Neurolytic Block Research Articles

Neurolytic Erector Spinae Plane Block in Advanced Abdominal Carcinoma: A Case Report on Pain Management

Pain management in patients with advanced abdominal carcinoma remains a significant challenge, particularly in settings where opioid availability is limited. This case report describes the use of a neurolytic erector spinae plane block (ESPB) in a 60-year-old female patient with recurrent periampullary carcinoma, who presented with severe, intractable abdominal pain that was inadequately controlled with a regimen of opioids and adjuvant analgesics. Despite receiving morphine, paracetamol, and pregabalin, the patient continued to experience significant pain and suffered from opioid-induced constipation. Given the complexity of her condition, a neurolytic ESPB was performed at the T12 level under ultrasound guidance. The procedure provided rapid and sustained pain relief, reducing her Numerical Rating Scale pain score from 8/10 to 1/10 within an hour postprocedure. Over the following months, the patient’s pain remained well controlled with minimal medication, allowing her to resume daily activities. This case highlights the potential of neurolytic ESPB as a valuable addition to the multimodal pain management strategies for cancer patients, offering effective pain relief with a favorable safety profile.

Pattern of Visual Analog Score Changes in Metastatic Urogenital Cancer Patients Undergoing Sympathectomy

This study aimed to evaluate the effectiveness of sympathectomy in reducing pain in patients with metastatic urogenital cancer. A single-blind randomized clinical trial involving five patients who underwent neurolytic ganglion impar block using a transcoccygeal approach, followed by radiofrequency ablation (RFA), was conducted. Five patients with metastatic urogenital cancer, averaging 58.4 ± 16.9 years old, showed a significant reduction in pain after sympathectomy. The average Visual Analog Scale (VAS) reduction was 2 points on the first day, 4 points on the third day, and 5 points on the fifth day. This pain reduction was accompanied by a decrease in the patients' dependence on opioid medication. Sympathectomy and radiofrequency ablation have proven effective in reducing pain in patients with metastatic urogenital cancer. These findings support the use of sympathectomy as part of comprehensive pain management in metastatic cancer patients, improving quality of life and reducing opioid usage. This approach offers a promising alternative for managing chronic pain in this patient population, particularly when oral therapy is insufficient.

A case series of fluoroscopy-guided neurolytic splanchnic nerve block for chronic pancreatitis pain.

Splanchnic nerve block (SPN) with local anesthetic and steroid is used to relieve the pain of chronic pancreatitis. However, it does not provide long-lasting relief. We hypothesize that the use of 70% alcohol will give adequate analgesia for more than months. The primary objective was to find out the analgesic efficacy of the use of 70% alcohol with SPN. Secondary objectives included the incidence of side effects, analgesic consumption postintervention, quality of life (QOL) assessed via a self-reported quality of life scale, and repeat block during the 1-year follow-up period. Retrospective analysis of all patients with chronic pancreatitis who received bilateral SPN over the last 4 years. SPN was performed using the posterior retrocrural approach with the patient in the prone position as described in the literature using a 23 G × 90 mm spinal needle bilaterally at the level of T12 using C-arm/fluoroscopy guidance. Data were collected from the procedure book of the pain clinic and medical records. Quantitative data for change in pre- to post-block VAS score was collected using the non-parametric Wilcoxon signed ranks test. The baseline VAS, post-procedure VAS, and VAS at 3 months follow-up was 7.69 ± 1.3,2.44 ± 0.96 and 1.56 ± 1.15. A pairwise comparison of VAS performed between baseline and immediate post-procedure, baseline, and VAS at 3 months was found to be highly significant. Fluoroscopy-guided neurolytic SPN with 70% alcohol gives significant pain relief for more than 3 months. It also leads to improvement in 3 months QOL.

Efficacy of splanchnic nerve neurolysis in the management of upper abdominal cancer pain: A systematic review and meta-analysis.

