Kabbara et al • Sensory Stimulation of the Lumbar Sympathetic Trunk

421 Pain Physician. 2003;6:421-424, ISSN 1533-3159

An Original Contribution

Paresthesiae During Radiofrequency Neurolysis of Lumbar Sympathetic Trunk in CRPS: Human Evidence of a SympathoSensory Connection? Abdallah I. Kabbara, MD, Thomas Chelimsky, MD, and Mark V. Boswell, MD, PhD Radiofrequency heat lesioning has been advocated to prolong the duration of therapeutic effect of lumbar sympathetic block in Complex Region Pain Syndrome (CRPS) of the lower extremity. Prior to radiofrequency lesioning of the lumbar sympathetic trunk, sensory and motor stimulation may be used to verify that the active needle tip is not adjacent to a spinal nerve to avoid unwanted neural injury. However, the value of sensory stimulation to aid in precise needle positioning at the desired target remains controversial. In this report we describe our observations using sensory stimulation to aid in needle placement for radiofrequency lesioning. We

confirm a novel observation that paresthesiae to the lumbar sympathetic trunk is possible and hypothesize on pathophysiologic meaning. Two representative patients are presented who underwent sensory stimulation of the lumbar sympathetic trunk during needle placement for lumbar sympathetic radiofrequency neurolysis. Sensory stimulation was elicited at the L3 or L4 vertebral level using a 15 cm insulated radiofrequency needle with a 5mm active tip. During sensory stimulation, patients described paresthesiae to the ipsilateral buttock and lower extremity. Stimulation intensity was less

than 0.8 V at 50 Hz at impedance of 300 Ohms or less. Motor stimulation did not occur up to the maximum voltage tested (2.0 V at 2 Hz) Sensory stimulation of the lumbar sympathetic trunk may be used to aid in localization of the active tip of the radiofrequency needle, in preparation for lesioning. A dermatomal sensory pattern was observed, suggesting that afferent sensory fibers travel in the lumbar sympathetic trunk. The implications of this observation for understanding the mechanism of CRPS-related pain are discussed. Keywords: CRPS, radiofrequency, sensory stimulation, sympathetic trunk

Lumbar sympathetic block with local anesthetic is a diagnostic and a therapeutic tool for treatment of complex region pain syndrome (CRPS) in the lower extremity. Radiofrequency heat lesioning (radiofrequency) of the lumbar sympathetic trunk has been advocated to prolong the duration of therapeutic effect (1). Radiofrequency of the sympathetic trunk or chain also has been used to provide sympathectomy to improve blood flow in the lower extremity in peripheral vascular disease (2). Other uses of radiofrequency include treating sacroiliac joint pain and pain associated with obturator and femoral nerve neuralgias (3, 4). More recently, pulsed radiofrequency has been proposed as an alternative to heat lesion radiofrequency (5, 6). Sensory and motor stimulation may be used to verify that the needle tip is not adjacent to a spi-

nal nerve to avoid unwanted neural injury (7). However, the value of sensory stimulation to aid in precise needle positioning at the desired target remains controversial (8, 9). We have found that sensory stimulation is useful in needle placement, much like sensory stimulation for placement of spinal cord stimulator electrodes. That is, paresthesiae may help guide proper needle placement. Standard heat lesion radiofrequency is not generally advocated for peripheral nerve ablation, but pulsed radiofrequency appears useful for treating peripheral neuralgias, without the risk of post-procedure neuritis or deafferentation pain. During needle placement for radiofrequency neurolysis, we noted that sensory stimulation of the sympathetic trunk at the L3 or L4 levels produced ipsilateral paresthesiae to the buttock and lower extremity, an observation previously reported by van Kleef and Sluitjer (10) for stimulation of the communicating ramus of the sympathetic trunk at the lumbar vertebral level. We use sensory stimulation routinely during placement of radiofrequency needles for lumbar radiofrequency sympatholysis, to avoid positioning the active tip adjacent to a spinal nerve and

to precisely localize the needle at the sympathetic chain. In this report we describe two representative cases where pulsed radiofrequency was employed for pain control, using sensory stimulation of the sympathetic chain to precisely guide needle positioning. In both cases, stimulation of the lumbar sympathetic trunk produced ipsilateral paresthesiae in a dermatomallike pattern to the back and lower extremity. This referral pattern may support the understanding of mechanisms of CRPS related pain based on animal models or suggests previously unrecognized neuroanatomic connections.

