Lumbar Sympathectomy: Purpose, Procedure, Benefits and Side Effects

Lumbar Sympathectomy is a surgical procedure used to reduce the symptoms associated with Raynaud's phenomenon, Sudeck's atrophy and certain types of pain in the lower back. The sympathetic nerve endings located in the lumbar spine region are cut in order to reduce the body's sensitivity to pain.

There are two main types of lumbar sympathectomy, endoscopic and open:-

• Endoscopic lumbar: Endoscopic lumbar sympathectomy is a minimally invasive procedure. It requires only a few small incisions in the abdomen to reach the sympathetic nerve chain. This procedure is done with a tiny camera attached to the endoscope to identify and cut the nerve chain.
• Open lumbar sympathectomy: Open lumbar sympathectomy is an open surgery which requires a larger surgical incision to access the sympathetic nerves. In this procedure, doctors must identify and remove parts of the nerve chain one by one. This can be a more time consuming process than endoscopic surgery due to the increased difficulty in identifying and removing each nerve from its surrounding tissue.

• Reduction in pain and discomfort: This procedure has been associated with a reduction in the sensations of cold, burning, and numbness known as 'sympathetic-mediated pain’ that often accompany illnesses such as diabetes, herpes zoster neuralgia, complex regional pain syndrome and people living with HIV.
• Improved circulation: Lumbar sympathectomy can improve blood circulation to the lower limbs by disrupting abnormal nerve pathways that produce constriction of small vessels. The improved flow of oxygenated blood helps to promote healing for those having localised muscle and joint problems in the lower extremities.
• Decreased sweating: This procedure can help reduce excessive sweating (hyperhidrosis) in areas such as the feet or hands when traditional therapies have failed to provide satisfactory results.
• Improved sleep: Those suffering from Raynaud's phenomenon or severe meralgia paresthetica may experience greater quality of sleep due to decreased limb discomfort after undergoing a lumbar sympathectomy surgery.
• Enhanced mobility: This type of surgery is successful at restoring patients with limited movement due to vasomotor diseases such as peripheral artery endofibrosis (PAES) or thoracic outlet syndrome (TOS).

• It is done to reduce chronic lower back pain known as lumbago that is resistant to other treatments, such as physical therapy and medication.
• To relieve conditions such as complex regional pain syndrome, causalgia, and sympathetically maintained pain.
• To improve circulation in the legs and feet by reducing the spasms of the small arteries in the legs (vasospasm).
• It is used to decrease sweating in the lower extremities caused by improper functioning of the sympathetic nervous system.
• To reduce muscle hyperactivity (spasticity) in the legs caused by an overactive sympathetic nervous system

Some of the potential risks associated with a lumbar sympathectomy procedure include: infection, bleeding, nerve damage, scarring, bladder and sexual dysfunction, labour or delivery complications in pregnant women.

• You should discuss the risks, benefits, and alternatives to lumbar sympathectomy with your doctor or medical team.
• Listen and follow all the instructions given to you by the doctor carefully before the surgery.
• Get all necessary tests done as per the recommendation of your doctor such as X-rays, CT scans, MRI scans etc.
• If you are taking any medications, inform your doctor so that he can advise accordingly on their usage before and after the surgery.
• Follow a healthy diet and exercise regularly before the surgery for your good physical health.
• Don't smoke and avoid drinking alcohol for at least 2 weeks before the surgery.
• Make arrangements for someone to drive you home after the surgery since it is likely that you will be unable to drive yourself due to sedation or other medication given during the procedure
• Ensure that a responsible adult is available to take care of you for at least 24 hours after the procedure

• It is done only in the presence of general anaesthesia and involves making an incision in the lower back, near the spine.
• The surgeon will then use an endoscope to identify and remove the affected nerve fibres from the sympathetic chain in that area.
• Once these fibres have been removed, they can no longer carry signals from the brain to certain parts of the body, such as the legs, feet, or torso.