Neurolytic splanchnic nerve block (NSNB) is practised in intractable abdominal pain secondary to intra-abdominal malignancies. This review evaluated the efficacy of NSNB. PubMed, Embase, Scopus, and Cochrane databases were searched for articles published from January 2001 to October 2023. Two independent reviewers extracted the data from the included studies. The quality of randomised controlled trials (RCTs) was assessed using the revised Cochrane risk-of-bias tool (RoB 2), and the Newcastle-Ottawa scale was used for cohort studies. Fourteen articles (4 RCTs, 3 non-randomised prospective, and 7 retrospectives) were included. Ten articles were quantitatively assessed and demonstrated significant pain relief at 1 week (standardised mean difference (SMD): 3.46 [2.09, 4.83], P < 0.001, I2 = 95%), 2 weeks (SMD: 4.45 [2.61, 6.29], P < 0.001, I2 = 95%), 4 weeks (SMD: 3.35 [2.23, 4.47], P < 0.001, I2 = 97%), 8 weeks (SMD: 3.7 [2.71, 4.7], P < 0.001, I2 = 86%), 12 weeks (SMD: 4.01 [2.66, 5.36], P < 0.001, I2 = 95%), and 24 weeks (SMD: 2.54 [1.71,3.37], P < 0.001, I2 = 84%). Daily narcotic consumption and quality of life (QOL) significantly improved post neurolysis, but survival rates showed controversial results. Significant heterogeneity was reported, and sub-group analysis revealed a moderate level of variability [I2 = 47.3%] pertaining to study design as a source of heterogeneity. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Pro GDT recommendation for the primary objective was 'high' for the analysis of RCTs and 'very low' evidence quality for observational studies. Only transient minor complications were reported. NSNB appears to be an efficacious technique that provides substantial pain relief, reduces opioid consumption, and ameliorates QOL.

Alcoholization of intercostal nerves for incident pain due to rib metastases.

Rib metastases may cause incident pain on coughing, deep respiration, or on specific thoracic wall movement. Proper titration of opioid doses relieves the background pain adequately, but does not allow a good pain control for incident pain. A patient with rib metastases presented incident pain due to minimal chest wall movement, limiting breathing. Alcoholization of intercostal nerves at T6,T7, T8, and T9, at level of ribs angle, RESULTS: Intercostal blocks were highly effective in relieving incident pain due to rib metastases. A simple and safe procedure may produce effective analgesia preventing incident pain due to rib metastases. Differently from other sites of bone metastases, ribs are easily localized and the neurolytic block results to be effective and safe.

Successful neurolytic thoracic sympathetic ganglion block using C-arm fluoroscopic cone-beam computed tomography in patients with postmastectomy pain syndrome: a report of 3 cases

BackgroundPostmastectomy pain syndrome involves persistent neuropathic and sympathetically maintained neuropathic pain that can be improved using a thoracic sympathetic ganglion block. However, conventional fluoroscopic procedures pose technical difficulties and are associated with potential severe complications. We report the use of C-arm fluoroscopic cone-beam computed tomography to enhance procedural success and treatment safety.Case presentationThree women diagnosed with postmastectomy pain syndrome and experiencing persistent pain underwent C-arm fluoroscopic cone-beam computed tomography-assisted ethanol neurolytic thoracic sympathetic ganglion block. Pain severity decreased substantially after the procedure. The therapeutic effects were sustained for 12 months in cases 1 and 2 and for 5 months in case 3. All patients experienced a remarkable decrease in allodynia and hyperalgesia intensities.ConclusionC-arm fluoroscopic cone-beam computed tomography-assisted neurolytic thoracic sympathetic ganglion block offers a valuable alternative for managing otherwise intractable postmastectomy pain syndrome before considering more invasive techniques.

Erector Spinae Plane Block for Cancer Pain – A Scoping Review of Current Evidence