From Departments of Anesthesiology and neurology, Case Western Reserve University School of Medicine and University Hospitals of Cleveland, Cleveland, Ohio. Address Correspondence: Mark V. Boswell, MD, PhD, Department of Anesthesiology, University Hospitals, 11100 Euclid Avenue, Cleveland, Ohio-44106.Email: [email protected] Funding: There was no external funding in preparation of this manuscript.

DESCRIPTION/METHODS A 44-year-old female with a history of right lower extremity CRPS of 2 years’ duration related to an ankle sprain that improved temporarily with local anesthetic lumbar sympathetic block. A 22 gauge 15 cm insulated radiofrequency needle with a 5 mm active tip (Sluijter-Mehta Kit – [SMK]; Radionics, Tyco Healthcare, Burlington, MA.) was positioned at the right anterior-lateral aspect of L4, just anterior to the fascia of the psoas muscle, the presumed location of the lumbar sympathetic trunk. Fluoroscopic guidance was used

Pain Physician Vol. 6, No. 4, 2003

422

Fig. 1. Anterior-posterior view (right is to the right of the image) of insulated radiofrequency needle in position at the L4 vertebral body for stimulation of the lumbar sympathetic chain. Stimulation at 0.7 V produced paresthesiae to the right posterior calf and ankle. The needle tip was not near spinal nerve or lumbar plexus.

Kabbara et al • Sensory Stimulation of the Lumbar Sympathetic Trunk

Fig. 2. Lateral view of radiofrequency Fig. 3. AP view with no sensory needle in position at L4 for lumbar stimulation elicited. sympathetic block, demonstrating adequate distance of active tip from the spinal nerve.

Fig. 5. Anterior-posterior view (left is to the left of the image) of insulated radiofrequency needle in position at Fig. 4. AP view after slight readjustment the L3 vertebral body. Stimulation of needle position producing sensory at 0.3 V produced paresthesiae to the stimulation at 0.3 V. patient’s left anterolateral thigh. The Fig. 6. Lateral view of radiofrequency active tip was not adjacent to spinal needle in position for radiofrequency of lumbar sympathetic chain at L3, for needle placement. Iohexol injection nerve or lumbar plexus. demonstrated typical spread at the andemonstrating adequate distance from terolateral aspect of the vertebral body of the spinal nerve. L4. The needle tip was not near the intervertebral foramen or spinal nerve (Figs. 1 and 2). Needle position was adjusted until maximal sensitivity was obtained with electrical stimulation. A Radionics Plus radiofrequency Generator (RFG-3C™ Plus; Radionics, Burlington, MA.) was used for stimulation and lesioning. At a stimulation frequency of 50 Hz (imped-

Pain Physician Vol. 6, No. 4, 2003

ance of 300 Ohms) the patient reported paresthesiae to the right posterior calf and ankle, at a threshold of 0.7V. Motor stimulation was negative up to the maximum tested voltage of 2.0 V. Three pulsed radiofrequency “lesions” were generated at L4, each at a frequency of 2 Hz, with a 20 ms pulse width for 120 sec at 42o C. The radiofrequency treatment provided more

than 50% pain relief for 3 months. Movement of the active tip 2 or 3 mm from target eliminated stimulation-induced paresthesiae (Figs. 3 and 4, a different patient). This suggests that paresthesiae were elicited from sympathetic trunk activation, rather than nonspecific stimulation of the

