T2-T3 Sympathectomy for Complex Regional Pain Syndrome

If you use opioids for chronic low back pain, knee pain or musculoskeletal pain, yes, they are habit-forming. But for cancer pain, and for pain like sickle cell disease — which we manage on the same lines as cancer pain — they are never habit-forming. Visceral pain is mediated by the sympathetic nervous system and doesn't respond to conventional NSAIDs, so it needs neuropathic agents and opioids in combination; back pain, knee pain and shoulder pain are peripheral musculoskeletal or neuropathic pain and don't carry the same opioid receptor expression, which is why the risk profile is so different between the two.

The nerve cannot truly regenerate in the clinical sense. When there is nerve injury, the patient can go into complex regional pain syndrome Type II. Nerve regeneration takes a very long time and the results are poor — if you believe you can treat a patient through nerve regeneration, in present-day practice that is a myth.

For nerve blocks we use ropivacaine. For steroids, we primarily use dexamethasone in spinal procedures. For joint injections, we usually use Kenacort (triamcinolone).

In India, opioids are scheduled drugs — you need a prescription from a competent doctor: a pain specialist, anaesthesiologist or neurologist, not a general surgeon or ENT. For morphine and fentanyl specifically, the hospital needs a government licence to hold a certain quantity, and we use a special designated government form that we stamp, with patients required to bring a consumption chart we submit to the drug controller. Tramadol, tapentadol and buprenorphine don't need special licensing, but you do need a valid prescription from a competent doctor.

The first issue is simply diagnosis — ninety per cent of doctors not trained for this kind of spinal pain can't diagnose facetogenic pain. We call it axial pain, which includes facetogenic and discogenic pain, and gabapentinoids are of no use for it whatsoever — yet eight out of ten patients with axial pain are given these drugs with no results. It's a diagnostic challenge first: specific questions in the history, a specific examination, then a diagnostic block to confirm the pain is coming from the facet before proceeding to facet joint RFA.

Complex regional pain syndrome of the upper limb arising from brachial plexus injury, post-mastectomy pain, post-amputation pain, or peripheral vascular disease.

No. It is performed percutaneously, placing two electrodes at T2-T3 under fluoroscopic guidance, rather than the thoracoscopic surgical approach still used at many centres, and can be done as a day-care procedure.

Yes. In one case, a patient whose hand had turned black and ischaemic after a failed embolectomy was treated with percutaneous sympathectomy as a day-care procedure with no open surgery.

Patients with brachial plexus injury treated with T2-T3 sympathectomy report some of the most significant pain relief seen in this practice.