Cancer patients experience pain secondary to the disease process or due to treatment. Refractory cancer pain can present a clinical challenge for pain physicians, which significantly affects patients’ quality of life and increases disability. Erector spinae plane (ESP) blocks have rapidly been used in both acute and chronic pain practice. However, the use of ESP block for cancer pain management remains unclear. Thus, we conducted this scoping review to perform a comprehensive overview of current evidence on ESP block for cancer pain management. We searched the PubMed and Google Scholar databases for relevant articles published between January 2016 and March 2023 using the keywords “erector spinae plane block,” “ESP block,” and “cancer pain”. After excluding duplicate and irrelevant articles, we included a total of 26 studies, which were case reports, case series, cohort studies, and randomized control trials. Both neurolytic and non-neurolytic ESP blocks were used for cancer pain. The ESP blocks were performed in all patients with severe pain (Visual Analog Score or Numerical Rating Scale &gt;7) and the majority of cases had some degree of pain relief. None of the studies has reported any serious complications related to procedure or drug used. There was heterogeneity in the type of drug, volume, and concentration used for ESP block. A definitive conclusion regarding the efficacy and safety of ESP block in cancer pain management was not possible. The current literature suggests that the ESP block can be helpful in cancer pain management. However, caution must be exercised not to overestimate the safety of either neurolytic or non-neurolytic ESP block as 88% (n = 23) of included studies were either case reports or case series. Randomized controlled clinical trials are warranted to establish the efficacy and safety of ESP block in cancer pain management.

Long-Term Analgesic Efficacy of Neurolytic Splanchnic Nerve Block via the Transintervertebral Disc Approach to Retrocrural Space: A Multicenter Retrospective Study.

The celiac plexus block is effective for treating intractable cancer pain and has been the focus of many studies. At our affiliated institution, fluoroscopy-guided splanchnic nerve block with a single needle via the transintervertebral disc approach was the first choice of treatment. The short-term efficacy of this technique has been reported, but the long-term efficacy is not clear. In the present study, we investigated the long-term analgesic efficacy of this technique. This multicenter, retrospective, observational study reviewed the medical records of patients who underwent neurolytic splanchnic nerve block (NSNB) via the transintervertebral disc approach for intractable cancer pain at five tertiary hospitals in Japan from April 2005 to October 2020. The primary outcome was the long-term analgesic efficacy of a one-time NSNB via the transintervertebral disc approach. In total, 76 patients were included in the analysis. The median lowest numerical rating scale (NRS) score was 1 within 14days. At 1, 2, 3, and 6months after the nerve block, the median NRS score was also ≤2, while the median equivalent oral morphine dose did not show any clinically noticeable increase at those times. The long-term analgesic efficacy of NSNB via the transintervertebral disc approach in patients with intractable cancer pain has been demonstrated.

Opioid withdrawal symptoms after neurolytic splanchnic nerve block in cancer patients.

Few reports on opioid withdrawal (OW) due to opioid tapering in cancer patients have been published. The incidence of and risk factors for OW after neurolytic splanchnic nerve block (NSNB) are unknown. This study aimed to elucidate the incidence of and risk factors for OW among cancer patients who could have reduced opioid doses after NSNB. This was a multicenter, retrospective, observational study. We reviewed the medical charts of patients who underwent NSNB for intractable cancer pain at four tertiary hospitals in Yokohama City from April 2005 to October 2020. We included patients whose opioid dose was reduced by > 5mg/day (equivalent oral morphine dose) within 14days after NSNB. We classified the patients into two groups according to the presence or absence of OW symptoms and compared them. Of the 50 patients who underwent NSNB, 24 were included in the study. OW was observed in five (20.8%) patients. Pain and opioid use duration were significantly longer in OW patients than in non-OW patients (median pain duration 689 vs. 195days; P < 0.043 and median opioid use duration 486 vs. 136days; P < 0.030). The opioid tapering dose was significantly larger in patients with OW than in those without OW (median opioid tapering dose 75 vs. 40mg; P < 0.046). OW was observed in 20.8% of the patients in the study. A longer pain and opioid use duration and a larger opioid tapering dose may predispose patients to OW.

Efficacy and Safety of Neurolytic Splanchnic Nerve Block via Transintervertebral Disc Approach to Retrocrural Space: A Multicenter Retrospective Study.