Kabbara et al • Sensory Stimulation of the Lumbar Sympathetic Trunk periosteum or adjacent non-neural tissue. A 42-year-old female with a 3-year history of CRPS in the left lower extremity after Achilles tendon injury, noted temporary pain relief with local anesthetic lumbar sympathetic block. The tip of an SMK needle was advanced to the left lumbar sympathetic trunk at L3, using fluoroscopic visualization. Injection of Iohexol contrast demonstrated typical spread at the anterolateral aspect of the vertebral body of L3 (Figs 5 and 6). Precise needle positioning was guided by sensory stimulation. Sensory stimulation of the lumbar sympathetic trunk at 50 Hz produced distinct paresthesiae to the patient’s left anterolateral thigh, at a threshold of 0.3 V (impedance of 300 ohms). Motor stimulation was negative at 2.0 V. The active tip was not adjacent to a lumbar nerve root or the intervertebral foramen. Three pulsed radiofrequency lesions were delivered at 2 Hz, 20 ms duration for 120 sec. The patient obtained more than 50% pain relief for 3 months.

DISCUSSION Lumbar sympathetic block with local anesthetic has been used for years to produce sympathectomy of the lower extremity for treatment of CRPS. More recently, radiofrequency has been used in an attempt to prolong the duration of sympathectomy. Haynsworth (11) reported that radiofrequency ablation of the sympathetic chain provided longer duration of pain relief and fewer complications than phenol neurolysis. van Kleef and Sluitjer (10) have reported sensory stimulation of the rami communicantes of the sympathetic trunk and found it helpful from a technical standpoint, because paresthesiae allowed accurate positioning of the needle tip for radiofrequency lesioning. However, they did not comment on the implications of their observation. We have documented that sensory stimulation with the radiofrequency needle after placement in the traditional position required for lumbar sympathetic block reliably produces paresthesiae to the ipsilateral low back and proximal lower extremity. Paresthesiae in a dermatomal pattern for the level stimulated were elicited. Needle position was documented fluoroscopically, and the active tip of the insulated needle was not adjacent to a nerve root, lumbar plexus or nerve. With the active tip of the insulated needle in the anatomical position of

the sympathetic chain, anterior to the fascia of the psoas muscle, paresthesiae were readily obtainable. Repositioning the active tip several mm away from the point of maximum stimulation reliably abolished the paresthesiae. This indicated that paresthesiae elicited by stimulation were specific for the sympathetic trunk or associated ganglion and not due to stimulation of periosteum or adjacent non-neural tissue. Our observations may be useful when considering the pathophysiology of chronic pain states, such as sympathetically maintained pain and CRPS. Abnormal sympathetic connections have been demonstrated in dorsal root ganglia after injury (12). Some studies suggest an important role of noradrenaline released by the sympathetic postganglionic axons in pain generation. This assumes efferent activity of the sympathetic nervous system in the pain process. By activating alphaadrenoreceptors, noradrenaline stimulates primary afferent neurons present in the injured tissue and may cause pain (13). Such connections may involve sympathetic synapses in the dorsal root ganglia DRG (13, 14). The concept of sprouting of sympathetic fibers in the dorsal root ganglion has been attributed to Raymon y Cajal (15). Our observations suggest three hypotheses: (I) the electrical stimulus excites sympathetic nerve fibers which have a pathologic synapse upon dorsal root ganglion cells These, in turn, are responsible for the patient’s sensory experience. This hypothesis would constitute human evidence of the lumbar sympathetic -dorsal root ganglia connection demonstrated in rats (13) (II) the sympathetic ganglion contains nerve fibers which conduct antidromically and synapse on dorsal horn cells in the spinal cord which then produce the sensation felt by the patient. (III) Afferent fibers actually travel through the sympathetic ganglion and are being stimulated by the radiofrequency needle directly. Evidence for the first hypothesis only derives from animal models in CRPS (13). Since both patients presented had CRPS, it would be of interest to know whether non-CRPS patients report a similar experience. If no sensation is reported by non -CRPS patients, then the first hypothesis would be most likely and our case report may provide the first known human evidence of the hypothesized connection between sympathetic and dorsal root ganglia in CRPS. If non –CRPS pa-

