Sympathetic Block Injections for Complex Regional Pain Syndrome

Stellate Ganglion Blocks

Stellate ganglion blocks are useful in the diagnostic and therapeutic treatment of complex regional pain syndrome. Complex regional pain syndrome is a diagnosis, which is made and treated with this block by your pain physician. This is a diagnosis and an injection, which targets the sympathetic nerve fibers to the region of the pain. The sympathetic nerve fibers are thought to carry painful nerve transmissions, which produce complex regional pain syndrome. If we can anesthetize those particular nerve fibers we can diagnose complex regional pain syndrome and these injections along with physical therapy can help treat this debilitating and chronic problem. After the diagnosis is made the patient will be offered the opportunity to have follow up treatments at times of pain when he cannot perform his physical therapy. Along with these two modalities, pharmacological treatment is also given. Complex regional pain syndrome is a very difficult disease to treat, especially after it has gone undiagnosed for over a year. Success can be seen the earlier treatment is start and continues. Please feel free to talk to your pain physician about the theories of the etiology or cause of complex regional pain syndrome. Here, in our pain clinic we try to inform the patient as much as possible so that his or her expectations of what the injections can do and how much work is involved by the patient in treating this disease process can be expected.

The possible side effects and/or contraindications are as follows:

  1. Anti-coagulation therapy. Any time there is risk of increased bleeding needle injections should not be used. Permission to come off your anticoagulants by the physician who placed you on them needs to be done before your pain physician can place an injection. There are risks in coming off anti-coagulants and these need to be discussed.
  2. Air in and around your lung is possible, yet rare.
  3. Recent heart attack.
  4. Glaucoma is a relative contraindication because these blocks have shown to provoke glaucoma.
  5. Certain cardiac arrhythmias are relatively contraindicated.

Possible side effects also include what is known as a Horner’s syndrome. These are side effects of the local anesthetic involved attacking the correct nerves that are targeted. These side effects include very warm upper extremity and side of your face. Also, the side of your face can become very dry as well as the mucous membranes on that side of your body. Your eyelid will droop and the blood vessels in your eye will dilate and make your eye look red. Also, changes in the pupil of the eye will occur, which may change your vision for the next hour or so. People also complain of a lump in their throat at the site of the injection where the local anesthetic is and the diaphragm can be affected. It is very important that if you do have a problem with your breathing in general before the injection you need to notify your pain physician before the injection.

The Injection: This is usually done in the surgery center with vital signs being monitored with the patient lying on their back in a sitting up position. The patient is asked to have a roll placed behind their shoulders and their head extended backwards and to have their mouth ajar for the injection. The injection itself takes less than one minute. It is a local anesthetic injection, which is done on the side of the neck involved. This is where the group of nerves lie that are of sympathetic origin to either upper extremity. Local anesthetic is placed in the skin before the injection. This is usually followed with a special needle just under the skin on the side of the neck. The muscle structures of the neck are displaced to the side and this is actually the most uncomfortable portion of the procedure, but this only lasts approximately 30 seconds as the needle is placed and a test dose of local anesthetic is injected. Once that is negative, the rest of the local anesthetic is injection in increments with aspiration in between to help prevent any sort of problems from the injection. The patient is awake and alert during the entire procedure and the injection take less than 30 seconds in most cases. If the patient feels any sort of side effects from the local anesthetic he/she will communicate with the pain physician and the infection will be slowed down or halted, depending upon the side effect. In general, this is a simple procedure that is relatively safe and is done on a routine basis in most pain clinics.

Complications: Complications are rare, but can include the following: Infection or bleeding at any needle injection site. Once again, if you are  on blood thinners you need to inform your pain physician and coming off the blood thinners needs to be discussed with your primary care physician who placed you on them. Air or fluid around the lung or injection of local anesthetic into the spine is possible. This is the reason why it is necessary for the physician who is performing this to be well-trained in the treatment of these complications, which includes life support, i.e. breathing for somebody who is unconscious. One can have local anesthetic toxicity during the injection if any of the local anesthetic winds up in a blood vessel. This is the reason why a test dose is performed, but even with the test dose one must always be aware of this as a complication. If this goes unrecognized or occurs quickly the patient can have a seizure from local anesthetic toxicity, which usually resolves spontaneously. Of course, all of these complications may seem frightening and I urge the patient to talk with their pain physician about these complications before the procedure so that their fears can be set aside and the complex regional pain syndrome that the patient has can be treated. A complete list of complications will be described to you. If this is a diagnostic block the patient’s pain from their complex regional pain syndrome should resolve in the next 10 minutes. Most patients with complex regional pain syndrome are kept for 30 to 45 minutes after this procedure and their pain scores are recorded. The patient returns depending upon how long the block lasts and how effective their physical therapy is with the block. These blocks can be performed over short periods of time because they do not include steroids. They simply include local anesthetic. As noted previously, this is just one facet of treatment for complex regional pain syndrome. Please talk to your pain physician about the whole treatment of this disease process.

