Lumbar and Thoracic Sympathetic

Radiofrequency Lesioning in
Complex Regional Pain Syndrome

G. B. Racz, MD*; M. Stanton-Hicks, MB, BS, DrMed, FRCA†

*Professor & Chair Emeritus, Department of Anesthesiology, Texas Tech University Health
Center, Lubbock, Texas, USA; †Professor Emeritus, Johannes Gutenberg University,
Mainz, Germany; Vice-Chairman, Division of Anesthesiology,
Cleveland Clinic Foundation, Cleveland, Ohio, USA

THE INDICATIONS RF Sympatholysis

Sympatholysis in Complex Regional Pain Syndrome The use of RF for neurolysis was first described by Cos-
man and Arnoff, but Sluijter4 should be credited with
If complex regional pain syndrome is defined in terms of
most development of RF lesions for pain management.
the consensus paper,1 most cases are preceded by a nox-
RF generators provide a high frequency current by
ious event and are associated with both spontaneous
closed circuit to cause neurolysis.5 The extent of the le-
pain or touch evoked pain, including hyperalgesia and/or
allodynia that is both disproportionate and not limited sion depends on the size of electrode surface, tissue tem-
to a single nerve territory. Associated vasomotor changes perature, and duration of lesion. It has been shown ex-
include abnormalities of temperature, sweating, and perimentally that RF current has a selective action on
edema in the affected region. Sympathetically main- myelinated nerve fibers and, unlike surgical sympathec-
tained pain as defined by Merskey and Bogduk2 is pain tomy, there appears to be minimal or no risk for deaffer-
entation pain.6,7
associated with the sympathetic nervous system and/or
More recently, pulsed RF that uses a low current and
circulating catecholamines that can be demonstrated by
minimal heating may be equally effective to the neuro-
a regional anesthetic sympathetic block. Therefore, pa-
lytic lesions produced by high temperatures.8,9 It can be
tients whose symptoms, both continuous pain and touch
evoked pain, are largely relieved by a stellate ganglion or expected that pain may return after neural regeneration.
If one considers that the sympathetic trunks and ganglia
dorsal sympathetic block and are potential subjects for a
prolonged sympatholysis using radiofrequency (RF). contain preganglionic and postganglionic sympathetic
This technique should be considered in the context of fibers, visceral, and somatic afferent fibers, RF lesioning
will affect all of these to varying degrees depending on
guidelines that have been published for therapy of com-
the parameters of the RF current that are chosen.
plex regional pain syndrome and is but one method of
providing analgesia to help a patient regain function by
ANATOMICAL CONSIDERATIONS
physiotherapeutic methods.3
Lumbar Region
Cell bodies of the preganglionic neurons are to the up-
Address correspondence and reprint requests to: Gabor B. Racz, MD,
Professor & Chairman, Department of Anesthesiology, Texas Tech Univer- per extremity are situated in the intermediolateral horn
sity Health Sciences Center, 3601 - 4th Street, Lubbock, TX 79430, U.S.A. from C7 through T9 and travel as white rami communi-
cantes that project to the paravertebral sympathetic gan-
© 2002 World Institute of Pain, 1530-7085/02/$15.00
glia. The postganglionic gray rami then leave the ganglia
Pain Practice, Volume 2, Number 3, 2002 250–256 to join segmental nerves to the head, neck, and upper
 RF Lesioning in CRPS • 251