423 tients also report the sensation then one of the two anatomic explanations may be more likely and would need further exploration. If afferent sensory fibers are present in the sympathetic trunk this might provides a novel explanation for how local anesthetic blockade can produce pain relief in CRPS. Rather than blocking presumed efferent sympathetic activity and thereby reducing peripheral sensitization, local anesthetic blockade may also inhibit painful afferent neural conduction directly in the sympathetic trunk. Although pulsed radiofrequency is not yet widely recognized as a treatment modality, pulsed radiofrequency of the DRG has been shown to result in expression of cFOS in the dorsal horn in the rat (14). In conclusion, we find that eliciting sensory paresthesiae for precise localization of the active tip of the radiofrequency needle is useful in preparation for lesioning of the sympathetic trunk. Our observations warrant further study. Studies of patients without CRPS, documenting sensory stimulation patterns, including measuring latency times and sensory voltage thresholds, may help confirm the presence of afferent sensory fibers in the sympathetic chain. Additionally, it would be useful to correlate skin blood flow changes with the distribution of paraesthesiae in-patients undergoing radiofrequency of the lumbar sympathetic chain for treatment of CRPS. Author Affiliation: Abdallah I. Kabbara, MD Fellow in Pain Medicine Department of Anesthesiology University Hospitals of Cleveland Cleveland, Ohio 44106 Thomas Chelimsky, MD Associate Professor of Neurology University Hospitals of Cleveland Cleveland, Ohio 44106 Mark V. Boswell, MD, PhD Associate Professor of Anesthesiology Chief, Division of Pain Medicine Department of Anesthesiology Director, Pain Medicine Fellowship Program Case Western Reserve University School of Medicine and University Hospitals of Cleveland 11100 Euclid Avenue Cleveland, Ohio-44106 E-mail: [email protected]

Pain Physician Vol. 6, No. 4, 2003

424

Kabbara et al • Sensory Stimulation of the Lumbar Sympathetic Trunk

REFERENCES 1.

2.

3.

4.

5.

Rocco AG. Radiofrequency lumbar sympatholysis. The evolution of a technique for managing sympathetically maintained pain. Reg Anesth. 1995; 20:3-12. Dominkus M, Kepplinger B, Bauer W et al. Percutaneous radiofrequency thermolesion of the sympathetic chain in the treatment of peripheral vascular disease. Acta Med Austriaca 1991; 18:S69-S70. Rathmell JP, Tarver JM, Memon Z. Radiofrequency sacroiliac joint denervation: the devil is in the details. Reg Anesth Pain Med 2001; 26: 592-593. Kawaguchi M, Hashizume K, Iwata T et al. Percutaneous radiofrequency lesioning of sensory branches of the obturator and femoral nerves for the treatment of hip joint pain. Reg Anesth Pain Med 2001; 26: 576-581. Sluijter ME. Radiofrequency. Part 1. A review of radiofrequency procedures in the

Pain Physician Vol. 6, No. 4, 2003

6.

7.

8.

9.

10.

lumbar region. Flivopress, Amsterdam, 2001. Munglani R. The longer term effect of pulsed radiofrequency for neuropathic pain. Pain 1999; 80:437-439. Lord SM, Barnsley L, Wallis BJ et al. Percutaneous radio-frequency neurotomy for chronic cervical zygapophyseal-joint pain. N Eng J Med 1996; 335:1721-1726. Dreyfuss P, Halbrook B, Pauza K. Efficacy and validity of radiofrequency neurotomy for chronic lumbar zygapophysial joint pain. Spine 2000; 25:1270-1277. Windsor RE. Radiofrequency lumbar zygapophysial (facet) joint denervation: A preliminary report of a new concept. Pain Physician 2003; 6:119-123. van Kleef M , Sluitjer ME. Radiofrequency lesions of the Dorsal Root Ganglion in the Treatment of Spinal Pain. Chapter 4. Treatment of Spinal Pain with Radiofrequency Techniques – Procedures. Universitaire Pers Maastricht, 1996, pp 44.

