Percutaneous Neurolysis Research Articles

Efficacy and Safety of Celiac Plexus Neurolysis in the Treatment of Chronic Pain Secondary to Oncological Pathology of the Upper Hemiabdomen: A Systematic Review and Meta-Analysis.

The management of chronic pain among patients with abdominal cancer is complex; against that, the neurolysis of the celiac plexus (CPN) is the best technique at the moment to determine the efficacy and safety in the treatment of chronic pain secondary to oncological pathology of the upper abdomen. This was a systematic review of controlled clinical trials between 2000 and 2021, in the sources MEDLINE/PubMed, Cochrane, Scopus, Web of Science, and Google Scholar. Three independent evaluators analysed the results of the bibliographical research. The quality of the studies was assessed with the Jadad scale and the mean difference (95% confidence interval) and heterogeneity of the studies (I2) were calculated with Review Manager 5.3. Seven hundred and forty-four publications were identified, including 13 studies in the qualitative synthesis and three studies in the quantitative synthesis. No difference was found in the decrease in pain intensity between 1 and 12 weeks after the intervention, comparing the experimental group with the control (P > 0.05). The adverse effects related to neurolysis were not serious and transitory, mentioning the most frequent adverse effects and reporting a percentage between 21% and 67% (with 17% for echoendoscopic neurolysis and 49% for percutaneous neurolysis). Celiac plexus neurolysis for the treatment of severe chronic pain secondary to oncological pathology in the upper hemiabdomen produces similar pain relief as conventional pharmacological analgesic treatment. It is a safe analgesic technique since the complications are mild and transitory.

The role of percutaneous neurolysis in lumbar disc herniation: systematic review and meta-analysis.

BackgroundRecalcitrant disc herniation may result in chronic lumbar radiculopathy or sciatica. Fluoroscopically directed epidural injections and other conservative modalities may provide inadequate improvement in some patients. In these cases, percutaneous neurolysis with targeted delivery of medications is often the next step in pain management.MethodsAn evidence-based system of methodologic assessment, namely, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used. Multiple databases were searched from 1966 to January 2021. Principles of the best evidence synthesis were incorporated into qualitative evidence synthesis. The primary outcome measure was the proportion of patients with significant pain relief and functional improvement (≥ 50%). Duration of relief was categorized as short-term (< 6 months) and long-term (≥ 6 months).ResultsThis assessment identified one high-quality randomized controlled trial (RCT) and 5 moderate-quality non-randomized studies with an application of percutaneous neurolysis in disc herniation. Overall, the results were positive, with level II evidence.ConclusionsBased on the present systematic review, with one RCT and 5 non-randomized studies, the evidence level is II for percutaneous neurolysis in managing lumbar disc herniation.

Computed Tomography-Guided Percutaneous Radiofrequency Ablation of the Splanchnic Nerves as a Single Treatment for Pain Reduction in Patients with Pancreatic Cancer.

The aim of this paper is to prospectively evaluate the efficacy and safety of percutaneous computed tomography (CT)-guided radiofrequency (RF) neurolysis of splanchnic nerves as a single treatment for pain reduction in patients with pancreatic cancer. Patients with pancreatic ductal adenocarcinoma suffering from abdominal pain refractory to conservative medication who underwent CT-guided neurolysis of splanchnic nerves by means of continuous radiofrequency were prospectively evaluated for pain and analgesics reduction as well as for survival. In all patients, percutaneous neurolysis was performed with a bilateral retrocrural paravertebral approach at T12 level using a 20 Gauge RF blunt curved cannula with a 1cm active tip electrode. Self-reported pain scores were assessed before and at the last follow-up using a pain inventory with numeric visual scale (NVS) units. The mean patient age was 65.4 ± 10.8 years (male-female: 19-11). The mean pain score prior to RF neurolysis of splanchnic nerves was 9.0 NVS units; this score was reduced to 2.9, 3.1, 3.6, 3.8, and 3.9 NVS units at 1 week, 1, 3, 6, and 12 months respectively (p < 0.001). Significantly reduced analgesic usage was reported in 28/30 patients. Two grade I complications were reported according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system. According to the results of the present study, solely performed computed tomography-guided radiofrequency neurolysis of splanchnic nerves can be considered a safe and efficacious single-session technique for pain palliation in patients with pancreatic ductal adenocarcinoma suffering from abdominal pain refractory to conservative medication. Although effective in pain reduction the technique seems to have no effect upon survival improvement.

