Ep. 48 Pain Procedures: Sympathetic Injections
Episode Summary
In this episode of 'It's Not In Your Head' podcast, cohosts Dr. Dan Bates and Justine Feitelson delve deep into sympathetic injections and how to use them with different pain presentations. They cover the mechanisms and efficacy of specific injections like stellate ganglion blocks, lumbar sympathetic ganglion blocks, and posterior tibial nerve stimulation. They also discuss the application of these blocks to manage complex conditions affecting the sympathetic nervous system such as Complex Regional Pain Syndrome (CRPS), post-traumatic stress disorder (PTSD), chronic pelvic pain, and more. Listen to learn about the risks, benefits, and real-life applications of these interventions as a patient or clinician.
Episode Overview
Justine and Dan continue their series on pain procedures, focusing on the sympathetic nervous system and injections such as stellate ganglion blocks, lumbar sympathetic blocks, pelvic sympathetics, posterior tibial nerve stimulation, and splanchnic blocks.
These procedures are particularly relevant for the “weird” chronic pain presentations that include things like complex regional pain syndrome (CRPS), pelvic pain, PTSD.
These tools are rarely magic fixes but can be valuable options when other treatments have failed.
Sympathetic nervous system basics
The sympathetic nervous system is the “fight or flight” branch that controls blood vessels, blood pressure, sweating, heart rate, and contributes to organ function, running as a chain along the front of the spine.
When it misfires or becomes sensitized, it can create pain plus “sympathetic” signs like abnormal sweating, swelling that comes and goes, skin color changes (blue, red, white), hair thinning, and even local bone density loss in under‑used limbs.
When and why these procedures are used
Main indications discussed are: CRPS (especially upper and lower limb), chronic pelvic pain (endometriosis, painful periods, prostatitis, coccydynia), neuropathic abdominal pain, and PTSD or severe anxiety that blocks progress with pain rehabilitation.
The research data are limited because these patients are rare, often in severe distress, and hard to randomize into placebo‑controlled trials, so much of the decision‑making relies on clinical experience and “treat‑to‑test” approaches.
Stellate ganglion blocks (neck)
Stellate ganglion sits around C6–C7 in the neck and is a major sympathetic outflow hub from the brain; blocking it is used most often for PTSD, some severe anxiety, upper‑limb CRPS, and tricky post‑surgical shoulder pain.
In PTSD, the model is: brain trigger → stellate ganglion → adrenal glands → adrenaline surge; if this pathway is sensitized, small triggers cause big body reactions, and blocking the stellate ganglion can dampen this loop for 3–12 months in some patients.
It is harder to pick predict responders ahead of time, so the “test” is doing the block and watching for improvement over days to weeks.
Risks include infection, bleeding, transient droopy eyelid and red eye on the treated side, temporary hoarse voice from laryngeal nerve spread, and the critical rule: never do both sides at once because bilateral laryngeal nerve block can close the airway.
Lumbar sympathetic blocks (low back)
Lumbar sympathetic blocks are usually done at L3, sometimes bilaterally, to target sympathetic supply to the legs, mainly for lower‑limb CRPS and other severe neuropathic leg pains.
A successful block often produces a warm, red, sweaty leg for a few hours, with pain relief that can start immediately from local anesthetic, deepen over a couple of weeks with steroid effect, and sometimes last 3–6 months.
Justine notes this was one of the most helpful early procedures for her own lower‑extremity CRPS before spinal cord stimulation, though over time the effects shortened.
Dan describes patients’ unique sensations, like deep “middle of the leg” pain during stimulation, which makes him suspect sympathetic involvement when people describe pain as coming from “inside” the limb rather than the surface.
Pelvic sympathetic blocks and coccydynia
For pelvic pain, Dan describes targeting the superior hypogastric plexus (front of L5) and the ganglion impar through or around the small sacrum–coccyx joint, often combined with a caudal epidural to cover joint, sensory, and sympathetic contributions.
Conditions include endometriosis‑related pain, dysmenorrhea, prostatitis, and coccyx pain (coccydynia), but Dan is cautious: while some patients respond very well, he sees a relatively high rate of post‑procedure pain flares, especially in pelvic conditions.
Because needles must work close to bowel and pelvic nerves, he emphasizes careful imaging guidance; rare but notable temporary risks include short‑lived pelvic floor weakness and incontinence if anesthetic spreads to pelvic nerves, resolving as the local wears off.
Posterior tibial nerve stimulation for pelvic pain
Dan is shifting away from direct pelvic sympathetic injections toward posterior tibial nerve stimulation or pulsed radiofrequency at the ankle, which is wired into pelvic sympathetic circuits.
Randomized trials (in areas like cancer pain, endometriosis, painful periods, and prostatitis) suggest that stimulating this ankle nerve can reduce pelvic pain, offering an indirect route that avoids “attacking” an already sensitized pelvis.
Both hosts like this approach for highly flared pelvic patients, since treating a distant site can lower the barrier of fear and reduce the risk of major symptom flares while still targeting the same pain circuits.
Splanchnic blocks and abdominal pain
Splanchnic ganglion blocks at T11–T12 are used for neuropathic abdominal pain; they must be done bilaterally because abdominal organs receive paired sympathetic input from both sides.
Dan finds them helpful in selected patients and uses them as a diagnostic test before offering spinal cord stimulation for chronic abdominal pain, since a good response to the block predicts better odds of neuromodulation success in this specific context.
They contrasts this with CRPS: a positive sympathetic block in limbs does not necessarily predict spinal cord stimulator response in the same clear way.
Expectations, limits, and decision‑making
Across all these procedures, effects are variable: some patients get meaningful relief for months, others get modest or short‑lived benefit, and some flare, especially with pelvic injections.
These injections are tools to “dampen one component” of a very tangled system, not as cures; they may open a window to engage more fully in rehab, psychology, and lifestyle‑based pain work, especially when PTSD, anxiety, and autonomic symptoms dominate the picture and are creating significant barriers to other changes that will also decrease pain.
For complex patients who have not gotten the results needed from treatments, Dan and Justine see sympathetic procedures as reasonable options to discuss with a specialist, as long as expectations remain realistic and individual risks are weighed carefully.