Cord Blocks Research Articles

Gold Standard Care of Chronic Scrotal Pain.

IntroductionChronic scrotal pain (CSP) can be a debilitating condition for patients and is often difficult to characterize.MethodsA review of literature was performed using Embase, Cochrane and Medline databases in the period 1.January 2010 to 1.January 2021. We found 132 articles, and the authors screened abstract and references. Thirty-seven articles are included after removing duplicates.ResultsThis review presents a variety of medical and surgical treatment options for CSP such as spermatic cord blocks (36–80% success rate), microsurgical denervation of the spermatic cord (76–100% success rates), Botox (56% success rate), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation, and radical orchiectomy (55–75% success rate).ConclusionAn overview of various treatment options, both non-surgical and surgical are provided, with the aim of establishing what may be the best treatment option for CSP.

Spermatic Cord Block Series as a Minimally Invasive Therapy for Chronic Scrotal Content Pain.

The primary aim of our study was to evaluate relief of chronic scrotal content pain after a series of spermatic cord blocks with a combination of local anesthetic and a steroid. Secondary aims were to assess factors associated with a positive response and complications. We performed a retrospective chart review of patients who underwent spermatic cord block series for chronic scrotal content pain at our practice between 2012 and 2019. Pain scores were compared before and after treatment using an 11-point numerical pain rating scale. We performed univariate analysis to assess differences between responders and nonresponders, and the relationship between symptom duration and response was analyzed by rank-order correlation. We included 44 men with chronic scrotal content pain present for a median duration of 24 months who underwent a spermatic cord block series. At a median followup of 16 months, 31 patients (70.5%) experienced sustained relief, including 9 patients (20.5%) with complete resolution of pain. There were no differences between responders and nonresponders in terms of symptom duration, perceived etiology, or previous treatments, and there was no association between response and duration of pain. Minor complications occurred in 5 cases (11.4%). Spermatic cord block series is a safe, minimally invasive treatment for men with refractory chronic scrotal content pain. Response to cord block series appears to be independent of symptom duration, perceived etiology or prior medical and surgical treatments. Future studies should be conducted to evaluate long-term durability and predictors of success.

077 Spermatic Cord Block Series as a Minimally Invasive Treatment For Chronic Scrotal Content Pain

Chronic scrotal content pain (CSCP) is a commonly encountered and potentially debilitating urologic condition characterized by pain or discomfort localized to the scrotum which has been present for a minimum of three months and interferes with daily activity. The diagnostic utility of spermatic cord block (SCB) in the evaluation of CSCP has been demonstrated; however, the therapeutic potential of SCB or a series of cord blocks as an alternative to microdenervation of the spermatic cord (MDSC) remains less clear, although there are reports in the literature that describe durable pain relief after SCB or a series of cord blocks with various combinations of local anesthetic, steroid, or other agents, such as onabotulinum toxin A.

Management of Chronic Orchialgia: Challenges and Solutions - The Current Standard of Care.

IntroductionChronic scrotal content pain (CSP) or chronic orchialgia can be debilitating for patients and difficult to treat. There is a paucity of structured treatment algorithms to approach this difficult condition.MethodsA review of the literature was performed. Conservative treatment options are presented and then targeted surgical interventions that the urologist may perform are then presented in a structured algorithm format. Many of these patients may obtain a significant reduction in pain with some of these treatments.ResultsThis review presents the pathophysiology, a new assessment tool, and various treatment options available for CSP patients, such as targeted spermatic cord blocks, targeted and standard microsurgical denervation of the spermatic cord (77–100% success rates), ultrasound-guided peri-spermatic cord and ilioinguinal cryoablation (59–75% success rates), scrotox (botox) (56–72% success rates), targeted ilioinguinal and iliohypogastric peripheral nerve stimulation (72% success rate), radical orchiectomy (20–75% success rate), targeted robotic-assisted intra-abdominal denervation (71% success rate) and vasectomy reversal (69–100% success rates).ConclusionA structured and evidence-based approach to help urologists manage patients with chronic orchialgia or scrotal content pain is presented.

