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In This Article

  • Summary
  • Abstract
  • Introduction
  • Protocol
  • Representative Results
  • Discussion
  • Acknowledgements
  • Materials
  • References
  • Reprints and Permissions

Summary

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.

Abstract

Chemical lumbar sympathectomy (CLS) is a commonly used, minimally invasive procedure for the treatment of conditions including ischemic diseases of the lower extremities, hyperhidrosis, etc. It is commonly practiced to position the puncture needle tip in front of the anterior fascia of the psoas major muscle and inject the inactivating agent around the sympathetic trunk, which is defined as conventional CLS. Although relatively rare, ureteropelvic damage is the most frequently reported complication of conventional CLS and can cause serious harm to patients. We found that injecting the inactivating agent behind the anterior fascia, which only targets gray rami communicantes, helped achieve therapeutic efficacy in vasodilation, sweat reduction, and pain relief comparable to conventional CLS, and serious complications were largely reduced. We define this procedure as selective CLS. Here, we present a protocol of selective CLS. The precise needle tract and accurate evaluation of the spreading of the contrast agent are critical to ensure that the drug is injected behind the anterior fascia of the psoas major muscle. The needle tip is at approximately one-third the dividing line of the vertebral body in the lateral view of a lumbar X-ray. The contrast is mainly confined around the needle tip and spreads outward and downward along the psoas muscle fibers. In this way, the anterior fascia provides a natural barrier for the ureteropelvic area, and the psoas major muscle provides a natural barrier for the lumbar nerve root. There are several highlights of this article, including 1) a detailed description of the selective CLS procedures, 2) an explanation of the anatomical basis for the implementation of selective CLS, and 3) an explanation of the differences between selective and conventional CLS.

Introduction

Chemical lumbar sympathectomy (CLS) has been shown to be an effective treatment for ischemic diseases1,2,3,4,5 including thromboangiitis obliterans (sometimes called Buerger's disease), ischemic diabetic foot, Raynaud's disease, parmoplantar hyperhidrosis6, erythromelalgia7,8,9, and livedo reticularis10. It has replaced open surgery due to a number of advantag....

Protocol

The protocol has been approved by the local medical and ethics committees. The procedure lasts approximately 15 min per side.

1. Indications

  1. Ensure the patient has the following indications for CLS: thromboangiitis obliterans (Buerger's disease), ischemic diabetic foot, Raynaud's disease, parmoplantar hyperhidrosis, erythromelalgia, phantom limb pain, or livedo reticularis of the lower extremities.

2. Contraindications

  1. Exclude .......

Representative Results

The needle tip should be in the optimal area as shown in Figure 1. In selective CLS, the contrast is injected behind the anterior fascia of the psoas major muscle, targeting gray rami communicantes. A comparison of contrast spreading in selective CLS (A) and conventional CLS (B) is shown in Figure 2.

The expected clinical effects are vasodilation (for treatment of Rayna.......

Discussion

Here we classify CLS as either conventional or selective CLS, with the major difference being the targeting of sympathetic trunk vs. gray rami communicantes (injection of phenol in front of vs. behind the anterior fascia of the psoas major muscle). We have implemented selective CLS in young, female patients with livedo reticularis10, children with erythromelalgia7,9, and senile patients with end-stage arteriosclerosis obliterans a.......

Acknowledgements

This work is funded by grants from Peking University Third Hospital Scientific Research Foundation for the Returned Overseas Scholars (Grant No: 77434-01, Long Zhang) and Beijing Higher Education Young Elite Teacher Project (Grant No: YETP0072, Wen-Hui Wang).

....

Materials

NameCompanyCatalog NumberComments
0.9% Saline solutionChinese Dazhong Pharmaceutical Co.,Ltd.8F84D710 mL ⅹ2
10-cm 9# puncture needlePeking University Third HospitalNot Applicable7# for children
2% Lidocaine Hydrochloride Injection solutionHubei Tiansheng Pharmaceutical Co.,Ltd.201804345 mL ⅹ2
5% Phenol diluted in aqueous solutionPeking University Third HospitalNot Applicable10 mL
Angiography system (DSA)PhilipsFD20have X-ray fluoroscopy function
Aseptic puncture kitPeking University Third HospitalNot Applicable6 pieces of surgical towel, gauze, cotton balls, blood vessel forceps, etc.
Contrast media(iodixanol injection; 320)GE Healthcare14160155320 mg I/mL
Infrared frontal thermometer OMRON health care (China) Co.,Ltd.MC-720
Iodophors skin disinfectants Shanghai Likang Disinfectant Hi-Tech Co., Ltd.20180404
Sterile surgical glovesBeijing Ruijing Latex products Co., Ltd. 2018070352
Syringes and needles 10 mLShandong Weigao Group Medical Plolymer Co.,Ltd.2018071110 mL ⅹ2
Syringes and needles 5 mLShandong Weigao Group Medical Plolymer Co.,Ltd.201807215 mL ⅹ1

References

  1. Karanth, V. K., Karanth, T. K., Karanth, L. Lumbar sympathectomy techniques for critical lower limb ischaemia due to non-reconstructable peripheral arterial disease. Cochrane Database of Systematic Reviews. 12, 011519 (2016).
  2. Kothari, R., Maharaj, A., Tomar, T. S., Agarwal, P., Sharma, D.

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