Name of Procedure
- Lumbar Sympathetic Block
The Quick Guide
To block and/or administer medications to lumbar sympathetic nerves
See our disposables/equipment article for “core” supplies that are common to all procedures. Highlights below:
- Core Equipment
- c-arm, c-arm compatible bed
- Core Disposables
- Procedure tray. As outlined in the above link, core supplies include a pointer, syringes for subcutaneous local, syringe for injectate, drape.
- Core Skills
Special items and suggested setup for this lumbar sympathetic block technique (see quick guide video above for example tray prep):
- 22g x 7″ quincke needle as your primary needle (2 if you plan to inject at L2 and L3)
- 2-3cc contrast in a 3cc syringe
- 10cc 0.25% bupivacaine in a 10cc syringe for injectate
- 3cc 1% lidocaine in a 5cc syringe attached to a 25g x 1.5″ hypodermic needle for subcutaneous local anesthetic
Landmarks and Patient Positioning
Position the patient in a basic prone position so that the bottom of the c-arm can go under the table below the area of the spine that is being treated (L2 and L3).
Here is your target and entry point [See our general guide about basics for using targets and entry points to start a procedure]:
- Initial Target: inferolateral corner of the L2 vertebral body
- Final Target: just anterior to the vertebral body (on lateral) and halfway between the lateral and midline of the vertebral body (on AP)
- Entry: Straight lateral to the Initial Target, by a few cm.
- Obtain a scotty-dog view on the side being treated. From here, further oblique rotation might be useful.
- Anesthetize the skin and insert a 22g x 7″ quincke needle to contact your initial target.
- From there, “walk” off laterally till you can feel/see the needle advance slightly anterior.
- Then change to a lateral view
- Continue to advance the needle with a lateral to medial trajectory (Imaging you’re trying to wrap the needle around the vertebral body so we can get to our final target).
- Keep advancing till the needle tip is just a few millimeters past the anterior border of the vertebral body.
- Once in position, aspirate to ensure that no blood returns
- Inject contrast under live fluoroscopy. This is to look for superior-inferior spread and to also evaluate if you can see vascular uptake.
- Once you confirm appropriate spread, you can inject your primary medication (we often use ~7mL of 0.25% bupivacaine).
- This can be done slowly and with with frequent aspiration.
- The procedure is sometimes repeated at L3, but often times a single injection at L2 is sufficient.
Oblique and one AP fluoro view showing a far lateral starting point and an anterior/medial trajectory.
Lateral fluoro views showing needle placement and contrast spread
- Starting with a far lateral needle entry point helps by giving you a more lateral to medial needle direction. So that by the time the needle is sufficiently anterior, it will also be sufficiently medial.
- Once the needle is past the anterior border of the vertebral body, make small changes since you will be close to the aorta.
- Note that this technique presented above shows the needle tip just anterior to the vertebral body, but if you look at a diagram of where the sympathetic chain runs, these don’t match up exactly: the needle is off the body and slightly anterior to the plexus.
- In our experience, the needle placement above works for a few reasons:
- We don’t often get vascular update (either from anterior vascular structures or vasculature around the vertebral body).
- We don’t often get spread along a muscle.
- Alternatively you can target to have the needle tip just posterior to the anterior border of the vertebral body.
- # of needles and targets:
- As noted above some people will place at L2 and L3. Alternatively you can place a needle at the top of L3 and you might get sufficient spread along the sympathetic chain.
- Additionally, targeting near the top or bottom of the vertebral body can avoid the waist of the body, which might avoid venous vasculature.
- Lumbar Sympathetic Block
- Good review of anatomy/indications/procedure technique. Final needle placement in this link differs slightly (as described in the tips section above).
- (more coming soon…)