1. Interventional Causalgia Treatment ( Image guided ) Jalal Jalal Shokouhi-M.D. Jalal Jalal Shokouhi-M.D. Radiologist General secretary of Iranian society of radiology, Head of Iranian cooperative Radiology, National medical university, Azad medical university,Health department of defense ministry, Tehran,Iran jalaljalalshokouhi@hotmail.com, www.medimage.ir jalaljalalshokouhi@hotmail.comwww.medimage.ir Mansour Fatehi-M.D. Mansour Fatehi-M.D. Radiologist Head of informatics committee of Iranian society of radiology, Day general hospital, Tehran, Iran, President of ICR 2009 Aliakbar Ameri-M.D. Aliakbar Ameri-M.D. Radiologist National medical university, Tehran, Iran, Last president of Iranian society of radiology

3. What is causalgia? Complex regional pain syndrome or reflex sympathetic dystrophy

4. Target: Pain therapy in war injured patients

5. History 1905: First sympathetic trunk block: selheim, followed by Lawen, Kappis and Finsterer During open surgery: Linson, Leffert and Todd

6. Common sympathetic ganglion blocks I.Stellate ganglion (upper extremity, lower facial and neck) II.Celiac ganglion block (upper abdomen) III.Lumbar sympathetic block (lower extremity, our paper) IV.Impar ganglion block (lower pelvis and perineal)

7. Lumbar sympathetic block: Title: Lumbar sympathetic block or sympathectomy for causalgia in war injured patients Site: L2 to L5 (L2 is the best) (Saving Aorta, IVC and Ureters) Approach: PA, off midline Drugs Drugs: Iodine contrast or air buble: localization Local anesthetics (Marcain, Bupivicain 0.5%) Corticosteroid ? Ethanol 65-95% Station: X-ray CT room Needle: Shiba, Sieble Grünemeyer G22, Coaxial

8. Interventionelle Computer-tomographie

12. AORTA GGL SYMP URETER CAVA V. LUMBAL l S

23. How to save ureters? How to save ureters? NaCl for pushing away ureters NaCl UreterUreter Aorta IVC

24.  Before by Linson, Leffert and Tod  89% pain reduction  80% treatment of dystrophic variants  Our team  85% first time  Repeated injections in few patients Results:

25. Our patients 68 (62 male,6 female) 18 of them had previous surgery and failed surgery results 4 of them: phantom pain after limb amputation None of them: complication All patients requested by neurosurgeon, vascular surgeon, general surgeon, orthopedic surgeon All patients: gunshot or metallic fragments All patients admitted after 2-6 years

26. Thank you for your attention