A study of series of lumbar sympathetic block for pain relief in patients of Thromboangitis Obliterans

 

Sunita Lawange¹, Ashok Lawange^2*

Abstract              Background: Thromboangitis Obliterans is a most commonly occurring peripheral vascular disease (PVD)characterized by recurring progressive non atherosclerotic inflammation and thrombosis of small and medium sized vessels, mainly arteries and veins of the extremities. Thromboangitis Obliterans (TAO)results in severe rest pain, ulcer, claudication pain and disability. It can also cause gangrene and amputation of limbs with progression of the disease. Percutaneous lumbar chemical sympathectomy is commonly used intervention to relieve pain in patients suffering from TAO. Aims and Objective: The purpose of our study was to evaluate the effectiveness and clinical outcome of percutaneous sympathectomy in relieving pain, ulcer healing, reduction in swelling and improvement of claudication distance in patients suffering from TAO. Results: Visual analog scale(VAS) and claudication distance were improved significantly after 3-4 blocks but no significant difference was observed between third and fourth block. Healing of ulcer, reduction of pedal swelling was seen after each block. Conclusion: A series of lumbar sympathetic blocks with bupivacaine and steroid is an effective and safe technique in relieving rest pain, improving claudication distance, ulcer healing in patients suffering from TAO when conservative management becomes ineffective. The number of blocks required in our study varied from three to five.

Keywords: Thromboangitis Obliterans(TAO), Buerger’s disease, Lumbar sympathetic block(LSB), Bupivacaine, Triamcinolone, Claudication distance(CD)

 

INTRODUCTION

Thromboangitis Obliterans(TAO) or Buerger’s disease is characterized by peripheral ischemia of an inflammatory nature with a self-limiting course. Shionoya's criteria¹ for the diagnosis of TAO are : history of smoking, onset before age 50, infrapopliteal arterial occlusion, either upper limb involvement or phlebitis migrans, absence of atherosclerotic risk factors other than smoking. Confident clinical diagnosis of TAO may be made only when all five requirements have been met. TAO was first reported in 1908 and is characterized by a recurring progressive inflammation and thrombosis of small and medium sized arteries and veins of hands and feet¹ and impending gangrene. The etiology still remains unclear but it is strongly associated with chronic tobacco smoking. It is still uncertain whether thrombosis or vascular inflammation is the first event². The involvement of the distal vessels and nerves within the neurovascular bundle occurs mostly in lower limbs and very rarely in upper limbs^3,4 TAO is the most common cause of peripheral vascular disease (PVD) in India. Contrary to that in western countries where it accounts for 0.5% to 12% of all peripheral vascular diseases, the incidence is 45% to 63% in India.² It is more common in people of low socioeconomic class who smoke bidis. The predisposing factors include male gender, cigarette smoking, infectious agents, environmental factors such as anxiety, stress and low socioeconomic status⁴. The only definitive treatment of TAO is abstinence from smoking which also helps in preventing disease progression⁵. Conservative management in the form of aspirin, verapramil, pentoxyphylline reduce pain and increase pain free walking distance in intermittent claudication but long term usage fails to prevent disease progression in patients who still continue to smoke. The majority of patients present with an advanced stage of ischemia hence, most of them require surgical intervention in the form of either lumbar sympathectomy, omentopexy,Illizarov techniques, revascularization or major or minor amputations and recently stem cell therapy helps in reducing the pain and promote healing of trophic changes⁵. Percutaneous lumbar chemical sympathectomy with complete cessation of smoking along with pharmacotherapy is the first step in managing rest pain of TAO. Lumbar sympathetic block is used for evaluation and management of sympathetically mediated pain in lower limbs in TAO^6,7. In spite of availability of various surgical and nonsurgical options in relieving pain in TAO results are often inconsistent. Supportive care should be directed towards maximizing blood supply to the affected limbs.

 

MATERIAL AND METHODS

After approval from the ethics committee and obtaining written informed consent from all the patients, thirty-eight male patients of TAO not responding to conservative mode of treatment and regularly visiting our pain clinic were enrolled in our study for a period of 6 months Diagnosis of TAO was made on clinical history, local and general examination and Colour Doppler study. The age varied from 25-50 years. Patients with ASA physical status I or II with history of smoking, rest pain, claudication pain, leg ulcer or gangrene and not responding to conservative mode of treatment were included in our study. Colour Doppler, study revealed absent dorsalis pedis artery pulsations, partial thrombosis of major vessels: popliteal artery, anterior and posterior tibial artery of the affected lower limb Patients giving history of systemic disease like diabetes mellitus, coagulopathies, heart disease, grossly infected ulcer or gangrene, allergy to used drugs, difficulty in lying down in prone position were excluded from our study profile, Basic investigations like complete hemogram, blood sugar level, coagulation ECG and colour Doppler was done to assess the condition of vessels before subjecting patients for lumbar sympathetic block Patients fasting status was ensured before taking them to the operation theatre. On arrival into OT, routine monitoring of non invasive blood pressure, heart rate, pulse oximetry was commenced and Intravenous assess achieved with lactated Ringer solution started as loading fluid. Patient were positioned prone with a pillow underneath abdomen to correct the lumbar lordosis. Under all aseptic precautions and under local infiltration with 2% lignocaine, the entry point was confirmed under fluoroscope and a 22 gauze 15 mm long spinal needle was introduced along the lateral border of L3 vertebral body in oblique view under C-arm guidance. Depth of the needle was confirmed in lateral view with a target to reach the anterolateral aspect of L3 vertebra. Iohexol Contrast was used to confirm the proper positioning of the needle. After confirming the proper positioning of needle tip 10 ml of 0.25% bupivacaine with 40 mg triamcinolone was given on the affected side. In case of bilateral involvement same procedure and drugs were repeated on other side also. Vital parameters were monitored throughout the procedure and patients were shifted to recovery and observed for 4 hours and then discharged accordingly. The block was repeated weekly in all patients and VAS score, claudication distance and condition of ulcer, pedal edema was assessed by a third person after every week. Patients were given analgesics, antibiotics and were asked to continue the vasodialators and antiplatelet drugs after the intervention.

 

RESULTS

In our study,38 patients were included over a period of 6 months. Mean age of the patients was in a range of 36.58+- 7.63.(table 1) Amongst all the patients 94.6% were heavy smokers, the great toe was involved in all cases with other toes and foot in some patients. The mean VAS Score before the intervention was 8-9/10 in all cases. The mean claudication distance was size of ulcer if any was 25 +- 15 metres. The effect of each successive LSB was compared with the previous VAS score and it was observed that after the first LSB, the VAS score improved significantly and came down to 6- 6.5/10.with each successive block VAS score to 3 and 1-1.5/10 subsequently.(Graph 1) The claudication distance CD also improved significantly after each block and was statistically significant. (p less than 0.05)(Graph 2) Ulcer diameter also showed significant decrease (graph 3) in size after each block. the ulcer diameter which was 3-4 cm before LSB improved significantly after each block.

 

 

 

 

 

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