Pelviureteric junction disruption as a complication of chemical lumbar sympathectomy

Chemical lumbar sympathectomy is a commonly performed procedure in vascular surgery and pain management. This case report discusses the management of a patient who suffered pelviureteric junction disruption following phenol injection for ischaemic leg pain despite radiological evidence of correct placement.The authors suspect this is an underreported complication, which could be relevant in obtaining informed consent.     

The outcome of percutaneous computed tomography-guided chemical lumbar sympathectomy for patients with causalgia after lumbar discectomy

BACKGROUND: Coldness, numbness, or causalgia usually affects the lower limbs in patients after back surgeries. The treatment of causalgia is still the source of continuing debate. We treated patients presenting with causalgia secondary to LD with CT-guided CLS and determined the therapeutic outcome at long-term follow-up. METHODS: From January 2002 to December 2002, a total of 15 patients (16 limbs) with causalgia after LD underwent the percutaneous CT-guided CLS. There were 7 male patients and 8 female patients, with an average age of 49.1 years. A total of 14 patients underwent unilateral procedures, and 1 patient underwent staged bilateral procedures. We followed up our patients for at least 24 months (24-36 months). RESULTS: There were 13 patients (14 limbs) diagnosed as Drucker stage I and 2 patients as stage II. There were 88% (14 limbs) that had an early satisfactory outcome after CLS and 75% (12 limbs) that had a late satisfactory outcome (more than 24 months after CLS). Stage I patients had more satisfying early and late outcome than stage II patients (P= .014 and P= .039, respectively). Female patients were more likely to have satisfactory late outcome than male patients (P= .034). There was no operative mortality. A patient had a complication of genitofemoral neuralgia, which had recovered in a month. CONCLUSIONS: We concluded that the percutaneous CT-guided CLS is an easy, safe, and reproducible technique, and it carries long-term benefit to patients with pain after LD presenting with causalgia, especially for patients with Drucker stage I and female patients.     

Indications for performing lumbar sympathectomy

The results of treatment of 123 patients with obliterative diseases of the lower extremities, who underwent lumbar sympathectomy, and 115, who underwent the conservative therapy, were studied. The best result of sympathectomy was noted in patients with the impairement in the major blood flow and microcirculation without trophic disorders. In trophic disorders, sympathectomy contributed to reduction of a level of amputation.     

Selection of patients for lumbar sympathectomy

We successfully predicted that patients presenting with critical ischemia of a limb and Doppler ratios greater than or equal to 0.3 would benefit from lumbar sympathectomy alone. However, we found that the procedure failed in 14 per cent of limbs whose ratios were greater than or equal to 0.3. In retrospect, all these patients were found to have deep infection. Had we known this fact prospectively, our predictions for success would have been close to 100 per cent. We were less than 50 per cent successful in predicting failure of the procedure, but the number of patients in this group is too small to draw reliable conclusions. We believe that patients with arm-ankle Doppler ratios greater than or equal to 0.3 whose manifestations of ischemia are limited to the skin will have a greater than 95 per cent chance of receiving a good result from lumbar sympathectomy alone and that this result will be maintained for many years.     

Laparoscopic lumbar sympathectomy for lower-limb disease

Background: The standard procedure for sympathectomy is open surgery. The oblique retroperitoneal approach is popular because it provides good visibility, albeit at the expense of requiring a long skin incision. Chemical sympathectomy has been introduced as a less invasive means of achieving sympatholysis; however, this method is also associated with a significant incidence of incomplete block and transient denervation. Laparoscopic surgery is a new approach that simplifies various surgical procedures. The aim of our report was to evaluate the benefits of endoscopic retroperitoneal surgery for lumbar sympathectomies. Methods: Between March 1997 and April 2000, seven patients underwent laparoscopic lumbar sympathectomy in our department (all men, with an average age or 45.1 years). The predominant presenting symptoms were unilateral pain at rest and lower-extremity coldness. Symphaectomy was performed using a retroperitoneal approach on six patients and an anterior transperitoneal approach on one patient. After laparoscopic lumbar sympathectomy, skin thermometry was carried out on all patients. Results: The postoperative skin temperature of the affected leg rose to 36.6 ± 0.5°C, as compared to 33.8 ± 0.8°C preoperatively. After laparoscopic lumbar sympathectomy, none of the patients complained of neuralgia. All patients achieved sustained symptomatic relief, and no major postoperative complications were noted. Conclusions: Lumbar sympathectomy can be performed laparoscopically. Currently, our standard technique is the retroperitoneal approach. More clinical experience and long-term follow-up will ultimately determine if this will become the procedure of choice. However, we believe that a learning period is necessary for this technique to be fully mastered.     