Celiac plexus block is effective for treating intractable cancer pain and has been the focus of many studies. Several guiding techniques such as fluoroscopy, computed tomography, and endoscopy have been devised, and the target of the block has varied in previous studies as both the celiac plexus and splanchnic nerve, which is the main origin of the celiac plexus, have been targeted. At our affiliated institution, fluoroscopy-guided splanchnic nerve block with a single needle via transintervertebral disc approach is the first choice. However, there have been few reports on the use of this technique. This study investigated the efficacy and safety of this technique. This multicenter retrospective observational study reviewed the medical records of patients who underwent neurolytic splanchnic nerve block (NSNB) via transintervertebral disc approach for intractable cancer pain at five tertiary hospitals in Japan from April 2005 to October 2020. The primary outcome was the clinical success ratio of NSNB, and the secondary outcome was the incidence ratio of NSNB-related adverse events. In total, 103 patients were included in the analysis. Of these, 77 patients met the definition of clinical success, with a ratio of 74.8%. The incidence ratio of NSNB-related adverse events was 40.8% (hypotension, 21.4%; alcohol intoxication, 13.6%; diarrhea, 11.7%; and vascular puncture, 3.9%; duplicates were present). All adverse events improved with observation and symptomatic treatment only. No patient had infection or serious adverse events such as organ or nerve damage. The clinical success ratio of this technique was 74.8%. Although the incidence of adverse events was 40.8%, all events were mild and no serious adverse events were observed. The findings demonstrate the efficacy and safety of our NSNB in patients with intractable cancer pain.

Computed tomography guided percutaneous trans discal splanchnic nerve block for cancer pain treatment. Case report

Two cases of percutaneous transdiscal splanchnic nerve block for cancer pain treatment presented. Case 1. 50 years old man with pancreatic head and trunk cancer T4N1M0. Patients condition: intractable pain in upper abdomen during last two weeks, dysphagia, weight loss. Cholecysto-entero, gastro-entero and entero- entero anastomoses performed under epidural+general anesthesia. During 7 postoperative days pain relieved by continuous epidural anesthesia (0.2% ropivacain 5ml/hour). On postoperative day 8 epidural catheter removed due to dis lodgement. Morphine sulphate 10 mg iv injections with 4 hour intervals and cox- 2 pathway inhibitors was not sufficient for pain relief (pain score – 6-8 VAS). Splanchnic neurolysis performed on postoperative day 14. Patient laid in prone position on the computed tomography table. After marking of injection sites, definition of needles traces and deep local infiltration with 1% lidocain, two 22 gauge 20 cm Chiba needles had been inserted transdiscally on the level of T12/ L1. Pain relieved after injection of 4 ml 2% lidocaine on each side10 ml 10% aqueous phenol had been injected on each side for neurolytic block 0.1 g cefazolin injected intradiscally Patient had complete pain relief until day 5, when he felt severe continuous pain on his upper right abdomen. After two weeks of follow-up incomplete right splanchnic block diagnosed and to perform of repeated right side splanchnic neurolysis had been decided. On day 14 after 1-st neurolysis, a 3½ inch 25 gauge Quincke needle had been inserted in right retrocrural space on the level of L1. After contrast and 4ml 2% lidocaine injection, 15 ml 95% alcohol injected Pain relieved completely. No additional analgesia requirements lifetime (10 weeks). Case 2. 62 years old male with gastric cancer. Cancer recurrence after partial gastrectomy and severe intractable abdominal pain. 120 mg morphine hydrochloride daily, pain score 6-8 VAS. T12-L1 computed tomography guided transdiscal splanchnic nerve block performed in patient prone position. After marking of injection site at left side from vertebral column and deep infiltration with 1% lidocaine, a 22G 20 cm Chiba needle had been inserted. 0.1g cefazolin injected intradiscally. Intervertebral disk penetrated centrally and contrast spread was equal on both sides between aorta and L1 vertebra. Pain relieved after injection of 5 ml 2% lidocaine and 15 ml 95% alcohol. After procedure pain score – 3-4, patient was needed in 10 mg morphine hydrochloride and 150 mg lyrica daily. Computed tomography guided transdiscal splanchnic neurolysis is a safe and effective treatment tool for upper abdomen cancer pain relief. In cases of incomplete neurolysis repeated neurolytic block may be helpful.

SY28-4 Nerve block and intrathecal analgesia for intractable cancer pain

The usefulness of the WHO method of cancer pain treatment has long been demonstrated: 76% of patients with cancer pain were successfully analgesized, but 8% required nerve blocks, 3% required neurolytic block, and 3% required intrathecal analgesia.

PALLIATIVE TREATMENT OF INTRACTABLE CANCER PAIN.

