Percutaneous Sympathectomy, Visceral Nerve Blocks and Pumps

Percutaneous sympathectomy interrupts the sympathetic nerve chain through needles instead of an operation, to relieve vascular, ischaemic and complex regional pain in the arms and legs. Dr. Ashu Kumar Jain, Chief – Pain Medicine & Palliative Care, Artemis Hospitals, Gurugram, India, performs it with radiofrequency in the cath lab as a day-care procedure, using two needles and no chest incision.

Sympathectomy belongs to a wider group of procedures that act on the sympathetic and visceral nerves, or deliver treatment directly to the spinal cord. The same group includes his procedures for cancer pain, for pelvic, coccyx and perineal pain, and the implanted devices he uses when other treatment has failed. The overview of the specialty, its safety and its costs is in the interventional pain management guide.

How percutaneous sympathectomy relieves pain

Percutaneous sympathectomy relieves pain by interrupting the sympathetic chain, which runs alongside the spine and controls blood vessel tone in the limbs, among other functions. In some conditions the chain drives pain directly, or narrows the vessels so that tissue becomes ischaemic and painful. Interrupting it at the right level opens the vessels and switches off that pain. The upper limb is supplied through the chain at the T2 to T3 level in the upper chest; the lower limb through the lumbar chain.

T2 to T3 sympathectomy for the arm and hand

Dr. Jain uses T2 to T3 sympathectomy for a range of upper limb problems:

• Raynaud's disease, in which the fingers turn white and then blue in the cold, and in severe cases develop ulcers or gangrene at the tips;
• peripheral vascular disease and arterial occlusion affecting the arm;
• brachial plexus injury, damage to the network of nerves supplying the arm, typically after an accident;
• post-amputation pain in the upper limb;
• complex regional pain syndrome (CRPS), a disproportionate, persistent pain in a limb, often with swelling and changes in colour and temperature.

Percutaneous vs surgical sympathectomy

Surgical sympathectomy is usually performed thoracoscopically, through ports in the chest wall under general anaesthesia. Dr. Jain's centre does not perform an operation for this. Instead, two radiofrequency cannulas are placed on the sympathetic chain under imaging in the cath lab, and the chain is ablated. There is no need to open the chest.

The effect can be visible on the table. In the cases he showed, a hand that was blue from peripheral vascular disease regained its normal colour after the procedure, and the pain resolved. One patient had already had vascular surgery, with a residual scar, yet her hand pain persisted; after sympathectomy the bluish discolouration of the fingers cleared and the pain went. Another, with a brachial plexus injury after an accident, had severe pain and swelling in the right arm and improved after the procedure.

Dr. Jain also described treating a close family member with Raynaud's disease affecting both hands, with the procedure performed on both sides. She has made a full recovery and remains well years later. Patients whose fingertips turn blue or black, he concluded, can be treated.

Lumbar sympathectomy for the leg and foot

The lower limb equivalent is lumbar sympathectomy, also a day-care procedure with good pain relief. Dr. Jain's indications are:

• gangrene of the toes or foot;
• diabetic foot;
• post-amputation and phantom limb pain;
• Buerger's disease, the "smoker's foot", an inflammatory disease of the small and medium arteries and veins of the limbs, closely linked to smoking;
• nerve injury with swelling of the limb;
• limb swelling caused by cancer in the pelvis;
• lumbar plexus injury.

For a referring doctor, the practical message is that a patient with ischaemic or neuropathic pain in the foot, who is often a poor surgical candidate, may be helped by a needle procedure in the lumbar region.

Nerve blocks and neurolysis for cancer pain

Dr. Jain uses three families of interventions for cancer pain, which his team treats in many patients as part of its palliative care work:

1. peripheral nerve blocks of one or more nerves;
2. alcohol neurolysis, a longer-lasting chemical interruption of a nerve;
3. sympathetic neurolysis, which targets the visceral nerves that carry pain from internal organs.

Upper abdominal cancer: splanchnic nerve RFA

Pain from the upper abdominal organs travels through the splanchnic nerves. For pain from cancer of the pancreas, gallbladder, liver, stomach, oesophagus and other upper gastrointestinal cancers, Dr. Jain performs splanchnic nerve RFA, which he reports gives very good results. He also offers these sympathetic procedures to patients whose pain persists after the cancer has been treated with surgery, chemotherapy or radiotherapy.

Pelvic pain: superior hypogastric plexus neurolysis

The superior hypogastric plexus, in front of the lower lumbar spine, carries pain from the pelvic organs. Dr. Jain uses superior hypogastric plexus neurolysis for pain from:

• cervical and uterine cancer;
• ovarian cancer;
• rectal cancer;
• other pelvic pain, including endometriosis, cystitis, and bladder and rectal pain.

He describes it as a very effective technique for these patients.

Coccyx and perineal pain: ganglion impar block and RFA

The ganglion impar is the lowest point of the sympathetic chain, lying in front of the junction of the sacrum and the coccyx. Dr. Jain uses ganglion impar block and RFA for:

• coccydynia, or tailbone pain, including pain from a displaced coccyx;
• perineal pain around the anus, rectum or vagina.

Many of these patients reach his clinic after repeated treatment elsewhere has failed. He puts the success rate in coccydynia and perineal pain at more than 95 per cent, and says no surgery is needed.

Pudendal nerve RFA

For pain in the testes or penis in men, and vaginal or vulval pain in women, Dr. Jain performs pudendal nerve RFA. The pudendal nerve supplies the perineum and genitals. He receives many international patients with undiagnosed testicular or penile pain, and describes the procedure as very effective.

Spinal cord stimulation for neuropathic and ischaemic pain

For neuropathic pain, ischaemic pain and phantom limb pain, Dr. Jain uses spinal cord stimulation. A stimulator delivers electrical impulses to the spinal cord through leads in the epidural space, changing how pain signals are processed.

The process begins with a trial. He showed a trial of a cervical cord stimulator in a young patient with a brachial plexus injury, followed by the surgeon placing the lead. The trial establishes whether the patient benefits before a permanent system is implanted.

Intrathecal pump for spasticity and severe pain

An intrathecal pump delivers medication directly into the fluid around the spinal cord. Dr. Jain uses it for:

• spasticity after spinal cord injury, in both legs or in all four limbs (quadriplegia);
• pain after spinal cord injury;
• cancer pain;
• failed back surgery.

The drug depends on the problem. For spasticity, he gives intrathecal baclofen; for pain, intrathecal morphine; where both are present, a combination of morphine and baclofen.

How the pump is implanted

The implant is a small operation. A catheter is introduced into the spinal canal through a puncture, fixed in the back through a small incision, and connected to the pump, which is implanted in the abdominal wall. Before implantation, a trial establishes the dose at which the patient is comfortable, and that dose is then delivered by the pump.

He showed a woman who had undergone surgery for a spinal cord tumour and was left with severe spasticity and pain. Within 24 hours of pump implantation she was pain-free and the rigidity had gone. In Dr. Jain's experience, once the trial has set the dose, the pump relieves spasticity and this kind of pain in all of his patients; only the dose varies from patient to patient. In standard practice, the screening trial also identifies patients who do not respond adequately, and they do not proceed to a permanent pump.

Matching the procedure to the problem

These procedures sit at the advanced end of interventional pain management, and the implanted devices cost considerably more than other pain procedures, as Dr. Jain noted in the question session; the figures he gave are in the interventional pain management guide linked above. Facet and disc procedures for the spine are covered in failed back surgery syndrome, sciatica and disc pain. Dr. Jain's later masterclass covered the medication side of this field, including opioids, in cancer pain management: nerve blocks, pumps and opioids.