Dear Editor,

We express our appreciation to Dr. Uğur Ertem for his interest in our research (1). The comments made by him enable us to highlight certain aspects.

Firstly, our patient had several comorbidities including cancer, medications used in cancer treatment, osteoporosis (OP), and senility, and these conditions are among the independent risk factors for the development of osteoporotic fracture in the patient (2, 3). These risk factors play an important role in the development of OP and we are aware that a significant association with osteoporotic fracture can be established. In light of this, we agree with Ertem’s comment.

Secondly, research investigating the correlation between epidural steroid injection (ESI) and bone mineral density (BMD) has revealed that cumulative dosages of methylprednisolone reaching 200 mg within one year and 400 mg within three years were linked to substantial reductions in BMD (4), nevertheless, we lack data regarding the appropriate dosage of steroids to administer during the ESI process when these risk factors of OP are present. As we stated in our article, to our knowledge, no studies have been conducted investigating the connection between lumbar sympathetic ganglion block (LSGB) and OP. Thus, we are unable to provide definitive evidence regarding the safe dosage or any correlation between LSGB and OP. Nevertheless, we believe that our recommendation in this case is valuable in a scenario that could lead to serious complications including  spinal vertebral fracture, even if it may be an incidental finding.

Thirdly, the LSGB using only local anesthetic, without the use of steroids can be performed, but it remains a topic of controversy (5). Thus, given the already severe risk factors for osteoporotic fracture and the need for repeat procedures, performing LSGB procedures without steroids may be a rational option in this high-risk patient group. Therefore, as mentioned in the original article, when conducting sympathetic blocks, it is preferable to either avoid using steroids completely or administer them at the minimum dosage in patients with these risk factors.

Finally, based on this knowledge, we suggest that LSGB should be performed without steroids in patients with cancer-related lymphedema due to serious complications.

We hope that we have adequately addressed all issues. Once again, we are grateful to Dr. Uğur Ertem for his valuable and thoughtful comments.