MiR-34a Inhibits Spinal Cord Injury and Blocks Spinal Cord Neuron Apoptosis by Activating Phatidylinositol 3-kinase (PI3K)/AKT Pathway Through Targeting CD47

Dysregulation of miR-34a has been reported for its implication in neuronal development. This study aims to explore the effect and possible mechanism of miR-34a on neuron apoptosis induced by Spinal Cord Injury (SCI). SCI model was established using Allen's weight-drop method and rats in the sham group were performed with laminectomy without weight-drop injury. Basso Bcattie Bresnahan (BBB) rating scale was applied to evaluate the locomotor function of rats. Pathological changes of spinal cord tissues in SCI rats were observed after hematoxylin and eosin (HE) staining. Rats were separately injected with miR-34a agomir, miR-34a agomir NC, si-CD47 and si- CD47 NC before their spinal cord tissues were collected for terminal-deoxynucleoitidyl Transferase Mediated nick end labeling (TUNEL) staining. Expressions of miR-34a, si-CD47, apoptosis related proteins and AKT pathway related proteins were measured by quantitative reverse transcription- polymerase chain reaction (qRT-PCR) and western blot. SCI rat models were successfully established evidenced by decreased BBB scores and HE staining. Injection of miR-34a agomir and/or si-CD47 could suppress neuron cell apoptosis, with deceased apoptotic index (AI) and pro-apoptotic protein (cleaved caspase-3 and Bax) levels, and increased expressions of anti-apoptotic proteins (Bcl-2 and Mcl-1). Phosphorylated levels of phatidylinositol 3-kinase (PI3K) and AKT were further increased in rats injected with miR-34a agomir and si-CD47, compared with miR-34a agomir or si-CD47 injection alone. MiR-34a can downregulate CD47 expression to activate PI3K/AKT signal pathway, and thus inhibit SCI induced spinal neuron apoptosis.

AB040. Post-vasectomy pain syndrome

Persistent pain after vasectomy is bothersome to both patients and urologists. The incidence of long-term pain after vasectomy, the so-called post-vasectomy pain syndrome (PVPS), is variable in the literature, ranging from 0.1% to 15%. The exact cause of PVPS is unknown, but several theories have been proposed, including interstitial fibrosis of the epididymal duct after obstruction of the testicular end of the vas deferens, and sperm granulation formation resulting in perineural fibrosis and inflammation. No risk factors such as immediate postoperative complications, age, socioeconomic status, or vasectomy techniques have been identified for PVPS. Conservative therapy, including scrotal elevation and support, heat or ice packing, and oral pain killers is the first line therapy for PVPS. Those who fail to have response to conservative treatment for at least three months should consider spermatic cord blocks. Surgical interventions could be employed if minimally-invasive procedures fail. Excision of the sperm granulation and intraluminal cautery occlusion of the vas deferens could be applied if the pain is localized to a sperm granulation, while epididymectomy could be performed in patients with palpable tenderness at epididymis. Vasectomy reversal and microscopic denervation of the spermatic cord might be helpful in about 70% of the patients. Inguinal orchiectomy is sometimes useful for severe cases of PVPS. Since PVPS is unpredictable, it is essential to inform the patients of this potential complication during preoperative counseling. More data are warranted to evaluate the role of abdominal robotic microsurgical neurolysis in patients with PVPS unresponsive to orchiectomy.

MP36-12 PREOPERATIVE PREDICTORS OF PATIENTS WHO FAIL MICROSURGICAL DENERVATION OF THE SPERMATIC CORD FOR CHRONIC SCROTAL CONTENT PAIN