In 10% to 30% cancer-pain cases standard analgesic therapy fails to provide effective pain relief. Interventional techniques, such as peripheral nerve blocks, neuraxial analgesia along with neurolytic blocks may be used for such refractory pain. Peripheral nerve blocks can be used when pain occurs in the territory of one or more peripheral nerves, but rarely as main therapy. Neuraxial analgesia is a valid option for progressive cancer pain, and healthcare possibilities and costs call into question the utility of intrathecal infusion pumps. Neurolysis is the targeted destruction of a nerve or nerve plexus, using chemicals, radiofrequency ablation (RFA), cryoablation, and neurosurgical procedures; however, it rarely completely eliminates pain because patients frequently experience coexisting somatic and neuropathic pain as well. Complex conditions of palliative patients along with limited high-quality randomized controlled trials limit the use of interventional procedures. Even so, some cancer patients benefit from interventional procedures to achieve pain alleviation and consequently improve quality of life.

This Month in Anesthesiology

This Month in Anesthesiology

Neurolytic Splanchnic Nerve Block and Pain Relief, Survival, and Quality of Life in Unresectable Pancreatic Cancer: A Randomized Controlled Trial

Neurolytic splanchnic nerve block is used to manage pancreatic cancer pain. However, its impact on survival and quality of life remains controversial. The authors' primary hypothesis was that pain relief would be better with a nerve block. Secondarily, they hypothesized that analgesic use, survival, and quality of life might be affected. This randomized, double-blind, parallel-armed trial was conducted in five Chinese centers. Eligible patients suffering from moderate to severe pain conditions were randomly assigned to receive splanchnic nerve block with either absolute alcohol (neurolysis) or normal saline (control). The primary outcome was pain relief measured on a visual analogue scale. Opioid consumption, survival, quality of life, and adverse effects were also documented. Analgesics were managed using a protocol common to all centers. Patients were followed up for 8 months or until death. Ninety-six patients (48 for each group) were included in the analysis. Pain relief with neurolysis was greater for the first 3 months (largest at the first month; mean difference, 0.7 [95% CI, 0.3 to 1.0]; adjusted P < 0.001) compared with placebo injection. Opioid consumption with neurolysis was lower for the first 5 months (largest at the first month; mean difference, 95.8 [95% CI, 67.4 to 124.1]; adjusted P < 0.001) compared with placebo injection. There was a significant difference in survival (hazard ratio, 1.56 [95% CI, 1.03 to 2.35]; P = 0.036) between groups. A significant reduction in survival in neurolysis was found for stage IV patients (hazard ratio, 1.94 [95% CI, 1.29 to 2.93]; P = 0.001), but not for stage III patients (hazard ratio, 1.08 [95% CI, 0.59 to 1.97]; P = 0.809). No differences in quality of life were observed. Neurolytic splanchnic nerve block appears to be an effective option for controlling pain and reducing opioid requirements in patients with unresectable pancreatic cancer.

A comparative study of transdiscal versus transaortic celiac plexus neurolytic block for upper gastrointestinal cancer patients. A prospective, randomized control study

Aim: To compare transdiscal and transaortic techniques of neurolytic celiac plexus block for upper gastrointestinal cancer patients. Methods: In this prospective randomized study 60 patients with upper gastrointestinal malignancies were included and randomly divided into two groups, group TD and group TA, receiving neurolytic celiac plexus blocks via transdiscal and transaortic techniques, respectively. The primary outcome was quality of life (QoL) as assessed by WHOQOL BREF questionnaire and secondary outcomes were pain relief using visual analogue scale (VAS), and occurrence of complications like hypotension, loose motion, bleeding and discitis. Result: QoL and VAS score were significantly improved in both groups post procedure. Transdiscal approach is more effective in improving VAS score than transaortic approach (1 vs 3) after 1 week and the relief of pain was better in TD group (3 vs 6) at the end of 2 months. Transdiscal approach was found to be more effective in improving QoL (227.00±28.85 vs 191.17±35.78) as compared to transaortic approach. However, post-procedural QoL improved in both groups when compared to pre-procedural QoL (p&lt;0.05). Hypotension, diarrhea and bleeding from aorta were higher in TA group; however, no serious complications were seen in any of the groups. Conclusion: Transdiscal technique is better in terms of adequate pain relief and improving QoL as compared to transaortic technique of NCPB in patients of upper GI malignancies and is associated with lesser incidences of complications.

