Chemical Neurolysis Research Articles

A meta-analysis on advantages of peripheral nerve block post-total knee arthroplasty.

BackgroundPostoperative pain management is crucial for patients undergoing total knee arthroplasty (TKA). There have been many recent clinical trials on post-TKA peripheral nerve block; however, they have reported inconsistent findings. In this meta-analysis, we aimed to comprehensively analyze studies on post-TKA analgesia to provide evidence-based clinical suggestions.MethodsWe performed a computer-based query of PubMed, Embase, the Cochrane Library, and the Web of Science to retrieve related articles using neurothe following search terms nerve block, nerve blockade, chemodenervation, chemical neurolysis, peridural block, epidural anesthesia, extradural anesthesia, total knee arthroplasty, total knee replacement, partial knee replacement, and others. After quality evaluation and data extraction, we analyzed the complications, visual analogue scale (VAS) score, patient satisfaction, perioperative opioid dosage, and rehabilitation indices. Evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation approach.ResultsWe included 16 randomized controlled trials involving 981 patients (511 receiving peripheral nerve block and 470 receiving epidural block) in the final analysis. Compared with an epidural block, a peripheral nerve block significantly reduced complications. There were no significant between-group differences in the postoperative VAS score, patient satisfaction, perioperative opioid dosage, and rehabilitation indices.ConclusionsOur findings demonstrate that the peripheral nerve block is superior to the epidural block in reducing complications without compromising the analgesic effect and patient satisfaction. Therefore, a peripheral nerve block is a safe and effective postoperative analgesic method with encouraging clinical prospects.

P20-10 Chemical neurolysis for refractory head and neck cancer-related pain

P20-10 Chemical neurolysis for refractory head and neck cancer-related pain

Ultrasound-Guided Alcohol Neurolysis For Treatment of Refractory Radial Neuralgia

Background: The radial nerve is especially vulnerable to injury due to its location near the humerus. When acute pain becomes chronic and surgical repair is no longer an option, it is necessary to have non-opioid, nonpharmacological methods of pain relief. Case Report: A 63-year-old man presented with severe radial nerve neuralgia secondary to traumatic left upper extremity injury 40 years ago. After several unsuccessful surgical interventions and failing medication management, he was sent to pain management as a last resort prior to elective amputation of the left upper limb. After initial evaluation, the patient underwent a diagnostic ultrasound-guided radial nerve block at the midhumeral level with complete but short-lasting relief of his pain. Shortly after, we performed ultrasoundguided alcohol neurolysis of the radial nerve at the same level. This treatment resulted in 100% pain relief for 10 months with gradual resumption of pain to previous levels at 12 months post neurolysis. Conclusion: Alcohol neurolysis is an effective and viable option for the treatment of neuralgia resistant to other therapeutic modalities. To our knowledge, this is the first case report that describes the use of ultrasound to perform chemical neurolysis of the radial nerve. Key words: Alcohol neurolysis, chronic pain, nerve ablation, neuralgia, neurolysis, opioids, radial nerve, traumatic injury, ultrasound

Interventional Radiofrequency Treatment for the Sympathetic Nervous System: A Review Article.

IntroductionInterventional techniques such as radiofrequency (RF) treatment can be used to interrupt pain signals transmitted through the sympathetic nervous system (SNS). RF treatments including the pulsed (PRF) and continuous (CRF) modalities show enhanced control over lesion size and enhanced ability to confirm accurate positioning compared to other interventional methods. PRF also acts to reduce the area of the lesion. In this article, we characterize the currently available evidence supporting the use and efficacy of RF treatments in sympathetically mediated pain (SMP) conditions.Study DesignA comprehensive literature review.MethodsA PubMed and Cochrane Library database search was performed for human studies applying RF treatment at sympathetic sites (sphenopalatine ganglion, stellate ganglion, cervical, thoracic, or lumbar sympathetic ganglia, celiac plexus, splanchnic nerves, superior hypogastric plexus, and ganglion impar) between January 1970 to May 2020. Data were extracted, summarized into tables, and qualitatively analyzed.ResultsPRF and CRF both show promise in relieving SMP conditions, such as complex regional pain syndrome (CRPS), pain in the perineal region, headache and facial pain, and oncologic and non-oncologic abdominal pain, in addition to other types of pain, with minimal complications. Furthermore, in most comparative studies, outcomes using RF treatments exceeded other interventional techniques, such as anesthetic block and chemical neurolysis.ConclusionsRF treatments can be effective in carefully selected patients who are refractory to conservative management. However, further randomized controlled studies are needed prior to implementing it into common practice.