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Prostate & Genitalia II1 Apr 2016MP36-12 PREOPERATIVE PREDICTORS OF PATIENTS WHO FAIL MICROSURGICAL DENERVATION OF THE SPERMATIC CORD FOR CHRONIC SCROTAL CONTENT PAIN John Richgels, Melissa Farmer, and Laurence Levine John RichgelsJohn Richgels More articles by this author , Melissa FarmerMelissa Farmer More articles by this author , and Laurence LevineLaurence Levine More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.1646AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Chronic scrotal content pain (CSCP) is a poorly understood variant of male pelvic pain with a debilitating impact on physical and psychological well-being. Strong evidence supports the efficacy of microdenervation of the spermatic cord (MDSC) in alleviating pain in a subset of men with CSCP, yet it remains a challenge to predict which men will benefit most from surgery. In theory, response to spermatic cord blocks (SCB) should identify men who will benefit from MDSC; in practice, highly variable SCB responses do not consistently predict MDSC pain relief. Identification of men who are unlikely to respond to MDSC can reduce risks associated with surgery and facilitate alternate treatment strategies with greater potential to alleviate pain. METHODS A retrospective chart review of 53 patients who underwent diagnostic SCB prior to MDSC evaluated the preoperative pain symptoms that predicted MDSC response. Post-surgical pain visual analog scale (VAS) and follow-up reports were used to define full response (< 1/10 VAS), partial response (> 50% VAS reduction), and nonresponse (0-10% VAS reduction). Clinical data was evaluated with χ2 analyses, principal components analyses (PCA) to identify symptom clusters, and logistic regression to discriminate partial- from non-responders to MCSD. RESULTS A subset of men reported complete pain relief (n=29), partial relief (n=9), and negligible relief (n=15). MDSC response was uncorrelated with preoperative pain intensity, quality or duration, or SCB response. Poor responders exhibited greater frequency of constant pain unrelated to prior surgery. A PCA symptom cluster including constant bilateral pelvic pain with no known pain triggers was exhibited by partial responders. Bilateral pelvic pain was the best discriminant predictor of partial versus non-response. CONCLUSIONS Results suggest that partial MDSC responders exhibited constant bilateral pain of non-surgical origin associated with no known pain triggers, consistent with spinally-mediated crosstalk and sensitization. In contrast, non-responders presented with constant unilateral pain of non-surgical origin with pain provoked by sexual activity and mechanical pressure/touch, consistent with centrally-mediated ″functional″ pain. Findings suggest that CSCP symptom patterns may provide insight into physiological mechanisms that maintain pain. When considered with SCB response, this approach can aid clinical decision-making for MDSC. Prospective studies are needed to evaluate generalizability of these findings. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e493-e494 Advertisement Copyright & Permissions© 2016MetricsAuthor Information John Richgels More articles by this author Melissa Farmer More articles by this author Laurence Levine More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Patterns of Local Recurrence for Mesothelioma Patients Treated With Extrapleural Pneumonectomy and Radiation Therapy Using the Electron-Photon Technique: The Dosimetric Challenges of Electron-Photon Match Lines and Blocks

Hemi-thoracic radiation therapy (RT) after extra-pleural pneumonectomy (EPP) appears to reduce local recurrence (LR). The large target volume and proximity of critical organs make RT planning challenging. The electron-photon technique (EPT) developed at Memorial Sloan-Kettering Cancer Center involves photon and electron fields matched in an attempt to deliver uniform dose to areas at risk. Dose inhomogeneities may occur at these electron-photon match lines and under blocks. The purpose of this retrospective study was to describe patterns of LR relative to electron-photon match lines and block placement in patients treated with the EPT. From 2003-2009, 34 patients with non-metastatic mesothelioma underwent EPP and adjuvant RT via the EPT. RT consisted of AP-PA photon fields to the hemithorax and mediastinum. Matched electron fields treated the chest wall under blocked abdominal and cardiac regions. Abdominal blocks were added at the start of RT; heart blocks were added for left-sided cases at 19.8 Gy; spinal cord blocks were added at 39.6 Gy. Prescribed dose was 54 Gy. CT scans with LRs were registered with planning CT scans to determine LR locations relative to match lines, blocks, and dosimetry. Twenty-eight patients were male (82%). Median age was 56.5 years. Histology was epithelial for 19 patients (56%) and mixed/biphasic for 15 (44%). Median dose was 54 Gy (range: 45-54). Median follow-up was 24.6 months; median time to LR was 14.8 months. Fifteen patients (44%) had LRs in 38 local sites; ten of these patients (67%) had additional distant failures. The most common LR sites were lateral costophrenic sulcus (53%) and mediastinum (40%). Twenty-one LRs (55%) occurred under a block, six (16%) in the full-dose photon field abutting a block, six (16%) out-of-field, and five (13%) in the full-dose photon field (Table). Twelve LRs (32%) were associated with a match line in areas where the actual dose (median 42.5 Gy) was significantly less than the nominal prescribed dose of 54 Gy (p = 0.003). LRs under heart or abdominal blocks also occurred in under-dosed locations (median actual dose 45 Gy vs prescribed dose 54 Gy, p = 0.05). The majority of LRs after hemithoracic RT using EPT occurred at match lines and/or under blocks in under-dosed areas. These limitations of EPT should be considered when selecting the adjuvant RT technique most appropriate for individual patients following EPP.Scientific Abstract 3010; TableNominal Prescribed Dose vs Median Actual Dose, by Location of LRs Relative to EPTLocation of LRNumber of LRs (%)Nominal Prescribed Dose (Gy)Median Actual Dose (Range) from Graphic Plan (Gy)P valueIn full-dose photon field5 (13)5454 (54)1.0In full-dose photon field abutting block (at match line)6 (16)5447.5 (30-54).08Abutting spinal cord block15445 (45)-Abutting heart or abdominal block55452 (30-54)-Under block21 (55)39.6-5439.6 (15-54)-Under spinal cord block1039.639.6 (30-50).45Under heart or abdominal block55445 (36-54).05Under abdominal block at match line65436 (15-50).02Out of field inferiorly, superior to L2 (inferior field borders for these patients: T11 and T12)6 (16)0<5 (<5-10)1.0 Open table in a new tab