extremity. For the lower extremity, the cell bodies reside needle injections, continuous infusions, injection of var-
in the intermediolateral horn between T10 and L3. ious neurolytic substances such as alcohol or phenol.
Their neurons pass to the corresponding segmental Other neuro-destructive procedures include surgical re-
nerve and these join the chain as communicating rami. section of the sympathetic ganglia and the use of RF le-
The lumbar sympathetic ganglia and chain are lo- sioning. More recently, pulsed RF can be used to achieve
cated on the surface of the psoas muscle. Therefore, the analgesia without local tissue destruction. Most past ex-
lateral view contour of the chain’s location will follow perience is derived from surgical resection of sympa-
the outline of the psoas muscle. The L-1 vertebral body thetic ganglia. However, the cost benefit ratio of the sur-
usually has no ganglion. The L-2 ganglion is further- gical sympathectomy has shifted during the past 10
most back from the anterior border of the vertebral years. A significant argument against surgical destruc-
body, at a distance of 12-13 mm at the junction of the tion at a single site is the fact that there are multiple spa-
upper two thirds and the lower one-third (see Figure 1). tial communications. Other commonly recurring com-
The L-3 ganglion is the highest where the ganglion is al- plications from destructive procedures are the high
most at the anterior border at the junction of the upper incidence of genitofemoral nerve injury and secondary
one-third and lower two-thirds. The L-4 ganglion is groin and thigh pain. Less frequently is the development
more posterior to the anterior border and is very vari- of injury to the lateral femoral cutaneous nerve follow-
able in its relationship to the discs. The L-5 ganglion is ing a large volume of injected neurolytic solution. Other
further posterior, but again extremely variable. If one complications are injury to bowels, kidneys, ureter, and
compares 2 sides, the locations may be different. The paralysis, particularly after lumbar sympathetic neuro-
most predictable sites are L-2 and L-3 ganglia. The ante- lytic injection.
rior communicating rami provide a conduit between In another study by the same group of investigators12,13
sympathetic ganglia, the spinal cord and innervation of a 5-mm active tip RF lesion was compared to a phenol
the disc. Recently, Nakamura has described an ascend- block of the lumbar sympathetic chain. One study found
ing communication at L1 and L2 where back pain may that a single phenol block was more effective than multi-
be influenced (blocked) by an L-2 sleeve injection.10,11 level RF lesions.11 However, phenol neurolysis was as-
A number of therapeutic options are available because sociated with a higher incidence of complications (see
of the communication between the sympathetic chain above). Noting that the 5-mm active tip RFA needle
and the spinal canal. Both sympathetic efferent and no- may have missed the sympathetic chain, these investiga-
ciceptive afferents may be blocked in the epidural space tors were able to achieve a similar degree of efficacy to
by single injections or continuous infusions. The sympa- that by phenol injection if multiple lesions were made by
thetic chain and ganglia may be blocked on the surface moving the tip of the needle anterior-posteriorly. This,
of the psoas muscle; this may also be done using single however, also increased the incidence of genitofemoral

Figure 1. The lumbar sympathetic chain is the highest or most anterior at the L3 level and variably lower at other levels. A - indicates
L2; B - indicates L3.
252 • racz and stanton-hicks