Ultrasound Guided Percutaneous Neurolysis for Sciatic Nerve Tethering Post Mid-Hamstring Tendon Repair

Ultrasound Guided Percutaneous Neurolysis for Sciatic Nerve Tethering Post Mid-Hamstring Tendon Repair

Interventional oncologic procedures for pain palliation

Cancer patients quite commonly will report different types of pain associated with the disease substrate. Systemic analgesia and radiotherapy provide only partial pain relief in the majority of these patients. Interventional Oncology techniques for pain management and mobility improvement in cancer patients include percutaneous techniques such as neurolysis, ablation and augmentation (both in the spine and peripheral skeleton) as well as trans-arterial embolization. Percutaneous neurolysis acts indirectly providing regional anesthesia whilst the rest of the aforementioned techniques act directly upon the tumor either by inhibiting local growth or by providing stability and skeletal augmentation. Whenever possible, techniques such as ablation and trans-arterial embolization apart from pure palliation may add to the principle of local tumor control. The aim of this review is to provide details concerning the Interventional Oncology techniques used for cancer pain management and to address the necessity for a tailored-based approach applying different techniques or combinations of them in different cases and locations.

Percutaneous Neurolysis for Pain Management in Oncological Patients.

Cancer pain is most commonly classified as nociceptive (somatic or visceral) or neuropathic. Different types of pain or pain syndromes are present in all phases of cancer (early and metastatic) and are inadequately treated in 56% to 82.3% of patients. Percutaneous neurolysis and neuromodulation are feasible and reproducible, efficient (70-80% success rate) and safe (≈ 0.5% mean complication rate) palliative therapies for pain reduction in oncologic patients with refractory pain. Percutaneous neurolysis can be performed either by injection of a chemical agent (phenol or alcohol) or by application of continuous radiofrequency or cryoablation. During chemical neurolysis nerve damage is achieved by means of Wallerian degeneration. A thorough knowledge of neural anatomy and pain transmission pathways is fundamental to appropriate patient and technique selection. Imaging guidance and strict asepsis are prerequisites. The purpose of this article is to describe the basic concepts of percutaneous neurolysis in oncologic patients. Controversies concerning techniques and products will be addressed. Finally, the necessity for an individually tailored approach for the selection of the different techniques and targets will be emphasized.

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.

Effects of neural therapy on quality of live in patients with inoperable lower extremity artery disease

Our aim was to evaluate the effects of percutaneous neurolysis of lumbal sympathetic ganglions on pain and the resulting changes in quality of life with validated objective and subjective methods. To follow the adverse effects and complications of the procedure. A prospective, non-randomized, interventional, clinical cohort study under real life conditons was conducted. The time of the observation was 6 months. Palliative neural therapy was performed to reduce the ischemic pain of the affected leg of the patients involved in the study. Prior to treatment and after 35 days, Visual Analogue Scale (VAS) was used to measure the intensity of lower limb pain. The related changes in the quality of life were followed by a general 36-Item Short-Form Health Survey (SF-36) questionnaire. We measured the changes of the patients' skin temperature and ankle/arm index. The post-treatment results were compared to the pre-treatment results. We compared the results of objective and subjective measures. We followed the side effects and complications of the pain therapy. Each of the examined subjects had obliterative (Fontaine II/b stage) arterial disease of the lower limbs, in which no revascularization intervention was feasible and their ischemic pain was of VAS≥7. Data of 124 patients (69 male, 55 female) could be evaluated. The decrease in intensity of limb pain in the post-treatment period was significant (p=0.001). Quality of life also indicated a significant improvement (p=0.004). Changes in skin temperature and ankle/arm index demonstrated significant improvement (p≤0.005): skin temperature increased from 27.6°C to 31.2°C, the ankle/arm index inceased from 0.67 to 0.83 on average. Changes in objective and subjective measures correlated with each other. No worthening of symptoms, serious adverse events or complications were observed. The chemical denervation of the lumbar sympathetic ganglions with percutaneous application is a minimally invasive intervention, useful in outpatient care, which can be well tolerated by the patient without any significant side effect or complication. Its hyperaemic effect and the pain reduction of the leg can improve the quality of life of the patients.

Pain management: The rising role of interventional oncology.

Patients with early or metastatic cancer may suffer from pain of different origins. The vast majority of these patients are not adequately treated by means of systemic analgesia and radiotherapy. Percutaneous neurolysis is performed using chemical agents or thermal energy upon sympathetic nervous system plexus for pain reduction and life quality improvement. Ablation and vertebral augmentation are included in clinical guidelines for metastatic disease. As far as the peripheral skeleton is concerned bone augmentation and stabilization can be performed by means of cement injection either solely performed or in combination to cannulated screws or other metallic or peek implants. This review describes the basic concepts of interventional oncology techniques as therapies for cancer pain management. The necessity for a tailored-based approach applying different techniques for different cases and locations will be addressed.

