Targeting Gray Rami Communicantes in Selective Chemical Lumbar Sympathectomy
January 10th, 2019
We present a protocol for selective chemical lumbar sympathectomy (CLS), which inactivates only gray rami communicantes and not the sympathetic trunk. Selective CLS can help achieve therapeutic efficacy in vasodilation, sweat reduction, and pain relief that are comparable to conventional CLS, and serious complications, particularly ureteropelvic damages, can be reduced.
Ureteropelvic damage is the most frequently reported serious complication of conventional chemical lumbar sympathectomy or CLS. Although it is relatively rare, it is very harmful to patients. This protocol aids in the precise delivery of the activating agents behind the anterior fascia of the psoas major muscle, allowing selective targeting of gray rami communicantes, thus the safety of CLS can be largely improved.
Before initiating the treatment procedure, confirm the presence of indications and lack of contraindications based on the patient's clinical and laboratory results. Disinfect an approximately 30 centimeter area of skin two times at the planned needle puncture site with 2%entoiodine and cover the patient's back with surgical towels. Using lateral thoroscopy guidance, anesthetize the skin and the entire needle tract with 5-8 milliliters of 0.5%lidocaine without vasoconstrictors, advancing the needle to the vertebral body surface gradually.
Position the needle tip in the optimal injection area by using lateral view lumbar x-ray. Then, inject 0.5 milliliters of contrast agent to confirm the needle tip is behind the anterior fascia of the psoas muscle. If the contrast agent remains mainly confined to the optimal area with spreading along the psoas major muscle, the needle placement was successful.
Inject 2 milliliters of 5%aqueous phenol solution into the injection site, adjusting the needle tip direction to ensure that 1 milliliter of phenol spreads toward the patient's head and that 1 milliliter spreads toward the patient's feet. When the phenol has been injected, withdraw the needle from the skin and compress and cover the puncture site with gauze to achieve hemostasis. Five minutes after the injection, confirm a satisfactory sympathetic interruption as a rise of at least 2 degrees Celsius in skin temperature.
If satisfactory interruption is not achieved, perform a supplemental injection to another optimal area with a total phenol volume of no larger than 10 milliliters in one day. Measure the patient's skin temperature again, calculating the average among the temperature increases in the shin, plantar, and dorsal foot. Before injecting the phenol solution, confirm that the needle tip is located within the optimal area.
In selective CLS, the contrast agent is injected behind the anterior fascia of the psoas major muscle, targeting the gray rami communicantes. The expected clinical effects are vasodilation, sweat reduction, and pain relief. A precise placement of the needle tip and evaluation of the contrast agent spreading are critical for ensuring an accurate targeting of the gray rami communicantes in CLS treatment.
With selective CLS, the risk of operation is largely reduced, so the indications for CLS could be widened.
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Overview
This article presents a protocol for selective chemical lumbar sympathectomy (CLS), targeting gray rami communicantes while sparing the sympathetic trunk. This approach aims to enhance therapeutic outcomes in vasodilation, sweat reduction, and pain relief, while minimizing serious complications such as ureteropelvic damage.
Key Study Components
Area of Science
- Neuroscience
- Clinical Protocols
- Pain Management
Background
- Ureteropelvic damage is a significant complication of conventional CLS.
- Selective targeting can improve safety and efficacy.
- The protocol focuses on precise delivery of activating agents.
- Clinical indications and contraindications must be assessed prior to treatment.
Purpose of Study
- To improve the safety of CLS procedures.
- To achieve comparable therapeutic efficacy to conventional methods.
- To reduce the incidence of serious complications.
Methods Used
- Disinfection of the skin at the needle puncture site.
- Use of lateral thoroscopy guidance for needle placement.
- Anesthesia of the skin and needle tract with lidocaine.
- Gradual advancement of the needle to the vertebral body surface.
Main Results
- Improved safety profile for CLS procedures.
- Effective targeting of gray rami communicantes.
- Reduction in ureteropelvic damage incidents.
- Therapeutic outcomes comparable to conventional CLS.
Conclusions
- Selective CLS enhances patient safety.
- Protocol can be effectively implemented in clinical settings.
- Further studies may validate long-term outcomes.
