46 Lumbar Sympathetic Block

Perspective

Lumbar sympathetic blocks are typically carried out to improve blood flow to the lower extremities or provide pain relief to the lower extremities.

Patient Selection

Patients requiring lumbar sympathetic block can be divided into two primary groups: (1) those requiring sympathetic block because of ischemic vascular disease to the lower extremities (these patients are often older); and (2) patients requiring the block for diagnosis or treatment of complex regional pain syndromes of the lower extremities (these patients have a much wider age range).

Pharmacologic Choice

Block of the sympathetic nervous system can be performed with lower concentrations of local anesthetics than almost any other regional block. For example, 0.5% lidocaine, 0.125% or 0.25% bupivacaine, or 0.1% or 0.2% ropivacaine are appropriate choices.

Placement

The lumbar sympathetic chain, with its accompanying ganglia, is located in the fascial plane immediately anterolateral to the lumbar vertebral bodies (Fig. 46-1). The sympathetic chain is separated from the somatic nerves by the psoas muscle and fascia. The lumbar regions L1, L2, and sometimes L3 provide white rami communicantes to the sympathetic chain, and all five lumbar vertebrae are associated with gray rami communicantes. These rami are longer in the lumbar region than in the thoracic region. This is anatomically important because it allows needle placement nearer the anterolateral border of the vertebral body in the lumbar region. Conceptually, the anatomy important to anesthesiologists performing lumbar sympathetic nerve block is also the anatomy important for celiac plexus nerve block.

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