Vasectomy reversal with ultrasonography‐guided spermatic cord block

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Vasectomy reversal is often performed in general or neuraxial anaesthesia. Even though the site of vasectomy reversal is easily amenable to regional/local anaesthesia, spermatic cord blocks are rarely applied because of their risk of vascular damage within the spermatic cord. Recently, we described the technique of ultrasonography (US)-guided spermatic cord block for scrotal surgery, which, thanks to the US guidance, at the same time avoids the risk of vascular damage of blindly performed injections and the risks of general and neuraxial anaesthesia. Vasectomy reversal can easily be done in regional anaesthesia with the newly described technique of US-guided spermatic cord block without the risks of vascular damage by a blindly performed injection and the risks of standard general and neuraxial anaesthesia. In addition, this technique grants long-lasting postoperative pain relief and patients recover more quickly. Microsurgical conditions are excellent and patient satisfaction is high. Thanks to these advantages, more patients undergoing vasectomy reversal might avoid general or neuraxial anaesthesia. • To assess the success rate, microsurgical conditions, postoperative recovery, complications and patient satisfaction of ultrasonography (US)-guided spermatic cord block in patients undergoing microscopic vasectomy reversal and to compare them to a control group with general or neuraxial anaesthesia. • The present study comprised a prospective series of 10 consecutive patients undergoing US-guided spermatic cord block for microscopic vasectomy reversal. • The cohort was compared with 10 patients in a historical control group with general or neuraxial anaesthesia. • Nineteen of 20 (95%) blocks were successful, defined as no pain >3 on the Visual Analogue Scale (VAS), no additional analgesics and/or no conversion to general anaesthesia. Median pain was 0 on the VAS (range 0-5). Additional analgesics were requested in one (5%) block, and there was no conversion to general anaesthesia. • Microsurgical conditions were excellent. • In the spermatic cord block vs general/neuraxial anaesthesia groups, median times (range) between surgery and first postoperative analgesics, alimentation, mobilization and hospital discharge were 12 (2-14) vs 3 (1-6), 1 (0.25-3) vs 4 (3-6), 2 (1-3) vs 6 (3-10), and 4 (3-11) vs 8.5 (6-22) h, respectively. • No complications were reported after the spermatic cord block. • Patient satisfaction was excellent. • US-guided spermatic cord block for microscopic vasectomy reversal is highly successful and provides long-lasting perioperative analgesia. • Times to alimentation, mobilization and hospital discharge are shorter under US-guided spermatic cord block than under general/neuraxial anaesthesia. • Additional anaesthetic pain management might, however, be required unexpectedly with US-guided spermatic cord block.

