Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome
Editorial Group: Cochrane Pain, Palliative and Supportive Care Group
Published Online: 7 JUL 2010
Assessed as up-to-date: 18 MAY 2010
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Straube S, Derry S, Moore RA, McQuay HJ. Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome. Cochrane Database of Systematic Reviews 2010, Issue 7. Art. No.: CD002918. DOI: 10.1002/14651858.CD002918.pub2.
- Publication Status: Edited (no change to conclusions)
- Published Online: 7 JUL 2010
This review is an update on 'Sympathectomy for neuropathic pain' originally published in Issue 2, 2003. The concept that many neuropathic pain syndromes (traditionally this definition would include complex regional pain syndromes (CRPS)) are "sympathetically maintained pains" has historically led to treatments that interrupt the sympathetic nervous system. Chemical sympathectomies use alcohol or phenol injections to destroy ganglia of the sympathetic chain, while surgical ablation is performed by open removal or electrocoagulation of the sympathetic chain, or minimally invasive procedures using thermal or laser interruption.
To review the evidence from randomised, double blind, controlled trials on the efficacy and safety of chemical and surgical sympathectomy for neuropathic pain. Sympathectomy could be compared with placebo (sham) or other active treatment.
We searched MEDLINE, EMBASE and The Cochrane Library to May 2010. We screened references in the retrieved articles and literature reviews, and contacted experts in the field of neuropathic pain.
Randomised, double blind, placebo or active controlled studies assessing the effects of sympathectomy for neuropathic pain and CRPS.
Data collection and analysis
Two review authors independently assessed trial quality and validity, and extracted data. No pooled analysis of data was possible.
Only one study satisfied our inclusion criteria, comparing percutaneous radiofrequency thermal lumbar sympathectomy with lumbar sympathetic neurolysis using phenol in 20 participants with CRPS. There was no comparison of sympathectomy versus sham or placebo. No dichotomous pain outcomes were reported. Average baseline scores of 8-9/10 on several pain scales fell to about 4/10 initially (1 day) and remained at 3-5/10 over four months. There were no significant differences between groups, except for "unpleasant sensation", which was higher with radiofrequency ablation. One participant in the phenol group experienced postsympathectomy neuralgia, while two in the radiofrequency group and one in the phenol group complained of paresthaesia during needle positioning. All participants had soreness at the injection site.
The practice of surgical and chemical sympathectomy for neuropathic pain and CRPS is based on very little high quality evidence. Sympathectomy should be used cautiously in clinical practice, in carefully selected patients, and probably only after failure of other treatment options.
Plain language summary
Cervico-thoracic or lumbar sympathectomy for neuropathic pain
Chronic pain due to damaged nerves is called neuropathic pain and is common. Some people postulate that neuropathic pain, particularly reflex sympathetic dystrophy and causalgia, is caused by the sympathetic nervous system (a part of the autonomic nervous system that is involved in the response to stress and in the control of the functioning of many internal organs). Sympathectomy is a destructive procedure that interrupts the sympathetic nervous system. Chemical sympathectomies use alcohol or phenol injections to destroy sympathetic nervous tissue (the so-called "sympathetic chain" of nerve ganglia). Surgical ablation can be performed by open removal or electrocoagulation (destruction of tissue with high-frequency electrical current) of the sympathetic chain, or minimally invasive procedures using thermal or laser interruption. Nerve regeneration commonly occurs following both surgical of chemical ablation, but may take longer with surgical ablation.
This systematic review found only one small study (20 participants) of good methodological quality, which reported no significant difference between surgical and chemical sympathectomy for relieving neuropathic pain. Potentially serious complications of sympathectomy are well documented in the literature, and one (neuralgia) occurred in this study.
The practice of sympathectomy for treating neuropathic pain is based on very weak evidence. Furthermore, complications of the procedure may be significant.