Rev. Bras. Anestesiol. vol.68 número1

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RevBrasAnestesiol.2018;68(1):100---103

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologia

www.sba.com.br

CLINICAL

INFORMATION

Neurolitic

block

of

the

lumbar

sympathetic

chain

improves

chronic

pain

in

a

patient

with

critical

lower

limb

ischemia

Elton

Pereira

de

Sá

Barreto

Junior

∗

_,

_Jedson

_dos

_Santos

_Nascimento,

Anita

Perpetua

Carvalho

Rocha

de

Castro

CETSantaCasadeMisericórdiadaBahia,Salvador,BA,Brazil

Received28February2015;accepted23March2015 Availableonline17September2016

KEYWORDS

Intractablepain; Ischemia; Treatment

Abstract

Backgroundandobjectives: Sympathectomyisoneofthetherapiesusedinthetreatmentof chronicobstructivearterialdisease(COAD). Althoughnotconsideredasfirst-linestrategy,it shouldbeconsideredinthemanagementofpaindifficulttocontrol.Thisclinicalcasedescribes theevolutionofapatientwithinoperableCOADwhorespondedproperlytothelumbar sympa-theticblock.

Casereport: Afemalepatient,afro-descendant,69yearsold,ASAII,admittedtothealgology serviceduetorefractoryischemicpaininthelowerlimbs.Thepatienthadundergoneseveral surgicalproceduresandconservativetreatmentswithoutsuccess.Vascularsurgeryconsidered thecaseasoutoftherapeuticpossibility,unlesslimbamputation.Atthattime,sympathectomy wasindicated.Afteradmissiontotheoperatingroom,thepatientwasmonitored,positioned andsedated.Theblockadewasperformedwiththeaidofradioscopy,bilaterally,atL2---L3---L4 rightandL3leftlevels.Ontherightside,ateachlevelcited,3mLofabsolutealcoholwith 0.25%bupivacainewereinjectedwithoutvasoconstrictor,andontheleftsideonlylocal anes-thetic.Theprocedurewasperformeduneventfully.Thepatientwasdischargedwithcomplete remissionofthepain.

Conclusion:Neuroliticblockofthelumbarsympatheticchainisaneffectiveandsafetreatment optionforpaincontrolinpatientswithcriticallimbischemiapatientsinwhomtheonlypossible interventionwouldbelimbamputation.

∗_{Corresponding}_author.

E-mail:elton.sa.junior@gmail.com(E.P.BarretoJunior). https://doi.org/10.1016/j.bjane.2015.03.011

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Neuroliticblockofthelumbarsympatheticchainimproveschronicpaininapatient 101

PALAVRAS-CHAVE

Dorintratável; Isquemia; Tratamento

Bloqueioneurolíticodacadeiasimpáticalombarmelhoradorcrônicaempaciente

portadoradeisquemiacríticademembroinferior

Resumo

Justificativa/objetivos: A simpatectomia é uma das terapêuticas usadas no tratamento da doenc¸aarterialobstrutiva crônica(DAOP).Emboranãoseja consideradacomoestratégiade primeiralinha,deveserlembradanomanejodosquadrosdedordedifícilcontrole.Estecaso clínico descreve aevoluc¸ão deuma paciente portadorade DAOPinoperávelque respondeu adequadamenteaobloqueiosimpáticolombar.

Relatodecaso: Pacientedosexofeminino,parda,69anos,estadofísicoII,acompanhadano servic¸o de algologia devido a dor isquêmicarefratária em membros inferiores. A paciente já haviasidosubmetida adiversasabordagenscirúrgicasetratamentosconservadores,sem sucesso.Acirurgiavascularconsiderouocasocomoforadepossibilidadeterapêutica,anãoser amputac¸ãodomembro.Nessemomento,foiindicadasimpatectomia.Apósadmissãonocentro cirúrgico, apaciente foimonitorada,posicionadaesedada.Obloqueiofoifeitocomauxílio daradioscopia,bilateralmente,nosníveisL2-L3-L4àdireitaeL3àesquerda.Doladodireito, em cadanível citado,foraminjetados3mLde álcoolabsolutocombupivacaína0,25% sem vasoconstritor edoladoesquerdosomente oanestésicolocal.Oprocedimentofoifeitosem intercorrências.Apacienterecebeualtacomcompletaremissãodador.

Conclusão:O bloqueioneurolítico dacadeia simpática lombaré uma opção de tratamento eficazeseguraparacontroledadorempacientesportadoresdeisquemiacrítica,nosquaisa únicaintervençãopossívelseriaaamputaçãodomembro.

