Lumbar Sympathectomy Revisited: Current Status in Management of Peripheral Vascular Diseases

Despite lack of objective evidence based-support, lumbar sympathectomy (LS) continues to hold a place in the treatment of refractory ischemic ulceration or persistent rest pain, especially when there is a distal ischemia, which is not suitable for direct arterial surgery. There is no physiological basis to use lumbar sympathectomy for patients with intermittent claudication. The non-specificity of the indications and lack of simple methods to predict success of this procedure have lead to many conflicting reports; however, the toe-temperature response following peripheral nerve block, transcutaneous oxymetry (TCPO2) or anklebrachial pressure index (ABPI) correlate best with the effect of LS. Among the patients with rest pain and no distal ulcerations, pain relief is obtained in 76% at 3 months after LS in those who did not require amputation.11,19,38 LS does not exempt the patient from a subsequent amputation as the vasomotor tone is usually normalized in 2 weeks to 6 months after operation. Therefore, the healing effect of LS on an ulcer may become negligible after this “grace period”.23 The relapsing and remitting nature of intermittent claudication makes the study of natural history of claudication difficult; hence, the patient selection and results vary considerably and this is the reason for conflicting reports in different studies. No controlled trial has been done till now to compare the natural history of PIDs with the results of LS. LS may not produce the dramatic improvements seen after reconstructive surgery but should be considered as first-line management in selected patients. For many, avoidance of further surgery will be achieved after LS, but should the procedure fail to secure appropriate relief of symptoms, reconstructive surgery can still be offered without disadvantage.39The magnitude of changes in blood flow and sympathetic activity are similar for LS and chemical sympathectomy.