Ultrasound-guided treatment of Morton's neuroma.

Morton’s neuroma is a painful lesion of the interdigital nerve, usually at the third intermetatarsal space, associated with fibrotic changes in the nerve, microvascular degeneration, and deregulation of sympathetic innervation. Patients usually present with burning or sharp metatarsalgia at the dorsal or plantar aspect of the foot. The management of Morton’s neuroma starts with conservative measures, usually with limited efficacy, including orthotics and anti-inflammatory medication. When conservative treatment fails, a series of minimally invasive ultrasound-guided procedures can be employed as second-line treatments prior to surgery. Such procedures include infiltration of the area with a corticosteroid and local anesthetic, chemical neurolysis with alcohol or radiofrequency thermal neurolysis. Ultrasound aids in the accurate diagnosis of Morton’s neuroma and guides the aforementioned treatment, so that significant and potentially long-lasting pain reduction can be achieved. In cases of initial treatment failure, the procedure can be repeated, usually leading to the complete remission of symptoms. Current data shows that minimally invasive treatments can significantly reduce the need for subsequent surgery in patients with persistent Morton’s neuroma unresponsive to conservative measures. The purpose of this review is to present current data on the application of ultrasound for the diagnosis and treatment of Morton’s neuroma, with emphasis on the outcomes of ultrasound-guided treatments.

Chemical Ablation of Genicular Nerve with Phenol for Pain Relief in Patients with Knee Osteoarthritis: A Prospective Study.

Radiofrequency ablation of the genicular nerve is performed for knee osteoarthritis (KOA) when conservative treatment is not effective. Chemical ablation may be an alternative, but its effectiveness and safety have not been examined. The objective of this prospective open-label cohort study is to evaluate the effectiveness and safety of ultrasound-guided chemical neurolysis for genicular nerves with phenol to treat patients with chronic pain from KOA. Forty-three patients with KOA with pain intensity score (Numeric Rating Scale, NRS) ≥4, and duration of pain of more than 6months were considered for enrollment. Ultrasound-guided diagnostic blocks of genicular nerves (superomedial, inferomedial, and superolateral) with 1.5mL of 0.25% bupivacaine at each site were performed. Those who reported more than 50% reduction in NRS went on to undergo chemical neurolysis, using 1.5mL 7% glycerated phenol in each genicular nerve. NRS and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were assessed before intervention and at 2weeks and 1, 2, 3, and 6months following the intervention. NRS and WOMAC scores improved at all time points. Mean pain intensity improved from 7.2 (95% confidence interval [CI]: 6.8 to 7.7) at baseline to 4.2 (95%CI: 3.5 to 5.0) at 6-month follow-up (P<0.001). Composite WOMAC score improved from 48.7 (95%CI: 43.3 to 54.2) at baseline to 20.7 (95%CI: 16.6 to 24.7) at 6-month follow-up (P<0.001). Adverse events did not persist beyond 1month and included local pain, hypoesthesia, swelling, and bruise. Chemical neurolysis of genicular nerves with phenol provided efficacious analgesia and functional improvement for at least 6months in most patients with a low incidence of adverse effects.