Introduction

Chronicobstructivearterialdisease(COAD)ischaracterized byareducedbloodflowinthelowerlimbsarterialbeds.It hasmultipleetiologies,ofwhichatherosclerosisisthemost important.Patientswiththisdiseaseremainasymptomatic untiltheaffectedvessellumenhasanobstructiongreater than50%,whenanintermittentclaudicationoccurs.Inthe laterstagesofthedisease,painatrest,ulcersandgangrene, andcriticalsignsofischemiaoccur.1

DatafromAmericanstudiesshowthatacriticalischemia is found in 12%of the adult population andis more com-monintheelderlyandinmales.2_The_treatment_is_based_on

the revascularization of affected arterial territory,either usingopen techniques, suchas bypasssurgery or through endovascularandstentingprocedures.3_In_some_cases,_the

outcomeis pooranditis notpossibletore-establish ade-quatebloodflow.Fortunately,lessthan10%ofpatientswith criticallowerlimbischemia(CLI)requireamputation.4_The

recommendedtreatmentaimstorelievesymptomsand con-sistsoftheuseofanalgesics,prostaglandinsandstemcells, the latter two remain experimental.5,6 _In _case _of

refrac-torypain,lumbarsympathectomyisrecommended.Theaim of thisarticle is toreportthe case ofa patientwithCLI, successfullytreatedwithneuroliticblockofthelumbar sym-patheticchain,andperformasystematicreviewoflumbar sympathectomyasCLItreatment.

Case

report

JRSB,female patient,Afro-descendant, 69years-old, pre-sentedwithsystemichypertensionandCOAD;monitorated inthealgologyserviceduetodifficulttotreatlowerlimb

pain.Thepainwasexcruciating(numericalverbalscale10), burningtype,moreseveretotheright,whichappearedeven atrestandworsenedwhenwalking,improving whenlimbs wereoutstanding. The physical examination showed non-fixedcyanosisinrighttoesandabsenceofpopliteal,fibular andtibialpulsesintheipsilaterallimb.

Thepatienthadalreadyundergone varioustreatments, includingmultiple surgical interventions, suchasstenting incommoniliacarteriesandfemoropoplitealbypassinthe right lower limb. However, there wasno improvement in pain symptoms. He was taken tramadol (400mg.day−1_),

amitriptyline (25mg.day−1_), _gabapentin ₍₃₀₀_mg.day−1_),

anddipyrone(8g.day−1_)._Important_to_note_that_the_doses

of amitriptyline and gabapentin are below those recom-mended, as the patient had major side effects caused by these two drugs. Arteriography showed right common femoralarteryobstructionandipsilateralocclusionofthe superficial femoral artery. Duplex scanning of the venous system showed thrombus in left common and superficial femoralveinsandleftpoplitealvein.Basedontheclinical picture,the vascular surgery indicated amputationof the rightlowerlimb duetothetechnicaldifficultiesofanew revascularizationandthepossibilityofworseningsymptoms ofcontralaterallimb,alsoaffectedbyvasculardisease.Due tointractablepain,the algologyservice suggestedlumbar sympathectomy.

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102 E.P.BarretoJunioretal.

andL3totheleft,bothwithanumber22GQuinckeneedle. Following confirmationof needlepositioning and observa-tionofcontrastdispersionineachlevelmentioned,3mLof absoluteethanolwithbupivacainewithoutvasoconstrictor (WV) were injected on the right side and 20mL of bupi-vacaine25% WV onthe leftside. The patient, therefore, underwentrightneuroliticblockandleftanestheticblock, inordertoachievevasodilationandcentraldesensitization, withconsequentpainrelief.Theprocedurewasuneventful andafter24hoursthepatientwasdischargedwithcomplete remissionofthepain.

Afteroverayearoftheinterventionthepatientremains painfree.

Discussion

Peripheralarterialdiseaseisquitecommon.Theestimated worldwideprevalenceofCOADis 10%.Itis believed, how-ever, that these data are still underestimated, as most patientsremainasymptomaticforalongtime.1

COAD has an insidious course. Patientswill only show symptoms when more than 50% of the vessel lumen is affected.Some,however,remainasymptomaticdespitethe diseaseseverityduetothepresenceofalargenetworkof collateralspresentinthelowerlimbs.Whenchronic obstruc-tionisnotcompensatedbythecollaterals,criticalischemia occurs. The manifestation of CLI is severe and persistent painatrestthatdoesnotdecreasewithusualanalgesics,it worsenswhenthelimbsareelevated anddecreaseswhen theyarepending,and maybe associated withulcersand gangrene.In moresevere cases,due topainseverity,the patientdoes notsleep and develop psychiatric disorders, suchasanxietydisorder.

