How is a cervicothoracic sympathetic block administered for pain management?

Updated: Jun 19, 2018
  • Author: Anthony H Wheeler, MD; Chief Editor: Meda Raghavendra (Raghu), MD  more...
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Answer

Answer

The lumbar and twelfth thoracic vertebral spines are identified and marked, and parallel lines to the vertical axis of the spine are drawn 7-8 cm from the axial midline. Then the tip of the twelfth rib is palpated and marked. Another mark is placed in the midline between the twelfth thoracic and first lumbar vertebral spines. Connecting lines between these 3 marks produce a flat isosceles triangle. Skin wheals are placed over the marks immediately below the twelfth rib, and a 12-15 cm, 20-gauge needle (without the syringe) is inserted.

Pertinent anatomy for celiac plexus block. Pertinent anatomy for celiac plexus block.
Pertinent anatomy for celiac plexus block (cross-s Pertinent anatomy for celiac plexus block (cross-sectional view).
Retrocrural and anterocrural relationships (celiac Retrocrural and anterocrural relationships (celiac plexus block).
Celiac plexus block, retrocrural (deep splanchnic) Celiac plexus block, retrocrural (deep splanchnic) technique. See text for details.
Surface anatomy and markings for celiac plexus blo Surface anatomy and markings for celiac plexus block.

The needle is inserted between the T12 and L1 vertebral spines in a plane that is 45° to the horizontal table. This placement allows contact with the L1 vertebral body at a depth of 7-9 cm. More superficial bony contact is usually caused by needle impingement upon a vertebral transverse process. C-arm fluoroscopy is helpful for guiding the direction and depth of the needle. After the vertebral body is identified clearly, the needle is withdrawn to subcutaneous level and the angle changed to allow the tip to slip past the lateral border of the vertebral body.

After the needle tip passes by the vertebral body, it should be inserted an additional 1.5-2 cm or until it approaches the aortic wall, which can be recognized by transmission of pulsations from this vascular structure through the needle. On the right, the needle insertion can be placed deeper, approximately 2-3 cm beyond the vertebral body. Aspiration after needle placement is critical prior to the injection of LA or a neurolytic agent. Besides blood, faulty needle puncture may yield urine or CSF.

Lumbar sympathetic blockade also should be performed by an experienced anesthesiologist, preferably using C-arm fluoroscopic guidance. Using the technique described by Brown, the patient is placed in prone position. The second or third lumbar vertebral spines are identified, and a mark is placed on the skin 7-9 cm lateral to the midline. A skin wheal is raised using a 15-cm, 20- or 22-gauge needle, which then is inserted through the skin at an angle of 30-45° from the vertical plane ascribed to the patient's midline. The needle is advanced until it contacts the lateral aspect of the L2 vertebral body.

Superficial contact usually is caused by encroachment upon the transverse process. The needle is repositioned and redirected in a cephalad or caudal manner to avoid the transverse process. The target position for the needle is the anterolateral surface of L2. When the needle is in position, and after aspiration, 15-20 mL of LA solution, usually 0.5% lidocaine or 0.125-0.25% bupivacaine, is injected.

Complications are rare but can occur, including accidental injection into the inferior vena cava on the right or the aorta on the left, damage to lumbar vessels, and unintentional needle penetration or anesthesia to neighboring somatic nerves. Sympathetic nervous system monitoring (which has not been discussed in detail) determines the presence and extent of sympathetic blockade.

Pertinent anatomy for lumbar sympathetic block (cr Pertinent anatomy for lumbar sympathetic block (cross-sectional view).
Surface technique of lumbar sympathetic block. See Surface technique of lumbar sympathetic block. See text for details.
Lumbar sympathetic block, cross-sectional techniqu Lumbar sympathetic block, cross-sectional technique. See text for details.

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