neuritis to that seen after phenol. While the complica- To demonstrate efficacy of sympathetic RF lesioning,
tions of neurolytic solutions are well recognized, injury 3 to 5 diagnostic and possible therapeutic injections
due to the physical placement of sharp needles led to the using similar, but uninsulated needles (15 cm blunt
development of a larger active tip on the curved RF Coude-Epimed, International) are given. The patient is
(Racz-Finch) (RFK) needle (Radionics, Inc., Burlington, positioned prone and the C-arm is rotated ipsilateral un-
MA). This allows for an increased lesion size in an area til the spinous process is aligned with the opposite verte-
where sensory stimulation can be carried out. The bral margin. The C-arm is then rotated distally approxi-
curved needle tip can then be rotated 180 for further le- mately 30 ipsilateral to the vertebral body. A point at
sioning.14 Sensory stimulation allows identification of the margin of the lower one-third of the vertebral body
the genitofemoral nerve. is marked and a 16-gauge introducing cannula is ad-
The size of the RF needle induced lesion spreads 1 mm vanced after local anesthetic infiltration in the direction
on either side of the active tip, and thus reduces the dan- of the target. The curved blunt RFA needle is then ad-
ger of genitofemoral induced neuritis. Rotation of the vanced through the cannula using the curved tip to steer
curved needle tip increases the width of the lesion from the needle to its target site. Its final position is deter-
5-6 mm to 8-9 mm (see Figure 2). The incidence of gen- mined by a lateral fluoroscopic view that should show
itofemoral nerve neuritis has been documented in a ret- the needle tip at the anterior lower one-third border of
rospective review by Racz et al.15 Other advantages of the vertebral body. As the needle tip passes through the
RF lesioning are its reproducibility and the fact that it psoas fascia, a distinct “pop” is felt. Aspiration should
can be conducted as an outpatient procedure.16 be negative and injection of 2 ml omnipaque 240 is seen
as a thin line at the anterior border, indicating its diffu-
TECHNIQUE sion on the surface of the psoas muscle (see Figure 3).
With the patient placed in a prone position under light The C-arm is rotated into a straight anterior-posterior
sedation, fluoroscopic guidance is used to guide the nee- position, and the contrast should spread longitudinally
dle to its target. The equipment used is a 25-gauge nee- on the psoas muscle. The needle is connected to the le-
dle for local anesthetic skin infiltration, a 16-gauge in- sion generator, and sensory stimulation is carried out
troducing cannula, and a 15 cm and 10 mm active-tip initially at 50 Hz to 1 V, verifying there is no proximity
curved blunt RFK needle; and local anesthetic steroid to the genitofemoral nerve. Three to 4 ml of local anes-
mixture—ropivacaine 0.5%, Triamcinolone 40 mg in thetic is injected. After waiting for 2 minutes, 80C 90-
10 mL, and a Radionics® RF lesion generator. second lesion is carried out with the needle tip rotated

Figure 2. Left side of picture A

shows 10 mm active tip curved
blunt needle producing lesion
in chicken breast following ro-
tating the needle from right to
left. Please also note that the le-
sion spreads approximately 1 mm
beyond the uninsulated active
electrode. B shows a single lesion
without rotating the active nee-
dle tip. The dime has been placed
on the chicken breast for size ref-
erence. Right side of picture A
shows the lesion produced by
180 rotation of the needle tip
with 90-second duration, 80C
temperature 2 lesions. B shows
the radiofrequency thermoco-
agulation of the chicken breast
following 90-second duration
80C lesioning. The size of le-
sion in picture A is 8 to 9 mm
and in picture B is 5 to 6 mm.
 RF Lesioning in CRPS • 253

cephalad. The needle tip is rotated 180 caudally, and a in the foot), would strongly suggest segmental innerva-
second 80C, 90-second lesion is performed. The L-3 tion by the sympathetic nervous system.
ganglion is targeted similarly. The C-arm is then rotated The improvement in safety and reduction of neuritis
until the spinous process moves to the contralateral during of lumbar sympatholysis has been the develop-
margin of the vertebral body, the target now being at the ment of the larger active tip curved blunt needle that has
junction between the upper one-third and lower two- removed the potential for injury to nerve roots.
thirds. Local anesthetic infiltration is followed by place-
ment of a 16 gauge-IV cannula using tunnel view. The
THORACIC REGION
RF needle is advanced in the manner described above
until its tip lies at the anterior border of L-3 vertebra. Background
After aspiration, 2 mL of omnipaque is injected. After Jonnesco first performed surgical removal of the stellate
sensory stimulation at 50 Hz up to 1 V, without causing ganglion for the treatment of angina pectoris in 1916.17
groin paraesthesia, an 80C 90-second lesion is followed The ganglion has also been the target for treatment of
by a second after rotating the needle 180. Lesions at L-4 patients with peripheral vasculopathies, such as Raynaud’s
and L-5 are carried out in a similar manner. The only disease and phenomenon, Burger’s disease and frost-
difference from that already described is that the target bite.18,19 Kuntz, in 1927, noted that at least 30% of
is now the middle of the vertebral body. The indication postganglionic sympathetic fibers bypass the stellate
for L-4, L-5 sympathetic ganglion lesioning is when a ganglion and join the brachial plexus through the tho-
patient has already had a previous surgical or other sym- racic outlet.20 While surgical procedures were under de-
pathectomy, where there is no clear response after lum- velopment, regional anesthetic approaches to the tho-
bar sympathetic blocks at L-4 and L-5. In such in- racic sympathetic chain were being described.21-23 In
stances, significant symptomatic improvement, (ie, SMP 1926, Mandl described the use of paravertebral sympa-

