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Intervention Review

Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome

  1. Sebastian Straube1,*,
  2. Sheena Derry2,
  3. R Andrew Moore2,
  4. Henry J McQuay2

Editorial Group: Cochrane Pain, Palliative and Supportive Care Group

Published Online: 7 JUL 2010

Assessed as up-to-date: 18 MAY 2010

DOI: 10.1002/14651858.CD002918.pub2


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.

Author Information

  1. 1

    University Medical Center Göttingen, Department of Occupational, Social and Environmental Medicine, Göttingen, Germany

  2. 2

    University of Oxford, Pain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics), Oxford, Oxfordshire, UK

*Sebastian Straube, Department of Occupational, Social and Environmental Medicine, University Medical Center Göttingen, Waldweg 37 B, Göttingen, D-37073, Germany. sebastian.straube@googlemail.com.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 7 JUL 2010

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This is not the most recent version of the article. View current version (02 SEP 2013)

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

Background

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.

Objectives

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.

Search methods

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.

Selection criteria

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.

Main results

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.

Authors' conclusions

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

  1. Top of page
  2. Abstract
  3. 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.