Radial Shock Waves Modify Post-synaptic Neuromuscular Transmission in the Medial Spastic Gastrocnemius Muscle: Case Report, Neurophysiological Evaluation, and Review

Spasticity is a frequent pathology, devastating in the quality of life of the patients who suffer it, and produces an important socio-economic impact derived from both direct and indirect expenses. Therapeutic interventions on spasticity include (1) pharmacological therapy, (2) physical therapy (electrostimulation, thermotherapy), (3) occupational therapy, (4) botulinum toxin, (5) chemical neurolysis, and (6) selective neurotomy. Focal or radial extracorporeal shock waves (ESWT) have recently been added to the therapeutic armamentarium for the management of spasticity with good results, although the underlying mechanism of action is unknown. There is consensus that ESWT improve spasticity, clinically assessed by clinical tests such as the Ashworth or Tardieu modified scale; however, there is no neurophysiological confirmation of its clinical effect. We present the case of a 61-year-old male patient with chronic spastic paraparesis who, after prolonged bedding due to abdominal eventration requiring hospital admission, presented worsening bilateral equine feet. Radial ESWT (3 bars, 1500 pulses, 8 Hz) were applied to the morphological most prominent part of the left medial gastrocnemius and repetitive stimulation was evaluated immediately after the intervention. With respect to the previous basal stimulation (control), a pathological decrement (> 10%) of the amplitude and area of the 4th potential was observed compared with the 1st potential, a response that is characteristic of alterations in neuromuscular to post-synaptic transmission. Radial electro shockwave therapy modifies neuromuscular transmission at the post-synaptic level. No adverse events were observed in the present clinical case.

A Review of Interventional Radiology Treatments for Chronic Pain

Interventional radiology procedures are being increasingly used to mitigate chronic pain. In addition to established therapies such as thermal bone lesion ablation, kyphoplasty, and chemical neurolysis, ongoing research has shown promising results for the use of embolization in treatment of osteoarthritic knee pain and chronic pain secondary to adhesive shoulder capsulitis. This review will highlight some of the most common interventional radiology pain procedures, as well as provide insight into future pain-relieving embolization.

Utilization of neurolysis in management of refractory head and neck cancer-related pain in palliative patients: A retrospective review.

Pain is a common symptom of head and neck cancers. In some instances, pain may not resolve with conventional modalities and become refractory. Chemical neurolysis is a technique that utilizes chemical neurolytic agents to temporarily denervate a targeted nerve and provide relief in pain-related symptoms. The aim of this investigation was to determine the effectiveness, safety, and predictors of chemical neurolysis procedures for management of refractory head and neck cancer-related pain. A retrospective chart review of patients who underwent chemical neurolysis procedure in the regions of head and neck for management of head and neck cancer-related pain was conducted between November 2017 and November 2018. All adult male and female patients who had undergone chemical neurolysis procedure in the head and neck region for management of refractory head and neck related pain, in Orofacial Pain Clinic, Shaukat Khanum Memorial Cancer Hospital and Research Center were included in the investigation. Among 33 participants enrolled, 72.7% of participants experienced 75% or greater relief in pain at the 1-month follow-up. However, 9.1% reported experiencing an adverse effect following neurolysis. A statistically significant association was found between neurolysis effectiveness and chronicity of pain. Chemical neurolysis can provide significant relief to patients with refractory head and neck cancer-related pain as an adjunctive therapy. However, it was found to be associated with mild risk of manageable adverse effects. Shorter chronicity of pain was found to be associated with successful outcome.

Study of Chemical Neurolysis, Radiofrequency Ablation and Combined Radiofrequency with Chemical Neurolysis of Lumbar Sympathetic Ganglion in Peripheral Vascular Diseases of the Lower Limbs

Lumbar sympathectomy is indicated for the treatment of intermittent claudication or rest pain in legs due to ischemia...