• Complete medical history and physical examination of the patient should be done before the onset of procedure.
• Perform a nerve conduction test to identify areas of sympathetic nerve activity.
• Order appropriate lab tests, such as an electrocardiogram (ECG) and complete blood count (CBC).
• Administer preoperative medications, such as antibiotics or blood thinners (as directed by your physician) to reduce risks associated with the procedure.
• Position the patient on their back for the procedure, with their legs bent at a 90-degree angle and their feet flat on the surface of the operating table.
• Lubricate and cover all exposed patient skin areas with sterile drapes or towels to prevent infection during surgery.
• Insert intravenous (IV) lines into separate veins in both arms that allow administration of drugs, monitoring of vital signs and providing fluids during surgery, as needed.
• Monitor vital signs (pulse rate and rhythm, blood pressure), ECG tracing, oximetry throughout procedure to ensure safety levels are maintained during surgery

• The patient is placed under general anaesthesia
• The skin in the lumbar area is prepared and a small incision is made
• The sympathetic chain, which runs along the spine, is located and severed
• Once the chain has been removed, test nerves are stimulated to ensure that the procedure was successful
• Any necessary sutures or dressings are applied before the patient is allowed to wake up from anaesthesia

• Have the patient monitored in the recovery area until they are awake and alert.
• Check their blood pressure, heart rate, and pulse to ensure they remain stable.
• Applying an ice pack to the incision site reduces pain and swelling if needed.
• Monitor the patient’s temperature and provide medications if needed for pain management post-procedure.
• Instruct them on how long to refrain from lifting, bending or twisting at the waist for 3-4 weeks post-procedure following doctor’s orders or risk damaging the repair site by putting too much strain on it too soon.
• Offer emotional support if needed and answer any of their questions about their recovery process
• Schedule a follow up appointment with their doctor in about 1 month after procedure for developing an exercise program or physical therapy plan going forward as is appropriate for their condition or symptoms which can help improve overall comfort and flexibility after surgery

The cost of lumbar sympathectomy in India typically ranges between INR 1,50,000 and INR 2,00,000. In some cases, hospital charges or additional medical expenses may be included in this range.

• Foods that should be included in your diet are:-
• Lean proteins, such as fish, poultry and beans; whole grains, such as oatmeal and quinoa; plenty of fruits and vegetables.
• Healthy fats, such as avocados, nuts and seeds; low-fat dairy products like milk or yoghourt; and olive oil.
• Eating smaller meals at regular intervals throughout the day is also recommended to keep energy levels up.
• Additionally, increasing water intake can help increase circulation in the body and help with healing after surgery.

Yes, lumbar sympathectomy is generally a safe procedure. It has been used for decades to relieve chronic pain and other symptoms caused by certain disorders, such as complex regional pain syndrome (CRPS).

• Like any other surgical procedure, lumbar sympathectomy may be associated with some degree of discomfort during and after the surgery.
• Patients typically report feeling soreness and mild pain following the operation;
• However, most patients find that this pain quickly subsides with appropriate post-operative management and care.
• While lumbar sympathectomy is not considered to be a particularly painful procedure overall, it is important to discuss any potential risks with your doctor prior to undergoing the surgery.

Recovery time following lumbar sympathectomy varies depending on the patient’s age and general health, as well as the surgical procedure performed.

Most patients return to their normal activities within two weeks. However, full healing can take up to six months in some cases.

• Pain in the lower body: Lumbar sympathectomy can cause pain in the lower body, including the legs, hips, and buttocks.
• Numbness and tingling: After sympathectomy, people may experience numbness and tingling in their legs and feet.
• Loss of sensation: People may also experience a loss of sensation in their lower body after lumbar sympathectomy. This can lead to difficulty with balance, coordination, and mobility.
• Muscle weakness: Weakness of the muscles in the lower body can also occur after lumbar sympathectomy, making it difficult to walk or stand for long periods of time.
• Urinary incontinence: A common side effect of lumbar sympathectomy is urinary incontinence due to weakened muscles in the bladder area that can no longer control urine flow.
• Infection risk: As with any surgical procedure, there is a risk of infection at the site of incision after lumbar sympathectomy.

• Follow the post-operative instructions of your doctor carefully.
• Take prescribed medications on time.
• Keep the wound clean and dry and take proper care of it.
• Avoid strenuous activities for a few weeks after the surgery.
• Monitor your blood pressure regularly as it may be affected by the procedure.
• Do not lift heavy objects or drive until your physician advises otherwise.
• Go to the doctor at regular intervals to look for the progress after the procedure has been done and also to look for any complications if they present.
• Wear support stockings or other compression garments as advised by the doctor to help improve circulation in the legs and reduce swelling, if needed

Lumbar sympathectomy is an effective minimally invasive procedure that can help to reduce pain and symptoms of neuropathy associated with lumbar disc herniation. When performed correctly, it can provide long-term relief from neuropathic pain and improve overall quality of life.