Thromboangiitis obliterans (TOA) or Buerger’s disease (BD) is a non-atherosclerotic segmental occlusive segmental small and medium-sized arteriovenous disease most commonly occurring in chronic young smokers. The first complete description of the disease was done by Leo Buerger in 1908 who published a complete description of changes in arteries (intimal thickening, occlusive thrombus, and preservation of arterial architecture) in young smokers and named the disease. Disease is prevalent worldwide ranging from 0.5 (Western Europe) to 66% (Asian countries, Japan, and Korea) ^[1] and 45 to 63% in India ^[2]. Onset occurs between 40 and 45 years with male-to-female ratio of 100:1. Disease has been strongly associated with tobacco consumption ^[3] but hereditary susceptibility, immune response, coagulation changes, and infection have also been suggested ^[1]. The disease has also been reported infrequently in non-smokers ^[4].

A 50-year-old female patient presented to our pain clinic in November 2017 with chief complaints of pain (burning), swelling, cold peripheries, and blackening of all five fingers of the right (Fig. 1c and d) and four fingers of the left (except thumb) hands (Fig. 1a and b) for the past 3 months. Pain was present during rest, increasing while lifting hands and relieving on bringing down. Diagnosis was made based on clinical examination and the color Doppler study of both upper limbs (Table 1). The patient was consulted with a colleague surgeon who referred the patient.

Under all aseptic precautions, 4-5 stellate ganglion blocks were given [accurate needle position (Fig. 2a) was confirmed in anteroposterior and lateral fluoroscopic view (Fig. 2a and c) and craniocaudal dye spread of dye (Fig. 2b) and excluding intravascular position] simply with 0.25% bupivacaine with 4 mg of dexamethasone (only once on both sides) on an alternate day basis using a 22G spinal needle under all aseptic precautions and C-Arm (fluoroscope) guidance at C6 level. After such blocks, chemical neurolysis was successfully done with 2 ml of 8% phenol mixed with 2 ml of 0.25% bupivacaine and 1 ml of radiocontrast non-ionic iodine dye, iohexol 300 under continuous fluoroscopic guidance (to avoid intravascular spread and apical pleura puncture) at C7. Phenol was injected after confirmation of needle position at the junction of the vertebral body and transverse process (Fig. 2a) at C7 in anteroposterior and lateral (Fig. 2c) view and with craniocaudal spread (Fig. 2b) of dye (1 ml, iohexol 300) with the excluding intravascular injection of dye (Fig. 1g, and 2b and c) 10 days apart on both sides (Fig. 1i and Fig. 2b and c) to avoid cardiac complications (bradycardia) and bilateral recurrent laryngeal nerve palsy. After the successful accomplishment of the procedure, there was an increase in the temperature of the hands, an improvement in vascularity and a reduction in swelling and pain. There was a dropping of eyelids, enophthalmos and conjunctival congestion for a transient period. The patient was monitored after every block for at least 2 h in the post-procedure room. In due course of time, the affected salvageable portion of the fingers was saved (Fig. 1e, f and h). The patient was kept on a tramadol-paracetamol combination, pregabalin 75 mg at bedtime, asprin 75 mg once daily, cilastazole 100 mg twice a day, and isosorbide mononitrate 10 mg twice a day by oral route. The patient was followed up for 5-6 months when the gangrenous part was detached from the healthy part (Fig. 1j). Recently till February 2024, there was no recurrence of disease as evident from telephonic contact.

Although exposure to tobacco consumption in any form is strongly associated  with   Buerger’s disease but it has been found in nonsmokers also ^[4]. There are risk factors other than tobacco such as periodontal disease, chronic anerobic periodontitis ^[5], HLA (A9 and B5) antigens, hypercoagulability, endothelial dysfunction, and immunologic mechanisms that have been proposed ^[6]. Raynaud’s phenomenon is present in about 44% of patients with thromboangiitis obliterans ^[1] which could be present in this patient. Preganglionic sympathetic nervous system fibers to the upper extremity originate in the first four or five thoracic segments (T1-T4/5) and synapse in the superior, middle, and inferior (stellate) cervical ganglia. In 80% of cases, the stellate ganglion comprises both the inferior cervical and first thoracic ganglia. Post-ganglionic nerves from the cervical ganglia extend into the head, neck, upper extremities, heart, and lungs and carry afferent pain fibers along with them. Postganglionic fiber distribution justifies stellate ganglion neurolysis or block in various chronic painful conditions of the upper limb ^[7]. Keeping in mind the complications ^[8] of bilateral stellate ganglion block at a time, we decided to go for a unilateral block on one side (left or right) and on the next day on the other side. We did chemical neurolysis at an interval of 10 days apart after confirming that there was no complication. Simultaneous bilateral stellate ganglion block is only indicated in pulmonary thromboembolism ^[9]. Bilateral stellate ganglion block is rarely given due to the concern of phrenic and recurrent laryngeal nerve palsy. However, in a case report of a systemic lupus erythematosus (SLE) patient involving fingers of both hands, the author had given repeated stellate ganglion block with 0.25% bupivacaine for the management of progressive gangrene due to vasculitis ^[10]. Phenol is a neurolytic agent and causes Wallerian degeneration of the nerve axon distal to the lesion ^[11]. Gabor B. Racz and Jerry T. Holubec used a solution of 2.5 mL of 6% phenol in saline, 1 mL of 80 mg methylprednisolone, and 1.5 mL of 0.5% bupivacaine (giving a 3% phenol solution) to perform a neurolytic block of the stellate ganglion ^[12]. We used 5-6 ml of drug volume consisting of 3-4 ml of 8% phenol, 1 ml of dexamethasone, and 1 ml of 0.25% bupivacaine and did not find any adverse event or effect. However, phenol has been used in different concentrations ranging from 3 to 12% for neurolysis in different studies ^[11]. Although smoking cessation is the mainstay of treatment for Buerger’s disease, this patient was a non-smoker. The patient also received oral treatment in the form of blood thinners such as cilostazol 100 mg twice daily [13, 14] and asprin 75 mg ^[15] once a day, for neuropathic pain due to nerve damage by ischemia, pregabalin ^[16] 75 mg at bedtime, and the collaterals which have been developed during disease process due to ischemia were tried to open up by vasodilators such as isosorbide mononitrate 10 mg twice a day ^[17].

Minimally invasive percutaneous stellate ganglion interval (10 days apart) phenol chemical neurolysis is a safe and effective treatment in terms of disease pain relief, disease progression, and complications related to cardiac (bradycardia) and recurrent laryngeal nerve in a patient suffering from Buerger’s disease of both hands.

Minimally invasive percutaneous bilateral stellate ganglion phenol chemical neurolysis a few days apart with 2 ml of 8% phenol with 0.25% bupivacaine under the guidance of continuous fluoroscope and radiocontrast dye iohexol 300 is a safe and effective treatment in Buerger’s disease involving both hands.