化学性腰交感神经切除术的临床应用

目的：总结化学性腰交感神经切除术（CLS）的临床效果。方法：按腰交感神经节阻滞的方法穿刺2针后，经X线拍片定位证实穿刺针尖位于腰2，3椎体前外侧后，分别注射6．7％石碳酸（或无水酒精）3－4ml后拔出穿刺针，结果：10年来共施行CLS 36例，其中血栓闭塞性脉管炎10例，雷诺病4例，动脉硬化性闭塞症21例，多发性大动脉炎1例，其中16例平均踝肱指数0．47，CLS后疼痛缓解者29例（81％），患肢转暖者27例（75％），CLS术后踝肱比0－1．3，平均0．58，CLS前后无统计学差异（P＞0．05），CLS后下肢神经痛3例（8％），随访32例，随访时间3个月至9年，在随访的患者中，CLS后有效的26例中，24例仍维持CLS时的效果，2例加重而截肢。结论：CLS是一种操作简单，并发症少，对于不可能采用其它方法治疗或治疗后效果不好的下肢缺血性疾病均可采用CLS治疗。     

Retroperitoneal hemorrhage from an unrecognized puncture of the lumbar right segmental artery during lumbar chemical sympathectomy: diagnosis and management

Lumbar chemical sympathectomy has been performed using fluoroscopic guidance for needle positioning. An 84 year old woman with atherosclerosis obliterans was referred to the pain clinic for intractable cold allodynia of her right foot. A thermogram showed decreased temperature of both feet compared with temperatures above both ankles. The patient agreed to undergo lumbar chemical sympathectomy using fluoroscopy after being informed of the associated risks of nerve injury, hemorrhage, infection, transient back pain, and transient hypotension. During the procedure and three hours afterward, no abnormal signs or symptoms were found except an increase in right leg temperature. The patient was ambulatory after the procedure. However, one day after undergoing lumbar chemical sympathectomy, she visited our emergency department for abdominal discomfort and postural dizziness. Her blood pressure was 80/50 mmHg, and flank tenderness was noted. Retroperitoneal hemorrhage from the second right lumbar segmental artery was shown on computed tomography and angiography. Vital signs were stabilized immediately after embolization into the right lumbar segmental artery.     

Acute hemodynamic effects of lumbar sympathectomy

Lumbar sympathectomy increases total limb blood flow after aortofemoral bypass in a high percentage of cases. This was true in eleven of fourteen extremities (78.6 per cent) in our series even though no specific selection criteria for entry into the study, other than the need for aortofemoral bypass, were used: that is, patients were entered into the study irrespective of preoperative ankle/arm pressure indexes or results of hyperemia testing. Overall, flow rates after sympathectomy was added to aortofemoral bypass were 1.55 times greater than after aortofemoral bypass alone. This degree of augmentation of flow may be important, particularly in cases of limited outflow.     

Retroperitoneoscopic lumbar sympathectomy for nonreconstructable arterial occlusive disease

AIM: The aim of this study was to present our experience with video-assisted lumbar sympathectomy for non-reconstructive arterial occlusive disease in a series of 23 consecutive patients whose predominant symptoms were unilateral rest pain, limited skin ulcerations or gangrene of the toes. METHODS: All the procedures were performed with retroperitoneal approach, dorsal position of the patient and simple digital dissection of the retroperitoneal space. RESULTS: The operations were successfully performed in all patients except for 2, who immediately underwent open conversion. A urinoma caused by ureteral lesion was the only severe complication in this series. The mean operative time of the procedure was 55 min and the hospital stay was 2 or 3 days. No parenteral analgesics were administered postoperatively. At 1 month from operation, 20 patients out of 23 had significant relief of rest pain and improvement of ischemic lesions. After a median follow-up of 36 months, 2 patients had died, 4 underwent some type of distal amputation, 1 had recurrent rest pain and the other 16 reported persistent improvement of pain or dystrophic changes. CONCLUSIONS: Retro-peritoneoscopic technique appears the modern and less invasive version of the lumbar surgical sympathectomy.     

Current status of lumbar sympathectomy.

A review of a recent series of lumbar sympathectomies would appear to support the continued use of the procedure in the treatment of selected patients with localized pre-gangrenous lesions or superficial ischemic ulcerations in whom arterial reconstructive operation is not feasible. A conclusion regarding the use of the procedure in conjunction with bypass grafting or thromboendarterectomy cannot be made. Indications for the treatment of nonatherosclerotic disease are briefly mentioned. Nevertheless, the morbidity and mortality from the operation itself is significant and suggests that its use as a temporizing measure in highly doubtful cases is not warranted.