Background & Aims
Background : Thromboangitis Obliterans or Buerger’s Disease is a most commonly occuring peripheral vascular disease (PVD) characterized by recurring progressive non- atherosclerotic
inflammation and thrombosis of small & medium sized vessels, mainly arteries and veins of the extremities. TAO results in severe rest pain, ulcer and disability .It can also cause gangrene and amputation of limbs with progression of the disease.
Percutaneous lumbar sympathectomy is commonly performed intervention , along with complete cessation of smoking and pharmacotherapy to relieve rest pain and suffering in patients suffering from TAO. Supportive care should be directed towards maximizing blood supply to the affected limbs.
AIMS: The purpose of our study was to evaluate the effectiveness and clinical outcome of percutaneous lumbar sympathectomy in relieving pain, healing of ulcer, reduction of swelling and improvement of claudication time in patients suffering from TAO.
Methods
After approval from the ethics committee 38 male pts of TAO were enrolled in our study for a period of 6 months. Diagnosis of TAO was made on clinical history, l and colour doppler study. The age varied from 25-50 years. Inclusion criteria included smoking, rest pain, claudication pain, leg ulcer and no response to conservative treatment. Basic investigations and colour Doppler study was done in all patients to evaluate extent of the disease before subjecting to intervention. Under all aseptic precautions LSB was performed in prone position under C arm guidance. 10 ml of 0.25% bupivacaine with 40 mg steroid was injected on affected side with 15 mm 22 Gz long spinal needle at L3 and L4 level. . and patients were shifted to recovery for observation .LSB was repeated weekly in all patients and VAS Score, Claudication distance , ulcer and pedal edema was assessed weekly. patients were given analgesics, antibiotics vasodialators and antiplatelet drugs after the intervention.
Results
In our study 38 patients were included over a period of 6 months. Mean age of 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 cases. The mean VAS score before the intervention was 8-9/10 .The mean claudication distance was 25+-15 metres.The effect of each successive LSB was compared with the previous VAS score and it was observed that after first LSB , The VAS score improved significantly and came down to 6/10 and 3 /10 and 1-1.5/10 subsequently (Graph 1). with each successful block. The claudication distance (CD) also improved significantly after each block and was statistically significant(p less than 0.05). The ulcer diameter also showed significant decrease in size after each block( graph 3). The ulcer diameter which was 3-4 cm before lumbar sympathetic block also improved significantly after each block.
Conclusions
Chronic pain remains a frequent diagnostic feature of many vascular diseases. The exact incidence and prevalence of PVD has not been studied but it remains a significant problem amongst Indian population. Apart from conservative and surgical procedures, interventions play a very important role, wherein they serve both diagnostic and therapeutic purpose in managing pain.
in our study we concluded that lumbar chemical sympathetic blocks in series using local anaesthetic and steroid under fluoroscopic guidance, is an effective and safe technique in relieving rest pain, improving claudication distance , reduction of swelling and healing of ischaemic ulcers because of marked reduction in peripheral resistance leading to increase in blood flow to skin and improvement of tissue oxygenation due to decrease in sympathetic tone .Detailed evaluation and multidisciplinary approach is mandatory in successful outcome in managing Thromboangitis Obliterans.
References
1. Lau H, Cheng SW. Buerger’s disease: a review of 89 cases . Aust NZ J Surg 1997 May :67; 264-269.ClinicNorth America 1985, 65: 393-403
2. Dargon PT, Landry GJ, Buerger’s disease, Ann Vasc Surg 2012; 26;871
3. Arkkila PE: Buerger’s disease . Orphanet J Rare Disease 2006; 1: 14
4. Piazza G et al: Thromboangitis obliterans AO circulation 2010:12: 1158
5. Vijayakumar A.Tiwari R et al: Current practices . Int J Inflmm 2013
6. Persson AV, Anderson AA: Selection of patients for lumbar sympathectomy , Surg Clinic North A merica 1985, 65: 393-403
7. NesalgikarPN, AjitMK, Nichol BJ et al. Lumbar chemical sympathectomy in PVD: Does it still have a role, Int J Surg 2009:145-149
8. Buerger L.TAO;JM .
9. Mils JL, Taylor LM ; Porter Buerger disease in the modern era : Amer J of Surg , 1987 ; 154; 123
10. Tay VK,T ie ML. CT and fluoroscopy guided chemical lumbar sympathectomy: simple, safe and effective, Australas Radiology,2002;46; 163-166.
11. Johanson A, Hao J, Local corticosteroid application blocks transmission in nociceptive C fibres . Acta Anaesthesiolb Scan d; 1990: 335-338.
12. Menon R,,Swannepoel A. Sympathetic blocks. Cont Edu Anaesthesia Critical care Pain 2010;10
Presenting Author
Sunita Lawange
Poster Authors
Topics
- Specific Pain Conditions/Pain in Specific Populations: Pain in Vascular Insufficiency