Targeting Gray Rami Communicantes in Selective Chemical Lumbar Sympathectomy

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 diseases^1,2,3,4,5 including thromboangiitis obliterans (sometimes called Buerger's disease), ischemic diabetic foot, Raynaud's disease, parmoplantar hyperhidrosis⁶, erythromelalgia^7,8,9, 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 .......

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 erythromelalgia^7,9, and senile patients with end-stage arteriosclerosis obliterans a.......

Materials

Name	Company	Catalog Number	Comments
0.9% Saline solution	Chinese Dazhong Pharmaceutical Co.,Ltd.	8F84D7	10 mL ⅹ2
10-cm 9# puncture needle	Peking University Third Hospital	Not Applicable	7# for children
2% Lidocaine Hydrochloride Injection solution	Hubei Tiansheng Pharmaceutical Co.,Ltd.	20180434	5 mL ⅹ2
5% Phenol diluted in aqueous solution	Peking University Third Hospital	Not Applicable	10 mL
Angiography system （DSA）	Philips	FD20	have X-ray fluoroscopy function
Aseptic puncture kit	Peking University Third Hospital	Not Applicable	6 pieces of surgical towel, gauze, cotton balls, blood vessel forceps, etc.
Contrast media（iodixanol injection; 320）	GE Healthcare	14160155	320 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 gloves	Beijing Ruijing Latex products Co., Ltd.	2018070352
Syringes and needles 10 mL	Shandong Weigao Group Medical Plolymer Co.,Ltd.	20180711	10 mL ⅹ2
Syringes and needles 5 mL	Shandong Weigao Group Medical Plolymer Co.,Ltd.	20180721	5 mL ⅹ1