(Kiosk 5) When Less Is More: Injectate Mixture for Lumbar Sympathetic Blockade in the Management of Chronic Lower Limb Pain: A Case Report

Case Diagnosis: Giant cell tumor status post resection complicated by complex regional pain syndrome type I.

Case Description or Program Description: A 40-year-old female presented with chronic pain in the left proximal tibia for 2 years. Upon further work up, she was found to have a giant cell tumor of the left proximal tibia status post excision and curettage, bone grafting followed by surgical stabilization of the left tibia. Shortly after, patient began to experience sharp, burning sensation and hypersensitivity localized to the area. Exam remarkable for edema, decreased range of motion and allodynia. Conservative treatment in the interim included physical therapy, Gabapentin and intra-articular corticosteroid injection to the left knee without relief.

Setting: Outpatient clinic and adjacent rehabilitation hospital

Assessment/Results: After failing initial interventions, patient underwent left lumbar sympathetic block with an injectate mixture of 4ml of Lidocaine 1%, 4ml of Marcaine 0.25% and 2ml of Decadron 10mg with up to 90% relief at two weeks follow up and subsequent decreased verbal pain scores at six months.

Discussion (relevance): Our patient was suffering from progressive complex regional pain syndrome (CRPS) type I which led to debility and decreased quality of life. Positive outcomes have been reported with lumbar sympathetic blockades. However, there is no pharmaceutical guidance of suitable injectate mixtures. In respects to local infiltration for sympathectomy treatment, injectate mixtures and their respectful volumes vary dependent upon training facilities. Considering the utility of a low volume blockade as an initial starting point may provide equal efficacy and impose less risks as opposed to large volume injections with certain injectate mixtures, providing practitioners with a standard to aid in diagnostic and therapeutic interventions.

Conclusions: This case report highlights the benefits of a lumbar sympathetic ganglion blockade in patients with CRPS of the lower extremities. However, injectate mixtures varies throughout the interventional pain community which raises the need for more robust investigations.