11.

12.

13.

14.

15.

Haynsworth RF Jr, Noe CE. Percutaneous lumbar sympathectomy: A comparison of radiofrequency denervation versus phenol neurolysis. Anesthesiology 1991; 74:459-463. Katz DM. Adler JE, Black IB. Catecholaminergic primary sensory neurons: Autonomic targets and mechanisms of transmitter regulation. Fed Proc 1987; 46:24-29. McLachlan EM, Janig W, Devor M et al. Peripheral nerve injury triggers noradrenergic sprouting within dorsal root ganglia. Nature 1993; 363:543-546. Higuchi Y, Nashold BS Jr, Sluijter M et al. Exposure of the dorsal root ganglion in rats to pulsed radiofrequency currents activates dorsal horn lamina I and II neurons. Neurosurgery 2002; 50:850-855. Garcia-Poblete E, Fernandez-Garcia H, Moro-Rodriguez E et al. Sympathetic sprouting in dorsal root ganglia (DRG): A recent histological finding? Histol Histopathol 2003; 18:575-86.

Paresthesiae During Radiofrequency Neurolysis of ... - Semantic Scholar

6, No. 4, 2003. Pain Physician. 2003;6:421-424, ISSN 1533-3159 .... Plus; Radionics, Burlington, MA.) was .... frequency denervation versus phenol neurol- ysis.

218KB Sizes 3 Downloads 273 Views

Recommend Documents

Paresthesiae During Radiofrequency Neurolysis of ... - Semantic Scholar
[SMK]; Radionics, Tyco Healthcare, Bur- lington, MA. ... ms pulse width for 120 sec at 42o C. The radiofrequency ... Hz, 20 ms duration for 120 sec. The pa-.

Cell Phone Radiofrequency Radiation Exposure ... - Semantic Scholar
Feb 23, 2011 - phone use on brain electrical activities, neurophysiology, and behavior. ... quency emissions from wireless phones, including both mobile and ...

Cell Phone Radiofrequency Radiation Exposure ... - Semantic Scholar
Feb 23, 2011 - signal exposure on brain glucose metabolism. JAMA. 2011;305(8):808-813. 2. Anderson V, Rowley J. Measurements of skin surface temperature during mo- bile phone use. Bioelectromagnetics. 2007;28(2):159-162. 3. Straume A, Oftedal G, John

Is Pulsed Radiofrequency a Neuromodulation ... - Semantic Scholar
that regulates or modifies electrical impulses flow- ing through neural tissues by enhancing, inhibit- ing, extending, or shortening them. Interventional.

Prediction Error during Retrospective Revaluation ... - Semantic Scholar
Dec 1, 2004 - in behavioral conditioning but also in predictive and ... Philip R. Corlett,1 Michael R.F. Aitken,2 ..... We therefore restricted this analysis to the.

Modeling cardiorespiratory interaction during ... - Semantic Scholar
Nov 17, 2014 - Towards a porous media model of the human lung. AIP Conf. Proc. ... University, PauwelsstraЯe 20, 52074 Aachen, Germany. (Received 1 .... world networks such as biological,36 neural,37 and social net- works.38 For a ...

The effect of disfluency on mind wandering during ... - Semantic Scholar
United States b University of Notre Dame, Department of Computer Science .... findings and those for tasks like list learning suggests that disfluency only affects surface level learning (e.g. ... The experiment utilized a between-subjects design.