High-resolution single-cell imaging for functional studies in the whole brain and spinal cord and thick tissue blocks using light-emitting diode illumination

Functional studies of neuronal networks require recordings from visually identified neurons in their natural environment preservation of which may demand experimenting with a tissue of a significant depth or the entire brain. Here we describe a new technique of single-cell imaging and visually controlled patch-clamp recordings in both brain slices of unlimited thickness and the whole brain or spinal cord preparations with a cut upper surface. It utilizes an upright microscope and ultra bright light-emitting diodes (LEDs) as a source of oblique illumination. This technique provided high quality images of superficial cells regardless of slice thickness or the presence of opaque structures, like metal plate or bone, below the tissue, when conventional differential interference contrast (DIC) optics became powerless. The technique opens broad possibilities for a single-cell imaging and visually guided recordings from intact neuronal networks in the entire brain or spinal cord.

Increased expression of cyclo-oxygenase 2 and vascular endothelial growth factor in lesioned spinal cord by transplanted olfactory ensheathing cells.

Olfactory ensheathing cells (OECs) were transplanted in adult rats after photochemical injury of the spinal cord. Rats received either 180,000 OECs suspended in DMEM or DMEM alone. Locomotor ability scored by the BBB-scale, pain sensibility, and motor and somatosensory evoked potentials were evaluated during the first 14 days post-surgery. At 3, 7, and 14 days, 5 rats per day of both groups were perfused and transverse sections from proximal, lesioned and distal spinal cord blocks were stained for COX-2, VEGF, GFAP and lectin. The BBB-score and the amplitude of motor and somatosensory evoked potentials were significantly higher in OEC- than in DMEM-injected animals throughout follow-up, whereas the withdrawal latency to heat noxious stimulus was lower in OEC- than in DMEM-injected rats. The area of preserved spinal cord and the levels of COX-2 and VEGF staining were significantly higher in OEC- than in DMEM-injected rats. GFAP- but no LEC-positive cells expressed COX-2 staining in OEC-transplanted rats. The density of blood vessels was also significantly increased in OEC- with respect to DMEM-injected rats. Our results show that OECs promote functional and morphological preservation of the spinal cord after photochemical injury, increasing neoangiogenesis and up-regulation of COX-2 and VEGF expression in astrocytes.

A Three-Dimensional (3D) Analysis of the Conventional Supra-clavicular Field in Breast Cancer

Purpose: To assess the 3D dose coverage of the supraclavicular fossa (SCF) and axillary apex (AA) following conventional dose prescription and blocking. Materials and Methods: 16 patients with breast cancer were evaluated using CT-based planning. The SCF, AA, and brachial plexus (BP) were outlined on the planning CT. Spinal cord and humeral head blocks were drawn on the 2D digitally-reconstructed radiograph without the targets displayed. The prescription point was placed 3cm deep, lateral to the sternocleidomastoid muscle, and superior to the medial third of the clavicle. From an oblique 6MV beam plan, dose-volume histograms were generated. Results: The fraction of SCF underdosed by 5% ranged from 2–85%. 2–5% of the SCF was underdosed in five patients, 13–20% in five, 24–30% in three and 68–85% in three. The portion of AA underdosed by 10% was 0–8% in five patients, 20–32% in four, 42–62% in three and 84–100% in five. The volume of BP receiving > 90% of the prescription dose varied from 7–93%. In 6/16 patients, >50% of the BP received >90% of the dose. 2D blocking was suboptimal for the SCF in 2 patients and for the AA in 6. Better target coverage and less volume above 100% of the dose was achieved with inverse planning. Conclusions: Although 2D SCF coverage was adequate in the majority of patients, the conventional field does not optimally cover the SCF in 3D. When the intention is to treat the AA, 3D planning may be required for adequate coverage. Intensity modulation may result in better coverage of the SCF and AA while reducing dose to the BP.

Efficacy of endoscopic hydrocele ablation.