Figure 3. Lumbar sympathetic radiofrequency thermocoagulation for treating sympathetically maintained pain in a patient with
post-traumatic lower extremity CRPS. Patient also has spinal cord stimulator in place. A - Lateral rotation and the “tunnel” view for
placing the introducer needle. (#16-gauge intravenous cannula). B - Curved blunt needle is passed through introducer needle and through
psoas muscle; injection of dye shows the surface of the psoas muscle where the sympathetic ganglion is located for the 180 rotation and
double lesioning. C - Similar placement of needle to L3 left in lateral view. Note the ventral border of the psoas is much more anterior indi-
cated by the dye. D - Anterior/posterior view showing the needle placement and dye spread on the surface of the psoas prior to the rota-
tional double lesioning. Through the use of multiple therapeutic modalities, patient has assumed full occupation.
254 • racz and stanton-hicks

thetic blocks for treating both visceral and anginal pain, lund and Racz.31 Two landmarks, the tubercle of the
and alcohol sympatholysis of the upper thoracic chain costotransverse articulation and head of the rib define
was described by Swetlow for severe angina.24,25 Alco- the procedure.
hol has been largely abandoned due to the occasional re- After positioning the patient prone with appropriate
port of spinal myelopathy.26 sterile preparation and draping, the image intensifier is
Phenol with contrast such as meglumine, while more positioned at a right angle over the spine with its center
controllable than alcohol, may cause intercostal neuritis on the second or third vertebral bodies. The image in-
due to the proximity of the intercostal nerve. Chemical tensifier is then rotated cephalad until the neck and
neurolysis of the sympathetic chain in the thoracic re- body of the target rib are seen as a straight line. This is
gion may cause side effects due to a lack of precision in now rotated obliquely until the tubercle of the rib is su-
localization of target sympathetic ganglia by spread to perimposed on the head of the rib (costovertebral articu-
involve other neural structures, eg, the intercostal nerve. lation).

