Nerve Blocks
Question:
Dear Dr. Hooshmand,
I am an anesthesiologist who has a small chronic pain practice. I am curious as to how you obtain a three-month lasting sympathetic block. Is this by using a local anesthetic? If so, what anesthetics are you using? Is this prolonged sympathetic blockade obtained by some other method? I look forward to your reply.
Answer:
Dear Doctor,
As you are well aware of, the standard stellate lumbar and sympathetic blocks are done with local anesthetics alone. The effect of using local anesthetics lasts no longer than a few hours to a few days. As such, they are mainly diagnostic rather than therapeutic blocks. In addition, repetitive sympathetic blocks are traumatic and in the long-run cause so much damage to the sympathetic ganglion that the patient develops "virtual sympathectomy"[1,2]. As is the case with all sympathectomies, the virtual sympathectomy only aggravates the condition by damaging the temperature regulation of the body.
The nerve blocks we give to patients, are epidural, caudal, paravertebral, occipital or brachial plexus nerve blocks which are done with a combination of 10-20 cc marcaine and a maximum of 5 to 20 mg Depo- Medrol®. As the name Depo - Medrol® implies, the prednisone is attached to a large molecule of protein which cannot penetrate through capillaries causing systemic side effects of corticosteroids unless it is given in toxic doses.
In patients who have had such epidural nerve blocks when they have a laminectomy, at the time of surgery we find wafers of crystallized molecules of Depo- Medrol®, still present in the extracellular tissue even years after the performance of the nerve blocks.
Clinically, the patient receives excellent pain relief and anti-inflammatory effects lasting anywhere for 2 to 6 months. Anti-inflammatory aspect of a block refers to the fact that the involved extremity usually shows neuroinflammatory edema and even skin rashes. Obviously, single injection of local anesthetic cannot do anything for this but the Depo- Medrol® markedly reduces the neuroinflammation. As a result, the neuroinflammation is not mistaken for carpal tunnel, thoracic outlet, or tarsal tunnel syndromes and the patient does not have to go through damaging and unnecessary surgical procedures.
H. Hooshmand, M.D.