We describe a new endoscopic technique that was used for the treatment of symptomatic scrotal hydroceles in 10 men. Through a small skin incision, the parietal surface of the tunica vaginalis was ablated endoscopically using either electrocautery or the KTP:YAG laser. This approach permitted visual inspection of the scrotal contents with minimal manipulation and was performed using monitored local anesthesia with bilateral spermatic cord blocks. With a mean follow-up interval of 6.1 months, no hydrocele recurrences, wound infections, or hematomas have been detected. The mean operative time was comparable (53 minutes) to that in a historical control group consisting of 15 men who had undergone open hydrocelectomy at our institution (46 minutes). Postoperative scrotal discomfort was minimal, with 6 of the 10 patients requiring no analgesics. Patients were able to resume their preoperative lifestyles an average of 2 days after surgery. In contrast, 11 of the 15 men in the control group was still complaining of scrotal pain, requiring oral analgesics, at their 2-week follow-up visit. Thus, endoscopic hydrocele ablation appears to be an effective and well-tolerated alternative to treat hydroceles with minimal postoperative discomfort.

Leptomeningeal metastases

Thirty consecutive patients with cytologically documented leptomeningeal metastases (LM) underwent intraventricular 111indium-DTPA (In) CSF flow studies (FS). Sixteen patients (53%) had normal In FS. Fourteen patients (47%) had documented compartmentalization of the CSF system. In four patients unsuspected CSF block was confined to the base of brain with limited spinal descent and poor cerebral convexity ascent of In. All patients received whole-brain irradiation and two were subsequently shown to have normal In FS. In 10 other patients, suspected (eight) and unsuspected (two) spinal blocks were seen. Patients with spinal blocks underwent CT myelography or spine MR and were subsequently treated with involved-field irradiation. Following radiation therapy, normal In FS were achieved in only two patients with documented spinal cord blocks. In conclusion, antegrade In FS in patients with LM are useful in defining levels of CSF blocks. Following treatment of patients with CSF blocks with involved-field irradiation, normal In FS can be restored in approximately one third.

Practical aspects of transmission cord blocks in radiotherapy.

We present the advantages of using partial transmission cord blocks throughout treatment, as opposed to adding full-thickness blocks near the end. Such blocks reduce the risk of block omission or mispositioning and require less total time for construction. We also present an argument for the existence of an optimal width for cord blocks used in mediastinal treatments. A figure of merit has been derived which quantifies the tradeoff between narrow blocks, which increase the variation in dose across the block shadow and the risk of positioning errors, and wide blocks, which may unnecessarily shield potential tumor sites. For 60Co, 4- and 10-MV beams, the figure of merit peaks at block widths of 2.0-2.5 cm at the level of the cord. Effective transmission data for cord blocks constructed of cerrobend are given for those three beams. Quality assurance studies show that transmission through cerrobend blocks can be controlled to the required precision.

Epidural block: myelographic evaluation with a single-puncture technique using metrizamide.

A simplified technique using metrizamide for myelographic delineation of extrinsic spinal cord blocks is described. This method was successfully used in eight consecutive examinations without adverse effects. A single lumbar puncture is followed by instillation of metrizamide into the subarachnoid space. With the needle left in place and the patient in the Trendelenburg position, the contrast agent is sequentially displaced above any encountered extradural blocks by further injection of diluent or sterile saline into the caudal thecal sac. Thus, multiple levels of blockage may be defined at their upper and lower margins. This method offers an expedient and safe alternative to combined lumbar and C1-2 lateral cervical puncture, leaves a minimum amount of metrizamide "trapped" below a block, and has several advantages over use of iophendylate. Additionally, the examination may be supplemented with CT scanning when desirable.

Technique to match mantle and para-aortic fields

A technique is described to match the mantle and para-aortic fields used in treatment of Hodgkin's disease, when the patient is treated alternately in supine and prone position. The approach is based on referencing the field edges to a point close to the vertebral column, where uncontrolled motion is minimal and where accurate matching is particularly important. Fiducial surface points are established in the simulation process to accomplish this objective. Dose distributions have been measured to study the combined effect of divergence differences, changes in body angulation and setup errors. Even with the most careful technique, the use of small cord blocks of 50% transmission is an advisable precaution for the posterior fields.