Anatomic Considerations
FIGURE IV
Wilkinson published a technique for RF sympatholysis
by percutaneous needle placement at T2, T3, and T4.27 A line projected at this point will allow a needle, when
As a result of a cadaver study, Yazebski and Wilkinson introduced, to be parallel to the neck of the rib. Either a
refined their technique at a more accurate location of 10 cm 21-gauge spinal needle, if undertaking a local an-
the ganglia on the left and right thoracic chains.28,29 esthetic block, or RFA cannula (Racz-Finch curved blunt
These investigators noted that the T2 ganglia varied needle, RadionicsEG) for RF lesion is inserted so that
from 12-31 mm dorsal to the ventral surface of the ver- when viewed, it appears as a dot (gun-sight view), de-
tebral body on the right and 6-27 mm on the left, scribed above. A 16-gauge introducer needle-cannula is
whereas at T3, the variation was 9-31 mm on the right used for placement of the blunt RF needle.
compared to 9-30 mm on the left. Less variation (1-2
mm) rostral to the midpoint of the vertebral bodies at FIGURES V AND VI
T2 and T3 was noted. The needle is advanced to the inferior edge of the rib af-
ter which a freely moving glass syringe partially filled
Technique
with air is attached and then advanced using continuous
The intercostal oblique approach to the thoracic sympa- percussion until a loss of resistance signals entry into the
thetic ganglia will be described.30 The reader is also re- pleural cavity. The image intensifier is now rotated to an
ferred to other techniques by Wilkinson27 and Skaebe- AP view that should show the needle to be parallel to the
inferior surface of the rib. The needle is now advanced
until its tip arrives at the capsule of the costovertebral
articulation.
When using a curved blunt (Racz-Finch) RFA needle
it is easier to introduce this through a 16-gauge intrave-
nous cannula that helps guide the needle to the inferior
surface of the rib. Injection of a small 0.1-0.2 mL of con-
trast will outline the capsule of the costovertebral articu-
lation. A small amount, 0.25-0.75 mL, of 0.75% Bupiv-
acaine should achieve a complete sympathetic block to
the upper extremity (temperature of 34.5C).
When making an RFA lesion, initial testing using sen-
sory stimulation at 50 Hz and 0.4-1 V, and motor test-
ing at 2 Hz and 2 V should always precede any lesion.
Two lesions of 80C for 90 seconds are usually made
with the curved tip of the RFTC needle rotated through
180. The same process is repeated at the T3 ganglia. If a
Figure 4. Position of C-arm to “look” along the inferior border pulsed RF is used, the temperature at the RFTC tip will
of the neck of the target rib with needle placement shown. not exceed 42C. An RF generator to achieve this uses a
 RF Lesioning in CRPS • 255

dure chest x-rays should be obtained. Patients are also

alerted to the possibility of slow onset pneumothorax
where prompt medical evaluation is recommended if chest
pain or shortness of breath develops.
RF neurolysis is an effective modality for the manage-
ment of sympathetically maintained pain in association
with complex regional pain syndrome.

REFERENCES
1. Stanton-Hicks M, Jänig W, Hassenbusch S, Haddox
JD, Boas R, Wilson P. Reflex sympathetic dystrophy: changing
concepts and taxonomy. Pain. 1995;63:127–133.
2. Merskey H, Bogduk N (eds). Classification of Chronic
Pain: Description of Chronic Pain Syndromes and Definitions
of Pain Terms. 2nd ed. Seattle, Wa: IASP Press; 1994.
3. Stanton-Hicks M, Baron R, Boas R, et al. Complex re-
gional pain syndromes: guidelines for therapy. Clin J Pain.
1998;14:155–66.
Figure 5. “Gun sight” view of needle correctly located under the
4. Sluijter ME, Van Kleef M. Characteristics and mode of
neck of the target rib.
action of radiofrequency lesions. Cur Rev Pain. 1998;2:143–150.
5. Wenger CO. Radiofrequency lesions for the treatment
pulse of 300 kilohertz for 30 milliseconds each 1-second of spinal pain. Pain Digest. 1998;8:1–16.
cycle, requiring a voltage of 25-35. 6. Vinas FC, Zamanorano L, Dujovny M, et al. In-vivo
The main advantages of RF sympatholysis are the and in-vitro study of the lesions produced with a computerized
avoidance of postsympathectomy neuritis, more precise radiofrequency system. Stereotact Funct Neurosurg. 1992;58:
121–133.
sympatholysis and avoidance of chemical neuritis or the
7. Slappendel R, Curl BJP, Braak GJJ, Gertzs WM, Booij
possibility of subperineural spread when using chemical
LDH, Voerman VF and Boo TD. The efficacy of radiofre-
agents to cause spinal myelopathy. The complications of quency lesioning of the cervical dorsal root ganglion in a dou-
a thoracic RF neurolysis are pneumothorax and intercostal ble-blind randomized study: no difference between 40 and 67
neuralgia. The incidence of pneumothorax is reduced by degree centigrade treatments. Pain. 1997;73:159–163.
the use of the curved blunt RF needle. Nevertheless, pa- 8. Sluijter M. Non-thermal radiofrequency procedures in
tients are advised against air travel for 2 days; post-proce- the treatment of spinal pain. Paper presented at: Second An-
nual Congress of the European Federation of IASP Chapters,
1997; Barcelona, Spain.
9. Mungiani R. The longer term effect of pulsed radiofre-
quency for neuropathic pain. Pain. 1999;80:437–439.
10. Nakamura S, Takahasi K, Takahaski Y, Morinaga T,
Shimada Y and Moriya H. Origin of nerves supplying the pos-
terior portion of lumbar intervertebral discs in rats. Spine.
1996;21:917–924.
11. Nakamura, S, Takahashi, K, Takahashi Y, Yamagata
M, Moriya H. The afferent pathways of discogenic low-back
pain: Evaluation of L2 spinal nerve infiltration. J Bone Joint
Surg. 1996;78:606–612.
12. Noe CE, Haynesworth R. Lumbar radiofrequency
sympatholysis. J Vasc Surg. 1993;17:801–806.
13. Noe CE, Haynesworth R. Percutaneous lumbar sym-
patholysis. J Vasc Surg. 1993;17:801–806.
14. Finch PM, Racz GB, McDaniel K. A curved approach
to nerve blocks and radiofrequency lesioning. Pain Digest.
Figure 6. Position of C-arm as viewed from the head with needle 1997;7:251–257.
placement at the inferior border of the neck of the target rib. 15. A new technique for lumbar sympatholysis using ra-
256 • racz and stanton-hicks