Lumbar Sympathetic Blocks

Please see Stellate Ganglion Blocks for general information. This injection is performed for complex regional pain syndrome of either lower extremity. This again is a diagnostic/therapeutic block to make the diagnosis of complex regional pain syndrome and to be used in it’s treatment.

The Injection: The patient is brought into the operating room and placed in a prone position with a pillow under the abdomen and the C-arm is used for fluoroscopic guidance of needle placement. Vital signs are monitored and antiseptic solution is placed over the lower back just lateral to the spine. A large amount of local anesthetic is placed in the lower back before the actual lumbar sympathetic block needle is placed. This needle is placed under fluoroscopic guidance until it reaches the group of nerves controlling the sympathetic nerves of the lower extremities. This group of nerves lies next to your second lumbar vertebral body. Once the needle is in place x-ray dye is used to confirm needle placement in multiple positions. Then a test dose of local anesthetic is given to help make the pain physician certain that the tip of the needle is not in a blood vessel or the nerves of the spine. Once this is done an incremental amount of local anesthetic is placed in and around the lumbar sympathetics of that side of the body. This procedure is usually done within a 30 to 45 minute time frame and the patient is asked to stay with us for a total of 30 minutes after the procedure is performed.

Complications: Complications as with any other needle injection include infection and bleeding as a possibility. Once again, no needles will be placed if the patient is on a blood thinner of any type and the patient needs to speak with his or her primary care physician before they come off the blood thinner. Local anesthetic toxicity is a complication that is usually preceded by ringing in the ears or metallic taste in the mouth. If the patient feels this they are to report that to their pain physician during the procedure. If they do not this can go on to become a seizure. Injection of local anesthetic into the thecal sac or epidural space can give the patient temporary anesthesia from the waist down for the next several hours. Damage to the kidney or ureters to the bladder or any other structures between the skin and the lumbar sympathetic complex can occur. In general these are very safe infections in the hands of your pain physician and have been done many times in the past. Please talk to your pain physician about the complications before the infection. Minimal side effects will include a very warm lower extremity on the side of the injection from the normal dilatation of blood vessels in that extremity secondary to the local anesthetic. If the patient does indeed have complex regional pain syndrome that pain should start to dissipate over the next 5 to 10 minutes. This injection is just part of the overall total treatment of complex regional pain syndrome, which will include physical therapy and other pharmacological drugs.

Bier Blocks

Bier blocks are used in an upper or lower extremity to help combat complex regional pain syndrome after the diagnosis is made. These blocks are usually placed for complex regional pain syndrome in a hand, arm, foot or leg.

The Injection: This injection is done in a surgical center. An IV is placed in the extremity that is effected. A second IV in the normal extremity may also be placed. The extremity that is effected will then be wrapped in a plastic bandage to help squeeze the blood out of this extremity and to keep it out a tourniquet is placed in the upper arm or upper leg. Then local anesthetic and possibly a second medication will be injected into the limb. This may or may not anesthetize the limb for the next 15 to 30 minutes depending upon the medication. At this point the tourniquet will be deflated, vital signs will be monitored, and the patient will remain in the surgery center for the next 30 minutes for evaluation.

Complications: Potential complications do depend upon the drugs that are used in the injection, which include guanethidine, bretylium, labetalol, prazosin, clonidine and reserpine. Please note that IV guanethidine and reserpine are not readily available in the United States. A mixed alpha or beta antagonist, labetalol, may be used. As above, potential side effects do depend upon the drugs, but can include low blood pressure, dizziness, black out, and transient drop in blood flow to that effected limb called ischemia, which may or may not produce neuropathy. Please note that it is recommend that the patient do not eat or drink for up to four hours prior to this procedure.

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