Clinical Identification of the Vertebral Level at Which the Lumbar Sympathetic Ganglia Aggregate

Abstract

BackgroundThe location and the number of lumbar sympathetic ganglia (LSG) vary between individuals. The aim of this study was to determine the appropriate level for a lumbar sympathetic ganglion block (LSGB), corresponding to the level at which the LSG principally aggregate.MethodsSeventy-four consecutive subjects, including 31 women and 31 men, underwent LSGB either on the left (n = 31) or the right side (n = 43). The primary site of needle entry was randomly selected at the L3 or L4 vertebra. A total of less than 1 ml of radio opaque dye with 4% lidocaine was injected, taking caution not to traverse beyond the level of one vertebral body. The procedure was considered responsive when the skin temperature increased by more than 1℃ within 5 minutes.ResultsThe median responsive level was significantly different between the left (lower third of the L4 body) and right (lower margin of the L3 body) sides (P = 0.021). However, there was no significant difference in the values between men and women. The overall median responsive level was the upper third of the L4 body. The mean responsive level did not correlate with height or BMI. There were no complications on short-term follow-up.ConclusionsSelection of the primary target in the left lower third of the L4 vertebral body and the right lower margin of the L3 vertebral body may reduce the number of needle insertions and the volume of agents used in conventional or neurolytic LSGB and radiofrequency thermocoagulation.

Continuous Lumbar Sympathetic Blockade Enhances the Effect of Lumbar Sympatholysis on Refractory Diabetic Neuropathy: A Randomized Controlled Trial

“…Diabetic neuropathy pain management remains a challenge, and the overall outcomes of current pain management in diabetic neuropathy need to be improved [ 6 ]. Lumbar sympathetic block has been used to diagnose [ 13 ] and/or treat various types of pain, including visceral pain and complex regional pain syndrome I [ 14 – 17 ]. However, only a limited number of studies have explored this strategy for treating painful diabetic neuropathy.…”

Correlation between paravertebral spread of injectate and clinical efficacy in lumbar transforaminal block

“…Second, we only planned approaches through the sub-pedicle area; therefore, we could not evaluate the extent of PV spread via other approaches, including retro-neural or retro-discal routes. Third, the lumbar sympathetic ganglia vary in number, size, and location, and presumably aggregate above L4 10 . In our study, the injection site was mostly at L4; therefore, the sympatholytic response may not have been expressed sufficiently.…”

“…The exclusion criteria included any history of lumbar surgery; lumbar neuroplasty; neoplastic diseases; peripheral vascular disease affecting pain, perfusion index and/or cold sensation; or use of medications affecting the vascular system 14 . We also excluded injections at L5, as the clinical response to the lumbar sympatholytic effect is known to be significant above the level of the L4 vertebral body 10 , 15 . The lesion level for transforaminal injections was selected on the basis of clinical manifestations, physical examination, and review of imaging studies 14 .…”

“…The caudal boundary of the thoracic PV space is connected with the origin of the psoas major muscle 9 . Lumbar sympathetic ganglia are located on the anterolateral aspects of vertebral bodies L2, L2–3 disc, L3–4 disc, and L5 10 , 11 . Lumbar sympathetic block is indicated for the diagnosis and treatment of pain associated with sympathetic dysfunction, and is related to its prognosis 12 , 13 .…”

Quantitative Analysis of Real-Time Infrared Thermography for the Assessment of Lumbar Sympathetic Blocks: A Preliminary Study

“…The injection of a local anesthetic drug (such as bupivacaine, lidocaine or ropivacaine) around the sympathetic ganglia temporarily alters their functions and provides pain relief [ 21 , 22 ]. When lower extremities are affected, lumbar sympathetic blocks (LSBs) are performed, blocking the lumbar sympathetic ganglia between lumbar vertebral levels L2 and L4 [ 23 , 24 ]. Lumbar sympathetic blocks have been questioned by several authors for the treatment of upper and lower limb CRPS [ 2 , 25 , 26 ].…”