diofrequency thermal coagulation and somatic nerve block. 23. Leriche R. La Chirurgie de rea Douleur. Paris, France:
Panel and video presented at: Annual Meeting American Soci- Masson et Cie; 1949.
ety of Anesthesiologists. 1995; Atlanta, GA. 24. Mandl F. Die Paravertebral Injection. Vienna, Austria:
16. Rocco AF. Radiofrequency lumbar sympatholysis. The Springer-Verlag; 1926.
evolution of a technique for managing sympathetically main- 25. Swetlow G. Paravertebral alcohol block in cardiac
tained pain. Reg Anesth. 1995;20:3–12. pain. M Heart J. 1926;1:393–412.
17. Bonica JJ. The Management of Pain. Philadelphia, Pa: 26. Reid W, Watt JK, Gray TG. Phenol injection of sympa-
Lee and Fabiger; 1953. thetic chain. Brit J Surg. 1970;57:45–50.
18. Bonica JJ. Sympathetic Nerve Blocks for Pain Diagno- 27. Wilkinson H. Percutaneous radiofrequency upper tho-
sis and Therapy. New York, NY: Breon Laboratories; 1984. racic sympathectomy: a new technique. Neurosurgery. 1984;
19. Brunn F, Mandl F. Die paravertebral Injektion zur 15:811–814.
Bekämpfung Visceraler Schmerzen. Wien Klin Aschsch. 1924; 28. Yazebski JO, Wilkinson H. T2 and T3 sympathetic gan-
37:511. glia in the adult human: A cadaver and clinical-radiographic study
20. Kuntz A. Components of splanchnic and intermesen- and its clinical application. Neurosurgery. 1987;21:339–342.
teric nerves. J Comp Neurol. 1956;105:251–268. 29. Wilkinson HA. Percutaneous radiofrequency in upper
21. Kappis M. Weitere erfahrungen mit der sympathek- thoracic sympathectomy. Neurosurgery. 1996;38:715–725.
tomie. Klin Wehr. 1923;2:1441. 30. Stanton-Hicks M. Thoracic sympathetic block: a new
22. Von Gaza W. Die resektion der paravertebralen nerven approach. Tech Reg Anesth Pain Manage. 2001;5:94–98.
und die isolierte durchschneidung des ramus communicans. 31. Skaebelund C and Racz G. Indications and techniques
Arch F Klin Chir. 1924;133:479. of T2 and T3 neurolysis. Curr Rev Pain. 1999;3:400–405.