About 5---10% of patients with COAD will progress to critical ischemia.1,7 _The _treatment _in _these _cases _is

performed through revascularization techniques, such as bypass,endarterectomy, andendovascular stenting. How-ever,in some situationsin whichtheaffected sitecannot berevascularized,theindicationforamputationistheonly therapeuticoption,asothertreatments,suchascelltherapy andtheuseofprostaglandins,L-arginine,andcarnitine,are stillexperimentalorhavediscreteresults,respectively.8---11

Lumbar sympathetic blockage arises as a treatment optionincasesinwhichthepainispersistent, revasculariza-tionisnotfeasible,andthereisindicationforamputation. Sympathectomy for arterial occlusion treatment is described since the beginning of the twentieth century, when in 1924 Jules Diez, used this technique to treat a patientwiththromboangiitisobliteransinArgentina.12_Since

then,severalstudieshavedemonstratedtheefficacyofthis therapyforpatientswithperipheralarterialdisease.

The pain control after sympathectomy is primarily relatedtothe vasodilatoryeffects that ithas onthe col-lateralcirculation.Theincreaseinoxygenationmeansless tissuedamageand,therefore,lesspain.Moreover,the inter-ruptionofpainfulroutesmaintainedbythesympatheticand theneuroliticdirecteffectonnociceptivefiberscontribute tothiseffect.Inthiscase,absoluteethanolwasused,which causesdehydrationofneuraltissue,resultinginsclerosisof nervefibersanddestructionofmyelin.

Yoshidaetal.,13_treating₂₀_patients_with_peripheral

vas-culardiseasewithphenolicsympatheticblockade,reported thatin73%ofcasestheresultswereconsideredgood. Dia-betes andankle brachialindex <0.3were associatedwith lowersuccessrate.

Holliday et al.14 _evaluated ₇₀ _patients _with _CLI

with-out possibility of vascular reconstruction. The short-term success rates(six weeks)ofpatientstreated withsurgical sympathectomy was 44% versus 18% for chemical sympa-thetic blockade. In the long-term (one year), however, success ratesweresimilar,47%and45%,respectively.The procedureswereassociatedwithlowmorbidity.

Sannietal.15_in_a_systematic_review_compiled_the_results

of 13 studies of the subject and concluded that lumbar sympathectomy improves on a sustained basis the symp-toms of patients with CLI.They further state that it is a minimallyinvasiveprocedurewithfewcomplicationsrates. Nesagikaretal.16 _by_applying_a_vascular_surgeon

question-naireonindications,outcomes,andcomplicationsoflumbar sympathectomy,reportedthatthemainindicationfor lum-barsympathectomyis painatrest inpatients withsevere peripheralocclusivediseasewithoutsurgical revasculariza-tionconditions.Lumbarsympatheticblockadewasalsoused totreatulcers,Raynaudphenomenon,andasa‘‘bridge’’for revascularization,inordertoimprovethesurgicaloutcome. Noseriouscomplicationswerereportedbyrespondents.

Infact, compared tothe surgical blockade the chemi-calblockadewithalcoholor phenolissafer, lessinvasive, withvirtuallynomorbidityandmortality.Fewcasesof uri-nary retention, neuritis,and hematomawere reportedas complications.16

Thedurationofanalgesiaisstilluncertain.Somestudies have shown that,aftera year,more thanhalf of patients remainpainfree.Moreover,becauseitisafairlysafe pro-cedure,thechemicalblockadecouldbeperformedasmany timesasnecessarytoachievecontrolofthepainful condi-tionofthepatient.17,18

Inthispaper, wereport thecase of apatientwithCLI successfully treatedwithlumbar sympatheticblock.After over a year ofthe intervention,the patientremains with controlledpainsymptomsandwasnotnecessarytosubject himtoamputation.

Giventheabove,itcanbeconcludedthattheneurolitic blockofthelumbarsympatheticchainisaneffective treat-ment option, relatively safe, for pain control in patients withcriticallimbischemia,inwhichtheonlypossible inter-ventionwouldbeamputation.Professionalswhoworkwith these patients should remember that lumbar sympathec-tomyisanadditionaltherapeuticstrategythatcanbeused in orderto avoid a surgical traumatic treatment, suchas limbmutilatingsurgeries,whichareassociatedwithaworse prognosis.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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