Lumbar Sympathetic Plexus Radiofrequency Ablation for Chronic Non-Cancer Pain: A Brief Review and Two Case Reports

Background: Lumbar sympathetic plexus (LSP) has been described as a target for managing chronic pain with a sympathetic component in the lower limbs such as complex regional pain syndrome (CRPS) or pain of ischemic origin. LSP neurolysis with phenol or ethanol has been applied; more recently, radiofrequency (RF) lesioning has been proposed as an alternative. RF denervation has the advantage of avoiding the complications associated with ethanol/phenol spread. Case Report: We describe 2 cases in which RF denervation of LSP was performed in patients suffering from chronic pain from CRPS and chronic ischemic disease of the lower limb. Conclusion: RF denervation of LSP could be considered as a treatment for CRPS and chronic ischemic pain when conventional medical therapy fails. Compared to chemical neurolysis, RF denervation carries less risk for postprocedural deafferentation pain. Key words: Complex regional pain syndrome; ischemic pain; lumbar sympathetic plexus; neurolysis; radiofrequency; sympathetically maintained pain

Effectiveness of Superior Hypogastric Plexus Neurolysis for Pelvic Cancer Pain

Background: The superior hypogastric plexus block has been indicated for visceral pelvic pain treatment associated with malignancy. The first international report of this technique was published by Plancarte et al, in which a posterior percutaneous approach guided by fluoroscopy was described by applying neurolytic agents. The considerable variability in the data reported gave rise to 2 clinical approaches to those who performed the blockade early and those who executed it at a later stage of cancer. Objectives: The present study aims to provide more evidence regarding the effectiveness of this procedure. Study Design: This is a retrospective, longitudinal, descriptive study. Setting: The study was held at the pain unit service of the National Cancer Institute, Mexico City. Methods: A nonprobabilistic sample was selected; the data collection took place from January 2006 to December 2016 with patients diagnosed with pelvic pain, confirmed by imaging and biopsy studies. Patients who received any other type of intervention of the sympathetic axis, patients with a different approach than the classic or paravertebral technique, and patients with low survival rate were excluded. The Student t test was used to measure the significant difference between Visual Analog Scale (VAS) and morphine equivalent daily dose. The Cochran–Mantel– Haenszel test and the Gamma test were used to measure the association between the initial Karnofsky and blockade success. Results: The study included a total of 180 patients. The success rate was 59.4% at 1 month, 55.5% at 3 months, and 48.8% at 6 months. There was a sustained and significant VAS reduction that was 49.55% at 3 months. A significant reduction in opioid consumption of 12.55% was found at 3 months. There was no significant statistical evidence related to either opioid consumption or the functionality of the patient before the blockade as an influential variable in the success of the procedure. Limitations: Retrospective study, developed in a single center. Conclusions: Although opioids remain the cornerstone of cancer pain treatment, they produce many deleterious side effects. The superior hypogastric plexus neurolysis represents a reproducible and effective alternative in the management of pain in this group of patients. Key words: Pelvic pain, neoplasms, chemical neurolysis, pain management, cancer pain, palliative care, analgesia, nerve block

Neurólise química acetabular em um cão com displasia coxofemoral

We report the use of neurolytic ethanolic suspension (NES) to promote acetabular desensitization in a dog with canine hip dysplasia (CHD). A male Dogo Argentino presented with a 120 days history of pain and lameness not responsive to conservative treatment. Acetabular chemical neurolysis was performed with a single application of NES The degrees of sensitivity and lameness were evaluated at 24, 48, 72 and 96 hours post-injection, and at 15, 30, 60, 90, 120, 150 and 180 days after the procedure. The use of NES in the hip joint capsule resulted in remission of lameness seven days after treatment, and was still effective at 180 days. This technique still requires further study, but demonstrates good prospects as a therapeutic option in the management of pain caused by Canine Hip Dysplasia.

Chemical neurolysis for treatment of post-carcinoma pain of the eyeball. Case report

Chemical neurolysis for treatment of post-carcinoma pain of the eyeball. Case report

Can recent chronic pain techniques help with acute perioperative pain?

This article discussed how the knowledge and technique of a few chronic pain procedures benefited the perioperative clinicians in their care of patients receiving specific orthopaedic surgical procedures. Recent emerging interest in hip and knee denervation for chronic pain management secondary to osteoarthritis stimulates publications on the new understanding of hip and knee joint innervation. The improved understanding of the anatomy allows better precision in targeting the articular branches. The procedures for chronic joint pain such as radiofrequency ablation, chemical neurolysis and neuromodulation procedure have recently been applied to the perioperative care in orthopaedic procedures because of the potential long-lasting analgesia, opioid-sparing effect and consequent improvement in physical function and health-related quality of life after surgery. Despite the widespread use of regional anaesthesia and multimodal analgesia in the perioperative pain management, more than two-third of the patients reported severe postoperative pain. Therefore, other therapeutic strategies used in chronic pain management such as radiofrequency ablation and neuromodulation have been proposed to optimize acute postsurgical pain. The early experience with those techniques is encouraging, and more studies are required to explore the incorporation of these procedures in the perioperative care.

