• Reference Number: HEY-611/2023
• Departments: Pain Medicine
• Last Updated: 29 September 2023

Introduction

This leaflet has been produced to give you general information about your treatment.  Most of your questions should be answered by this leaflet.  It is not intended to replace the discussion between you and the healthcare team, but may act as a starting point for further discussion.  If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

What is a Lumbar Sympathectomy?

A lumbar sympathectomy injection is one method used to provide pain relief by blocking the pain-inducing sympathetic nerves in the lumbar (lower) region of the back. Sympathetic nerves are responsible for controlling the automatic functions of our body’s skin temperature but can also be responsible for increasing pain we experience from an injury, long after the injury has healed.

Can there be any complications or risks?

As with any procedure, side-effects may occur. However, these are usually minor and there is little risk of serious harm. There is a very slight chance of getting an infection where the needle is placed. You may develop bruising or Haematoma in the injected area in your back. You may also develop diarrhoea.

The sympathectomy injection might cause drop in your blood pressure. With a longer acting block there is a chance that you will develop ‘postural hypotension’. This is a tendency to have dizzy or fainting episodes when you stand up quickly. This can last for about 2 weeks and you should be careful not to stand up and walk too soon after lying down.

There is a small chance of damage to the nerves supplying sensation to the legs. This affects less than 5 per cent of patients and can be temporary or permanent. This can cause pain, usually at the top of the thigh and usually gets better within four to six weeks.

There is a very small risk of damage to nearby structures like bowel, kidneys or one of the blood vessels in the abdomen. This is extremely rare but can very occasionally require an operation to treat. There is a small chance of developing bladder incontinence.

There is a possibility of sexual problems in men having a lumbar sympathectomy on both sides. If you are sexually active, you should discuss this with your doctor before the procedure.

I have heard that steroids are being used unlicensed / off label, what does this mean?

Steroid medications (corticosteroids) are licensed for use through specific routes of administration only. However, for managing chronic pain they are in use through variety of routes for number of years and some routes of administration to treat pain are not on license. This is referred to as off-label use. The manufacturer of the medicine may not have applied for a specific licence to extend its usage.

Many medicines used in pain medicine are used off-label. You can discuss this further with your doctor.

Advice to be read before having a pain relief procedure?

The following information has been produced to ensure that you are able to have your pain relief procedure.  It is essential that you read and follow the advice given below before you come to the hospital. If you do not follow the advice you may not be able to have your treatment.

• Please contact the Pain Service if any of the following apply to you:
• You are diabetic and take medication to control your diabetes. (Please see below for further advice)
• You have recently had an admission to hospital.
• You have tested positive for MRSA.
• You have an infection and are currently taking antibiotics.
• If there is any possibility you may be pregnant.

Continue your other regular medications including your pain relief.  However, If you take any anticoagulants or blood thinning medications (examples are listed below but may not include some of the newest drugs introduced since the publication of this leaflet), please notify the Pain Service at least 10 days before your appointment.  You may need to stop taking these drugs at least 1 week prior to the procedure unless your doctor has advised against this.

• Warfarin (Marevan)
• Clopidogrel (Plavix)
• Dabigatran (Pradaxa)
• Rivaroxaban (Xarelto)
• Apixaban (Eliquis)
• Edoxaban(Lixiana)
• Prasugrel (Effient)
• Ticagrelor (Brilique)
• Dalteparin (Fragmin) injections
• Enoxaparin (Clexane) injections
• Tinzaparin (Innohep) injections
• Dipyridamole (Persantin Retard)
• Phenindione
• Acenocoumerol (Sinthrome)
• Asasantin Retard

You may have to wait a while before your procedure, so please bring something to read or do to keep yourself occupied. Please bring a dressing gown and slippers to wear.

Please leave any valuables or jewellery at home.  It is essential that after the procedure you arrange for an adult friend or relative to collect you by car or taxi. You will not be able to use the bus or train to travel home.

Hospital transport may be available if there is a medical need. If you think you may be eligible, please contact the doctor.