Reply to: Tips for pericapsular nerve group (PENG) neurolytic blocks.

Reply to: Tips for pericapsular nerve group (PENG) neurolytic blocks.

Management of Intractable Symptoms in Oncologic Care.

For patients undergoing evaluation and treatment of cancers, symptom management is a critical component of their treatment plan. For some patients, symptoms may become intractable or refractory to common therapies. Here, we review treatment options for these severe symptom conditions. Medication options and regimens have improved to treat refractory symptoms. Medications can be tailored to treat chemotherapy-induced nausea and vomiting based on current guidelines. Interventions such as venting gastrostomy can mitigate symptoms associated with malignant bowel obstruction, when life expectancy is long enough to realize this benefit. Opiates can reduce refractory dyspnea, consistent with guidelines from the American Thoracic Society. Interventional therapies for intractable pain, such as neurolytic blocks and intrathecal pumps, have shown promise in managing symptoms when traditional therapies have been ineffective. Refractory symptoms can be managed in cancer care. The use of multimodal therapies delivered by interdisciplinary teams appears to be the most effective way to approach these clinical situations.

The Role of Double Modality Ultrasonographic and Fluoroscopic Guided Superior Hypogastric Plexus Neurolysis in Treating Intractable Pelvic Cancer Pain: A Comparative Study

BackgroundSuperior hypogastric neurolytic block is performed to block visceral pelvic pain. This could be performed through the anterior approach guided by CT or ultrasound and through a posterior approach, guided by fluoroscopy or CT.MethodsSixty adult patients with severe visceral pelvic pain (VAS>70 mm) were randomly divided into two groups. Group S: SHP block was done ultrasound guided using the anterior approach and confirmed by fluoroscopy. Group F: SHP block was done fluoroscopic guided using the posterior oblique approach. The VAS (visual analog scale), duration of the technique, time of X-ray exposure, patient satisfaction score, patient global impression of change (PGIC), quality of life score, and daily morphine consumption (mg/day) were measured pre-procedure and at the 1st, 4th, 8th, and 12th week after the procedure. In addition, any side effects of the procedure were recorded.ResultsThere was a significant difference in VAS between the two groups (P<0.01) (better in group S). The quality of life score was improved from the pre-procedure in both groups (P<0.05), and morphine consumption was significantly lower in group S than in group F (P<0.05) at the 1st, 4th, and 8th week and not significant at the 12th week. The two groups show a statistically significant difference as regards the duration of the procedure and X-ray exposure (P<0.01). There was a statistically significant difference in the satisfactory score between the two groups at the 1st, 4th, 8th, and 12th week (P<0.01). As regards the PGIC score, there was no statistically significant difference between the two groups (P>0.05). In group S, no back pain was reported, while 11 patients of group F complained from post-procedure back pain (P<0.001).ConclusionThe anterior ultrasound guided SHPB aided by fluoroscopy is suggested to be more superior to the standard fluoroscopic guided technique in relieving pelvic cancer pain and decreasing morphine consumption.

Successful intrathecal neurolytic block for the management of cancer pain in a 10-year-old child: a case report

BackgroundCancer pain management in children is challenging owing to their unique patient characteristics. We present the case of a 10-year-old girl whose cancer pain was successfully managed using an intrathecal neurolytic block.Case presentationThe patient experienced severe cancer pain due to recurrent right ilium osteosarcoma. The tumor progressed rapidly despite chemoradiotherapy and gradually invaded the right lumbar plexus, which resulted in severe neuropathic pain in the right lower extremity. Systemic analgesics failed to attenuate the pain. We performed an intrathecal neurolytic block using 10% phenol-glycerol. The neurolytic block completely relieved her right lower extremity pain. After the block, the patient’s quality of life improved, and she spent her time with family.ConclusionsThe intrathecal neurolytic block successfully relieved the patient’s cancer pain. Successful intrathecal neurolytic blocks require meticulous pain assessment of individual patients, to avoid possible serious complications such as paresis/paralysis and bladder/bowel dysfunction.