Cause of kinematic differences during centrifugal ... - Semantic Scholar
passive force corresponds to a reduction in the net-force .... in the net muscle force profiles shown in Fig. 14. ..... Pfann, K. D., Keller, E. L., & Miller, J. M. (1995).

Cause of kinematic differences during centrifugal ... - Semantic Scholar
dactics, San Francisco, 1999) we simulated the muscle forces during centrifugal and centripetal ..... passive force corresponds to a reduction in the net-force.

The effect of disfluency on mind wandering during ... - Semantic Scholar
United States b University of Notre Dame, Department of Computer Science .... findings and those for tasks like list learning suggests that disfluency only affects surface level learning (e.g. ... The experiment utilized a between-subjects design.

Teacher Concerns During Initial Implementation of ... - Semantic Scholar
Many schools are initiating projects that place laptop computers into the hands ..... Participants raw scores for. Part. A. 13. 14. 16. 18. 11. 15. Part. 5. 9. 8. 10. 15.

Cause of kinematic differences during centrifugal ... - Semantic Scholar
0042-6989/02/$ - see front matter У 2002 Elsevier Science Ltd. All rights reserved. ... In this paper we investigate the degree to which the mechanical and the ...

Malaria and immunity during pregnancy and ... - Semantic Scholar
Mar 3, 2015 - 1 Macfarlane Burnet Institute of Medical Research, 85 Commercial Road, Melbourne, ...... of malaria in Lake Vera, California, 1952–1953.

Selective requirements for NRP1 ligands during ... - Semantic Scholar
endothelial tip cells and axon growth cones send out filopodia to explore their territory for guidance cues (Gerhardt et al., 2003;. Ruhrberg et al., 2002).

Malaria and immunity during pregnancy and ... - Semantic Scholar
Mar 3, 2015 - E-mail: [email protected]. 999. Parasitology ...... supported by another study which found greater fre- ... Evidence to support this is limited,.

Temporal changes in blood variables during final ... - Semantic Scholar
STATISTICAL ANALYSIS. All statistical tests were performed using SAS software version 9.1 (SAS Institute; www. ... assessed using linear regressions on log10-transformed data. RESULTS ..... Successful recovery of the physiological status of coho salm

Cone of Experience - Semantic Scholar
Bruner, J.S. (1966). Toward a theory of instruction. Cambridge, MA: The Belknap Press of. Harvard University Press. Dale, E. (1946) Audio-visual methods in teaching. New York: The Dryden Press. Dale, E. (1954) Audio-visual methods in teaching, revise

Physics - Semantic Scholar
... Z. El Achheb, H. Bakrim, A. Hourmatallah, N. Benzakour, and A. Jorio, Phys. Stat. Sol. 236, 661 (2003). [27] A. Stachow-Wojcik, W. Mac, A. Twardowski, G. Karczzzewski, E. Janik, T. Wojtowicz, J. Kossut and E. Dynowska, Phys. Stat. Sol (a) 177, 55

Physics - Semantic Scholar
The automation of measuring the IV characteristics of a diode is achieved by ... simultaneously making the programming simpler as compared to the serial or ...

Physics - Semantic Scholar
Cu Ga CrSe was the first gallium- doped chalcogen spinel which has been ... /licenses/by-nc-nd/3.0/>. J o u r n a l o f. Physics. Students http://www.jphysstu.org ...

Physics - Semantic Scholar
semiconductors and magnetic since they show typical semiconductor behaviour and they also reveal pronounced magnetic properties. Te. Mn. Cd x x. −1. , Zinc-blende structure DMS alloys are the most typical. This article is released under the Creativ

vehicle safety - Semantic Scholar
primarily because the manufacturers have not believed such changes to be profitable .... people would prefer the safety of an armored car and be willing to pay.

Reality Checks - Semantic Scholar
recently hired workers eligible for participation in these type of 401(k) plans has been increasing ...... Rather than simply computing an overall percentage of the.