The lumbar sympathetic chain consists of four paired ganglia running along the anterolateral aspect of the lumbar vertebral bodies, medial to the psoas muscle and lateral to the aorta on the left (and IVC on the right). It connects to the thoracic sympathetic chain above and the sacral chain below. It sends grey rami communicantes to lumbar spinal nerves and postganglionic fibres to the lower limb vasculature and pelvic viscera via the lumbar splanchnic nerves.
Lumbar sympathectomy (surgical or chemical) is performed for inoperable peripheral vascular disease, CRPS type I of the lower limb, and hyperhidrosis plantaris. CT-guided lumbar sympathetic block targets the L2-L4 level just anterior to the vertebral body margin, lateral to the aorta. Phenol or absolute alcohol neurolysis provides prolonged sympatholysis. The lumbar sympathetic chain is at risk during retroperitoneal and anterior lumbar spine surgery (ALIF), where injury produces retrograde ejaculation from hypogastric nerve disruption at L1.
Anterior lumbar interbody fusion (ALIF) approach through the retroperitoneal space risks the lumbar sympathetic chain at L1-L2 and the superior hypogastric plexus at L5; sympathetic injury produces retrograde ejaculation from unopposed parasympathetic control of the bladder neck, and careful identification of the sympathetic chain before retraction reduces this complication.
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