Effective botulinum toxin injection guide for treatment of cervical dystonia.

The aim of this study was to elucidate the distribution of the accessory nerve within the sternocleidomastoid muscle (SCM) to aid identifying the optimum sites for botulinum neurotoxin (BoNT) injections and applying chemical neurolysis. Thirty SCM specimens from 15 Korean cadavers were used in this study. Sihler's staining was applied to 10 of the SCM specimens. Transverse lines were drawn in 20 sections to divide the SCM into 10 divisions vertically, and a vertical line was drawn into the medial and lateral halves from the mastoid process to the sternoclavicular joint. The most densely innervated areas were 5/10-6/10 and 6/10-7/10 along the lateral and medial parts of the muscle, respectively. We suggest injecting BoNT in the medial region 6/10-7/10 along the SCM prior to injecting in the lateral region 5/10-6/10 along the muscle to ensure safe and effective treatment. Clin. Anat. 33:192-198, 2020. © 2019 Wiley Periodicals, Inc.

PROLONGED PAIN RELIEF WITH USE OF 10% LIDOCAINE NEUROLYSIS FOR REFRACTORY MERALGIA PARESTHETICA

Meralgia paresthetica is a sensory neuropathy characterized by anterolateral thigh pain associated with paresthesiae. It is hypothesized that entrapment, compression, or stretching of the lateral femoral cutaneous nerve as it exits through the inguinal ligament. Often times life style modification, neuropathic pain medications, and or steroid injections can help relieve the pain. In some circumstances, the pain is refractory and more invasive procedures such as radiofrequency ablation and or even surgery may need to be pursued. The authors report the successful use of 10% lidocaine for chemical neurolysis for Meralgia paresthetica in a 47-year-old female refractory to conventional treatment. In this case report, we will discuss the risk factors, pathomechanics, diagnostic challenges, therapeutic options and novel approach employed by the authors. Key words: 10% lidocaine, chemical neurolysis, meralgia, aresthetica, neuropathic pain

Abstract CT147: Celiac plexus radiosurgery a new palliative modality for upper gastrointestinal malignancies - final quality of life results from a proof-of-concept clinical trial

