "Treatment-of-choice for Buerger's disease (thromboangiitis obliterans): Still an unresolved issue." Clin Rheumatol 2008;27:813. |
|9.||Lawrence PF, Lund OI, Jimenez JC, Muttalib R. Substitution of smokeless tobacco for cigarettes in Buerger's disease does not prevent limb loss. J Vasc Surg 2008;48:210-2. |
|10.||Mashiah A, Soroker D, Pasik S, Mashiah T. Phenol lumbar sympathetic block in diabetic lower limb ischemia. J Cardiovasc Risk 1995;2:467-9. |
|11.||Cheng J, Daftari A, Zhou L. Sympathetic blocks provided sustained pain relief in a patient with refractory painful diabetic neuropathy. Case Rep Anesthesiol 2012;2012:2853-28. |
|12.||Carroll I, Clark JD, Mackey S. Sympathetic block with botulinum toxin to treat complex regional pain syndrome. Ann Neurol 2009;65:348-51. |
|13.||Van Eijs F, Stanton-Hicks M, Van Zundert J, Faber CG, Lubenow TR, Mekhail N,et al. Evidence-based interventional pain medicine according to clinical diagnoses. 16. Complex regional pain syndrome. Pain Pract 2011;11:70-87. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]