Sometimes pain injections are done under sedation (a drug is given to make you drowsy and relaxed but still conscious). If you are having sedation for the procedure, then you should not have anything to eat on the morning of your treatment. You may have a drink (tea or coffee without milk) if you wish, up to 2 hours before your appointment time.

Advice for diabetic patients only

If you are diabetic and booked to attend treatment under sedation in the morning, you should not have breakfast or your morning medication, but please bring the medication with you.

If you are booked for treatment under sedation in the afternoon, please have your breakfast and take regular medications before 7.00am. Thereafter only drink clear fluids (not milk) for up to 2 hours before the procedure.  Please inform the Pain Service staff as soon as you arrive that you are diabetic, the staff will then assess your diabetes and if necessary, take appropriate action to monitor and control your blood sugar while you are in our care.

Your blood sugar level may raise and remain raised for few days after the procedure due to steroid medications that might be used during the injection. It is advisable to monitor your sugar level regularly for one week following the procedure.  Any concerns please contact your doctor.

What happens before the procedure?

You will be admitted by the nursing staff who will ask for and record some information about you.  Your blood pressure will be checked and you will be given a gown to put on. The doctor will explain the procedure and ask you to sign a consent form.  Please make sure you have understood what has been said and feel free to ask any questions.

What to expect during the procedure

As a precautionary measure, a thin plastic tube (cannula) may be inserted into a vein in your arm/hand before the procedure itself.  This allows us to give medication if there are any issues during the procedure.

Regarding the procedure itself, after cleaning your back and shoulder with antiseptic solution, local anaesthetic will be injected into your skin to numb it first.  Under X-ray screening or ultrasound guidance, a fine needle is introduced into back towards the area to be treated.  Once the optimal position is obtained, local anaesthetic with or without steroid will be injected close to the nerve.

What happens after the procedure

You will be taken on the trolley to the recovery area where the nurse will check your blood pressure and pulse.  You will be asked to rest for about an hour.  After that you will be able to get up, but please check with the nurse before you do so.

Once you are mobile, you will able to go home accompanied by an adult friend or relative.

Please ensure that you have arranged for someone to drive you home after this procedure. Failure to do so will result in your procedure being cancelled. If you have had sedation, we recommend that you arrange for someone to stay with you overnight and that you do not drive for 24 hours.

What to expect when you return home

Take it gently for a few days but gradually build up your activities. You should continue to take all your usual medication/pain relief as the pain may be slightly worse until the nerve block starts to work.

Some people find that they get relief from their pain but, after a couple of months this wears off.  Others may experience complete relief; however, there is a chance that the pain will not improve, not change or will get worse.

During the reduced pain period you should try to gently increase your exercise. Simple activities like a daily walk, using an exercise bike or swimming on your back will help to improve your muscle tone and strengthen your back. The best way is to increase your activity slowly.

Try not to overdo things on a good day as this may result in you experiencing more pain the following day.

Follow-up

A letter will be sent to your doctor and you will be reviewed either by telephone or seen at the Pain Clinic in due course.

Points to remember

You will need to have arranged for someone to drive you home after this procedure.

• Please bring your glasses if you need them for reading.
• Always bring a list of all current medication.
• Continue taking all your usual medication on treatment day (please see above advice if you are a diabetic patient)
• If there is any possibility you may be pregnant please inform the doctor or nurse.
• Finally, if you are planning to travel abroad or fly within two weeks after the injections, please let your doctor know as it may be best to change the date of the injections.

Additional Information

If you experience unusual symptoms such as a marked increase in pain/swelling around an injection site, fever, severe headache, new symptoms of pins and needles, new muscle weakness in your arms, or you are very concerned about how you feel after the procedure, please contact your doctor.

In the event of an emergency and outside normal working hours (9.00am – 4.00pm) of the Pain Clinic please contact your own doctor, Local Walk in Clinic / Minor Injuries Unit

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the Pain Service, Outpatients Department, East Riding Community Hospital, Beverley Pain Service (01482) 478868

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.