Abstract Background: Many patients with upper-abdominal malignancies suffer from severe low back / epigastric pain caused by infiltration of the celiac plexus. The celiac plexus is a network of nociceptive nerves, located along the aorta. Contemporary approaches (opioids, celiac plexus chemical neurolysis, systemic chemotherapy) are often inadequate. The celiac plexus has not previously been targeted using radiation. We hypothesized that ablative radiation targeted to the celiac plexus would alleviate pain and improve quality of life (QOL). Methods: We conducted a single arm prospective clinical trial. Eligible patients had celiac-pain &amp;gt; 4/10 on Numerical Rating Scale (NRS) and completed treatment per protocol with at least one post-treatment visit. The celiac plexus was irradiated from D12 to L2. Radiation was given as either five fractions of 9 Gy or a single-fraction 25 Gy. The primary endpoint was NRS pain 3 weeks post-treatment. Secondary endpoints were toxicity, pain at 6w, analgesic use, and pain interference with daily activities as evaluated by ‘Brief pain assessment short-form’. Analgesic use was not restricted. Here we report results from those who received single fraction treatment. Results: 19 patients were evaluable. The median age of the study population was 67 yr with a median ECOG of 2, 89% had pancreatic cancer. Patients were a median 8 months from diagnosis, and had received a median of one systemic treatment. Toxicity was limited to grade 1-2. Average pain decreased from 5.9/10 at baseline, to 3.1/10 at 3w, and to 1.8/10 (both p &amp;lt; 0.0001) at 6w post-treatment. Number of rescue analgesic doses decreased from 3.6 (baseline) to 1.9 at 3w and 1.7 at 6w (both p&amp;lt;0.001). Improvement was seen in all domains of pain-interference (table). Conclusions: Single fraction celiac plexus radiosurgery alleviates pain, and improves quality of life among patients with advanced upper-GI cancer. An international phase II trial is accruing. Pain interference measuresdomainweek 0 (baseline)week 3p (w0 vs v3)week 6p (w0 vs v6)General Activity7.93.4&amp;lt;0.00012.0&amp;lt;0.0001Mood6.93.6&amp;lt;0.0051.80.0001Walking ability4.21.80.051.00.01Normal Work7.43.4&amp;lt;0.0051.30.0001Relations with other people62.40.0031.70.003Sleep6.93.2&amp;lt;0.0051.80.0001Enjoyment of life8.32.4&amp;lt;0.00011.8&amp;lt;0.0001 Citation Format: Yaacov R. Lawrence, Liat Hammer, Ofir Morag, Maoz Ben-Ailan, Dror Alezra, Ofer Margalit, Naama Halpern, Ben Boursi, Einat Shacham Shmueli, Galia Jacobson, Uri Amit, Tamar Katzman, Kinneret Shefer, Ilana Weiss, Inessa Yanovsky, Adam P. Dicker, Talia Golan, Zvi Symon, David Hausner. Celiac plexus radiosurgery a new palliative modality for upper gastrointestinal malignancies - final quality of life results from a proof-of-concept clinical trial [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr CT147.

Can percutaneous alcoholization of Morton’s neuroma with phenol by electrostimulation guidance be an alternative to surgical excision? Long-term results

BackgroundPercutaneous alcoholization with phenol by electrostimulation guidance for the treatment of Morton’s neuroma is proposed to determine a permanent chemical neurolysis. Methods115 patients for 125 Morton’s neuromas were treated. Ten patients were affected by multiple neuromas. Visual Analogue Scale and AOFAS score were used for the clinical assessment. ResultsThe mean follow-up was 8,3 years. The pre-alcoholization VAS was 85.84 ± 12.00, while at follow-up scored 28.85 ± 31.35, showing a significant decrease improving in 113/125 cases (90.4%). Treatment was considered successful with a reduction of the VAS value superior to 50% in 89 out of 125 patients (71.2%). The mean overall AOFAS score at -up was 85.09 ± 13.41. ConclusionsNeedle-electrode guided percutaneous alcoholization is an outpatient, minimally invasive procedure with low rate of complications. Better results of those obtained with traditional conservative treatments and comparable with those reported with other alcohols injections or surgical nerve excision were observed. Level of evidenceLevel IV, retrospective case series.

Elimination of pain syndrome in patients with advanced pancreatic head cancer

Pain syndrome, along with mechanical jaundice, is one of the most evident clinical manifestations of pancreatic cancer and is often a sign of tumor neglecting. Existing treatment options for chronic pain in cancer patients are diverse and include the various ways of impact on the different links of pathological pain: medicinal, endoscopic, surgical. With this pathology, drug therapy using analgesics, weak and strong opioids, is usually not effective enough. In such cases, preference is given to chemical neurolysis — denervation of the autonomic structures of the retroperitoneal space, carried out under the guidance of ultrasound or computed tomography. Conducting percutaneous neurolysis of the celiac plexus with the use of alcohol or phenol is prescribed upon insufficient effectiveness of pharmacotherapy. Surgical methods of anesthesia are used extremely rarely, as they considerably worsen the patient’s condition, without significantly affecting the quality of life or the prognosis. Thoracoscopic splanchnicectomy is considered a modern and effective method of endoscopic treatment of pain in unresectable pancreatic cancer, the conduction of which can significantly decrease the intensity of pain, reduce the number of narcotic analgesics and improve the quality of life of cancer patients. This minimally invasive intervention is the basis for the subsequent lifelong systemic drug therapy.