Turning Down the Heat:

Lumbar Sympathetic Block

for Autoimmune-Associated

Erythromelalgia

University of Cincinnati

Department of Anesthesiology and Pain Medicine

Kunal Parmar, MD; Laura DeVita, MD

INTRODUCTION

Erythromelalgia is a rare neurovascular pain disorder

involving episodes of burning pain, erythema, warmth,

and edema affecting the distal extremities, particularly

the hands or feet. Symptoms are exacerbated by heat or

exertion and relieved with cooling. Treatment can often

be difficult in patients with underlying autoimmune

conditions, such as in our patient. For patients who

don’t respond to medications, interventional options

like lumbar sympathetic block (LSB) may provide relief.

This case highlights the potential role of sympathetic

blockade in managing lower-limb erythromelalgia when

typical pharmacologic therapies fail.

CLINICAL COURSE

A 64-year-old woman with fibromyalgia and systemic

lupus erythematosus (SLE) on immunosuppressants,

presented with bilateral foot pain.

• She described the pain as constant, burning,

tingling, and sharp, rated 6 out of 10 on the visual

analog scale (VAS), which worsened with heat and

movement.

• Her symptoms improved with cooling measures

and topical compounded creams.

• Examination revealed erythema and tenderness

in both feet.

• Imaging was unremarkable.

• She had been treated with pregabalin, duloxetine,

capsaicin, and mexiletine, with partial relief but

eventually returned three years later with

intolerable side effects. TENS therapy was

attempted without improvement.

• She complained of worsening pain causing new

functional limitations and poor sleep.

• Given the persistence of her symptoms and

reduced quality of life, she underwent bilateral L4

lumbar sympathetic block under fluoroscopic

guidance.

• At one-month follow-up, she reported improved

pain, better mobility, and increased

independence with daily activities.

Lumbar sympathetic block may offer a

meaningful improvement in pain and

function for patients with

erythromelalgia, particularly when

standard treatments are ineffective.

It should be considered early in the

treatment course for appropriately

selected patients.

PROCEDURE

The left L4 vertebral body was identified using

fluoroscopic guidance. On oblique view skin infiltration

with 1% lidocaine was performed at the needle entry

site. A 22 gauge, 5-inch spinal needle was advanced and

the needle was placed anteriorly of the vertebral body

under fluoroscopic guidance. No paresthesia was

noted. The procedure was repeated on the right side.

The needle tip position was confirmed using contrast

agent and fluoroscopy (see below). A solution consisting

of 3 ml. of 0.25% Bupivacaine with epinephrine

1:200000 was injected as a test dose, there was no

change in the heart rate. 40 mg of kenalog was injected

in each needle, followed by another 3 cc of 0.25%

marcaine. After the procedure the needle was

removed. No complications were noted.

CONCLUSION

This case underscores the potential utility of LSB in

patients with erythromelalgia who have failed or

cannot tolerate pharmacologic therapies. While

evidence remains limited, existing literature supports

sympathetic blocks as a therapeutic option in select

cases of both primary and secondary

erythromelalgia, including those associated with

autoimmune disease.