Priapism Following a Lumbar Sympathetic Nerve Block

Abstract

Objective. To understand an unusual complication of a common procedure.Design. This article chronicles the side effect of a lumbar sympathetic nerve block (LSNB). Setting. Loyola University Medical Center Outpatient Chronic Pain Clinic. Patients. One.Results. Our patient had several hours of priapism following a LSNB. Conclusions. A bilateral lumbar sympathetic nerve block can lead to unopposed parasympathetic penile stimulation and cause priapism.A 41-year-old presented to the outpatient Chronic Pain Clinic for continued treatment of complex regional pain syndrome type 1 (CRPS 1) in his left foot. The patient had sustained a gunshot wound to the left foot 7 years earlier.He had undergone multiple corrective surgeries to the foot. The patient's ability to walk had improved somewhat over the years, but his pain had continued to worsen. Prior to this encounter, he had received ankle blocks on two occasions with pain relief lasting only 2 days following each injection. Over a 6-week period in 2005, our clinic performed a series of four lumbar sympathetic nerve blocks (LSNBs), with pain relief lasting 2-4 weeks after each procedure. The patient was lost to follow up for the next 5 years.On this most recent encounter, the patient presented with the same pain complaint as he had 5 years earlier.He described his pain as sharp and constant in his entire left foot. His average pain score on a visual analog scale was 7/10. On exam, the patient was 5′9″ and 220 lbs. He had allodynia throughout the entire left foot, with mild swelling of the left ankle. There was decreased dorsiflexion and plantar-flexion at the left ankle. Temperature of the left foot prior to the procedure was 32.8°C compared with 31.4°C in the right foot. He was consented for LSNB.In the fluoroscopy suite, the patient was placed in the prone position and his back was prepared and draped sterilely. The temperatures of his feet were the same as in the exam room. We sedated the patient with a total of 2.5 mg i.v. midazolam. Using A/P and lateral fluoroscopic guidance, we placed a 22-gauge 5-in spinal needle at the anterio-lateral aspect of the L-3 vertebral body (Figure 1). Radiography with contrast injection confirmed correct needle placement (Figure 2), and 15 mL of 0.25 % bupivacaine with epinephrine 1:200,000 was then slowly injected. Vital signs were stable throughout the procedure. The patient was monitored for 30 minutes after the procedure. The temperature of his left foot increased from 32.8 to 33.2°C. In his right foot, the temperature also increased from 31.4 to 33.0°C.Within 10 minutes of the LSNB, the pain score in his left foot decreased from 7/10 to 3/10, and his range of motion improved significantly. The patient was discharged home. Three hours after the procedure, the patient called the clinic complaining of an erection that began on the car ride home, and was starting to become painful. After discussion with the Urology Service, we instructed the patient to present to the Emergency Department for evaluation. Fearing an additional embarrass...

Case Report

“…There is limited evidence reported in the literature regarding patients experiencing a priapism after an ALIF, however cases have been reported during other surgical procedures. Sniderman et al (2011) chronicled the side effect of a lumbar sympathetic nerve block that resulted in their 41-year-old patient experiencing an erection on the car ride home. Even though the patient was instructed to go to the emergency department for the evaluation of the painful erection, the patient feared embarrassment and painful treatment and chose not to present to the emergency department.…”

1.5 T augmented reality navigated interventional MRI: paravertebral sympathetic plexus injections

“…In cadaveric models, the blind techniques has sometimes resulted in pleural and renal needle localization (20); however, image guidance does not completely eliminate the risks associated with paravertebral sympathetic blocks. Studies have reported several complications, such as genitofemoral neuralgia, necrosis of the psoas muscle, injury of the kidney and ureter, bleeding, hypotension and impotence, permanent lesion to the lateral femoral cutaneous nerve, hemopneumothorax, priapism, Horner's syndrome, and massive retroperitoneal hematoma (21)(22)(23)(24)(25)(26). In addition, there are unique risks both to the patient and the operator associated with modalities that utilize ionizing radiation (27), and consideration for MRI-guided procedures may have particular relevance for patients who are younger or may require repeat procedures (28).…”