Lumbar sympathetic ganglion block treatment in a patient with thalamic pain

Theresia Chandra Tania Novy; Vitaka Dwi Charisma; Tertianto Prabowo

doi:10.4103/jrap.jrap_7_22

CASE REPORT

Year : 2021 | Volume : 7 | Issue : 2 | Page : 52-54

Lumbar sympathetic ganglion block treatment in a patient with thalamic pain

Theresia Chandra Tania Novy¹, Vitaka Dwi Charisma¹, Tertianto Prabowo²
¹ Bandung Pain Rehab Centre, Bandung, Indonesia
² Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Universitas Padjadjaran - Dr. Hasan Sadikin General Hospital, Bandung, West Java, Indonesia

Date of Submission	10-Oct-2022
Date of Acceptance	14-Nov-2022
Date of Web Publication	08-Mar-2023

Correspondence Address:
Theresia Chandra Tania Novy
Bandung Pain Rehab Centre, Supratman Street No. 57, Cihapit, Bandung Wetan, Bandung, West Java
Indonesia

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrap.jrap_7_22

Abstract

Thalamic pain is a neuropathic pain that may be induced in patients recovering from a cerebrovascular accident. Ultrasound-guided lumbar sympathetic ganglion block (LSGB) has been used to treat pain from various diseases. A 43-year-old man came to our clinic with persistent pain described as a burning sensation on the left lower limb of his body. The pain was resistant to any typical neuropathic pharmacologic medication. We approached the treatment using the ultrasound-guided LSGB technique, then administered 5 milliliters (ml) of injectate that contain 4 ml of 1% lidocaine and 1 ml of 5 milligrams (mg) dexamethasone on each of L2, L3, and L4 lumbar sympathetic ganglion chain levels. Thus, our patient received 15 ml of injections in total. After four visits and within 6 weeks of treatment, there were some improvements and a reduction of the Numeric Rating Scale pain score on each visit. LSGBs coupled with ultrasound-guided technique seem to benefit our patients with thalamic pain.

Keywords: Case report, lumbar sympathetic ganglion block, thalamic pain, ultrasound

How to cite this article:
Tania Novy TC, Charisma VD, Prabowo T. Lumbar sympathetic ganglion block treatment in a patient with thalamic pain. J Recent Adv Pain 2021;7:52-4

How to cite this URL:
Tania Novy TC, Charisma VD, Prabowo T. Lumbar sympathetic ganglion block treatment in a patient with thalamic pain. J Recent Adv Pain [serial online] 2021 [cited 2023 Mar 31];7:52-4. Available from: http://www.jorapain.com/text.asp?2021/7/2/52/371251

Introduction

Thalamic pain, also known as central poststroke pain (CPSP), is a neuropathic pain that can of patients recovering from cerebrovascular accidents, usually accompanied by other sensory deficits.^[1],[2] Its prevalence is within 1%–35% in stroke patients, and it affects patients' quality of life.^[3],[4]

Thalamic pain is often treatment resistant.^[5] Several treatments are available, but the options are limited. Lumbar sympathetic ganglion block (LSGB) is both diagnostic and treatment tools that have been used in complex regional pain syndrome, phantom limb pain, and several vascular diseases.^[6] LSGB is usually coupled with fluoroscopy and computed tomography (CT) scan imaging-guiding techniques. However, both techniques exposed the patient to the risk of radiation.^[7] In this report, we intend to provide new insights into thalamic pain treatment, using the ultrasound-guided LSGB technique.

Case Report

A 43-year-old man came to our clinic on September 4, 2019, with a chief complaint of pain on the left lower limb of his body, specifically on L2, L3, and L4 levels of lumbar dermatome sensory distribution. The patient described the pain as a burning sensation and has been treated in multiple health centers. The patient was prescribed pharmacologic medications such as tramadol, baclofen, gabapentin, and amitriptyline. However, the patient felt no improvement. The pain emerged after he had a hemorrhagic stroke on October 23, 2010. At the initial pain assessment, he said that his pain intensity was 15, whereas the maximum value of the Numeric Rating Scale (NRS) pain assessment was 10. Based on history taking and physical examination, we diagnosed the patient with thalamic pain.

Before initiating the treatment, we educated the patient about the risk and benefits of the treatment. The patient understood the risk and the benefits and then consented to the treatment. We treated the patient using interventional pain management procedures, with the LSGB, and the before and after NRS score was recorded during each visitation, as shown in [Table 1]. We applied ultrasonography as a guiding technique using a short-view approach. We inserted a 3.5-inch-long and 25 gauge needle from lateral to medial using in-plane technique to reach the lumbar sympathetic ganglion chains, as shown in [Figure 1]. Then, we injected a 5 ml injectate that contained 4 ml of 1% lidocaine and 1 ml of 5 mg dexamethasone on each of L2, L3, and L4 levels of lumbar sympathetic ganglions. Thus, the patient received 15 ml of injections in total. After drug administration, the patient still continued to consume analgesic drugs with a taper-down dose.

