Lumbar Sympathetic Block for Bilateral Post-Prostatectomy Lower Extremity Pain in the Femoral Nerve Distribution

Abstract

Objective: Lower extremities nerves damage is a known complication of prostatectomies. Lumbar sympathetic block is a well-established treatment for sympathetically-mediated lower extremity pain. We report a case of bilateral lower extremity pain in a femoral distribution that developed after a robotic assisted prostatectomy and resolved after a lumbar sympathetic block.Case Report: A 69-year-old male patient presented with bilateral thigh pain one month after an uneventful robotic-assisted laparoscopic prostatectomy in the femoral nerve distribution. CT scan was unremarkable save for expected postsurgical changes. The patient failed conservative treatment. Considering a possible sympathetically-mediated pain, we performed a right lumbar sympathetic block that improved his pain. Conclusions:A lumbar sympathetic block can be used a salvage therapy when conservative management fails. Materials and MethodsPatient informed consent was obtained for submission of the case report. Case PresentationA 69-year-old male patient with a history of well controlled noninsulin-dependent diabetes presented to the pain clinic with unbearable bilateral thigh pain. One month prior to presentation he underwent an uncomplicated robotic-assisted laparoscopic nerve sparing radical prostatectomy with lymph node dissection. Three days after an uneventful postoperative course, he developed a worsening sharp, shooting pain involving the L1, L2, L3, L4 dermatomes, worse on the right side, exacerbated by weather changes, associated with allodynia and hyperalgesia over the affected areas. There was no associated motor weakness, swelling, fever, or muscle spasm. CT scan of the abdomen and pelvis with and without contrast were unremarkable save for expected postsurgical changes.The patient failed conservative treatment including Amitriptyline, Gabapentin, Zonisamide, Duloxetine, and Oxycodone. Due to lack of response to neuropathic medications and a possibly sympathetically-mediated pain, we attempted a right lumbar sympathetic block the mid L3 vertebral body. On follow-up, the patient reported 80% pain reduction, with pain reported as 2/10 which decreased from 8-9/10 pre-injection and an increase in function.