Table 1: The follow-up of the patient in each visitation with the Numeric Rating Scale

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Figure 1: Lumbar sympathetic ganglion block using (a) USG and (b) Doppler USG) (Original Figure). USG: Ultrasonography

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Within 1 month and on each visitation, we were able to reduce the patient's pain. During each visit, the NRS scores were reduced by 28% on the first intervention, 57% on the second and third visits, and 28% on the last visit. The recurrence of pain after LSGB occurred between 1 and 3 weeks after the treatment. No complications or side effects were reported.

Discussion

The pathophysiology of thalamic pain remains unclear. However, some hypotheses have been suggested, such as postinjury central neurochemical changes, spinothalamic tract hyperexcitability, and lesion in the lateral thalamus that disrupts the pain inhibition pathway.^[8] It was hypothesized that the pain arises only in the thalamic lesion. However, any lesion from spinothalamic tract structures may elicit similar pain symptoms.^[3] Patients may describe the pain as a burning sensation, followed by freezing, stabbing, and electric shock sensations that arise from the affected region.^[2],[3]

LSGBs are usually done in L2, L3, and L4 levels.^[9] In our patient, we performed multiple level LSGB between L2 and L4 levels. It is mentioned in some studies that multiple-level injections mostly give better results compared to single-level injections. However, multiple-level injections may expose the patient to some complications such as lumbar nerve neuralgia, subarachnoid injection, and visceral organ perforation.^[9]

Our patient received a total of 15 ml of injections. We believe the injection volume is still within the safety range and the outcome is still within our expectations. However, it is important to mention that a larger volume of injection (>5 ml) may increase the risk of sensory and motoric complications. Larger volumes of injection were intended to provide wide coverage of the sympathetic ganglion to avoid any injury to the ganglion by injecting too close to the structure.^[9] However, with the advanced guiding technique, drug administration could be delivered with improved accuracy, and lesser doses could be applied.^[7],[9]

Fluoroscopy and CT scans are the most used imaging techniques that are usually coupled with LSGB, which have variable success rates ranging from 67% to 83%. However, radiation exposure adds another risk to the patient, therefore, the ultrasonography-guided technique has been introduced as an alternative to these techniques.^[10] Ultrasonography itself has its own advantages due to its low radiation exposure and better visualization of the soft tissues.^[7]

We used ultrasound as a guiding technique, and no complications or side effects were reported. The use of the ultrasound-guided technique may be more beneficial than other imaging-guiding techniques because one study found no difference in the success rate between the ultrasound-guided technique and fluoroscopy-guided technique. Therefore, the ultrasound-guided technique may be preferable compared to other imaging-guided techniques, due to its safety and convenience and the relatively similar success rate to the fluoroscopy-guided technique.^[7]

Until now, no study has ever discussed any association between the sympathetic nervous system and the pathogenesis of pain in thalamic pain, but our results suggest that the sympathetic nervous system has a role in the pathogenesis of pain. One study showed that more than 50% of patients with CPSP have symptoms of autonomic dysregulation.^[11] This suggests that there may be a link between the autonomic nervous system and thalamic pain. It is known that dysregulation sympathetic nervous system may elicit pain through uncontrolled sympathetic signaling which uncontrolled sympathetic signaling causes vasoconstriction and pain in the affected area.^[6] Another piece of evidence mentioned that the afferent nociceptive pain signal modulates the pain intensity in CPSP, in which the afferent signal may be affected by the sympathetic nervous system.^[12] Thus, the improvement of our patients after being treated with LGSB may be mediated through these mechanisms.

Although our study gives a satisfactory result, several limitations exist. Our research design is a case report, which requires further studies with a higher level of evidence to confirm our findings. Evidence that discusses the pathogenesis of thalamic pain and the side effect of LSGB treatment on patients with thalamic pain is still lacking. Therefore, more studies are still required to support our claims, and further studies in the future are needed to support our findings.

Conclusion

LSGB coupled with ultrasound-guided techniques seems to benefit our patients with thalamic pain. The treatment reduced pain in our patient and the use of ultrasound-guided technique enhances the accuracy and safety of the LSGB. Our patient did experience any complications during the treatment. However, several limitations exist, thus further studies are still needed to verify our findings.

Declaration of patient consent

We declared that we have obtained the consent of the patient. The patient has given his consent for his clinical information to be reported in the journal. The patient understands that their name and initials will not be published

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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