Abstract No. 458 - Patency of balloon angioplasty or stent placement for treating venous stenosis in pediatric liver transplant recipients

No. 459 Percutaneous, computed tomography guided neurolysis with continuous or pulsed radiofrequency as palliative therapy for pain reduction in oncologic patients D. Filippiadis, A. Mazioti, M. Tsitskari, K. Malagari, N. Kelekis, A. Kelekis; University General Hospital “ATTIKON,” Marousi/Athens, Greece; University General Hospital “ATTIKON,” Athens, IL; American Medical Center, Nicosia, MD; Athens 15669, Greece; University of Athens, Athens, Greece Purpose: The purpose of our study is to evaluate efficacy and safety of percutaneous computed tomography guided neurolysis with continuous or pulsed radiofrequency as palliative therapy for pain reduction in oncologic patients Materials: During the last 12 months, 18 patients (6 male / 12 female)were referred to our department for percutaneous computed tomography guided neurolysis with continuous or pulsed radiofrequency as palliative therapy for pain reduction. Malignant substrate included pancreatic carcinoma (n1⁄46), pancoast tumor (n1⁄42), renal cell carcinoma (n1⁄42), lymphoma (n1⁄42), endometrial carcinoma (n1⁄42), colon carcinoma (n1⁄42) and ovarian carcinoma (n1⁄42). Patients underwent neurolysis by means of radiofrequency (Diros Technology In, Ontario Canada) in celiac and splachnic plexus (n1⁄46), in thoracic plexus (n1⁄42), in lumbar plexus (n1⁄42), in superior hypogastric plexus (n1⁄46) and in stellate ganglion (n1⁄42). Pain prior, one week after and at the last follow-up (average follow-up 6 months) were compared by means of a numeric visual scale (NVS) questionnaire. Results: Median procedure time was 44 min. Median amount CT scans, performed to control correct positioning of the cannula and precise electrode placement was 8. Comparing the pain scores of questionnaires prior (mean value 9.50 NVS units, range 8-10 NVS units) and post (mean value 3.27 NVS units range 2-6 NVS units) treatment, there was a mean decrease of 6.23 NVS units on terms of pain reduction and life quality improvement. Overall mobility improved in 18/18 (100%) patients. No complication was observed. Conclusions: Radiofrequency ablation (pulsed or continuous) for percutaneous neurolysis under CT guidance is a safe and efficient technique for the pain palliation in oncologic patients. Thorough knowledge of nervous anatomy and pain transmission pathways is fundamental for proper patient and technique selection.

Percutaneous Neurolysis with Continuous Radiofrequency Energy for the Treatment of Symptomatic Sacroiliac Joints: Study of Clinical Safety and Efficacy

Purpose: To prove safety and efficacy of percutaneous neurolysis with continuous radiofrequency energy for the treatment of symptomatic sacroiliac joints in a series of consecutive patients. Materials and methods: During the last 2 years, 15 patients suffering from low back pain due to degenerative disorder of the sacroiliac joint underwent percutaneous neurolysis with continuous radiofrequency energy. Under extended local sterility and fluoroscopy 4 cannulas were placed along the sacral foramina and at the L5- S1 level and neurolysis session was performed post motor and sensory evaluation test. NVS pain scores prior and post therapy were compared using Paired Samples t-Test and Wilcoxon Signed Rank Test. Results: Mean pain score prior to any therapy was 8.05±1.449 NVS units. Mean pain score post therapy was 2.37 ± 2.715, 2.42 ± 2.754, 2.70 ± 2.928 and 3.55 ± 2.837 NVS units at 1, 6, 12, 24 months. The comparison of the patients’ selfreported outcomes concerning pain reduction and mobility improvement prior and post therapy is statistically significant (p<0.001). No complication was noted. Conclusion: Percutaneous neurolysis with continuous radiofrequency energy seems to be a safe and efficient technique for the treatment of symptomatic, sacro-illiac joints resulting in significant pain reduction and mobility improvement. Proper patient selection is a prerequisite for high success rate.

Percutaneous Epidural Lysis of Adhesions in Chronic Lumbar Radicular Pain: A Randomized, Double-Blind, Placebo-Controlled Trial

Background: Chronic radicular pain can occur after disc pathology and failed back surgery. An evidence-based effective therapeutic option is not available nor does a gold standard exist. Objectives: A randomized controlled trial to analyze the clinical efficacy of percutaneous epidural lysis of adhesions in chronic radicular pain. Study Design: Prospective randomized placebo controlled interventional trial. Power calculation based on a feasibility trial. Setting: Medical university centers. Methods: Within 4 years a total of 381 patients with chronic radicular pain lasting longer than 4 months which failed to respond to conservative treatments were screened and 90 patients were enrolled. They were randomly assigned to receive either percutaneous neurolysis or placebo with concealed allocation in permuted blocks of 4 to 8, stratified by treatment center. The primary outcome measure was the differences in percent change of Oswestry Disability Index (ODI) scores 3 months after intervention. Secondary outcome measures were difference in percent change of ODI scores and Visual Analog Scale (VAS) 6 and 12 months after intervention and success rates defined as at least 50% reduction in ODI scores and VAS scores (mean change from baseline) at 3, 6, and 12 months after treatment. Explorative, 2-sided group comparisons for baseline characteristics between active treatment and controls were done using the t-test for 2 independent samples for quantitative data and Fisher’s exact test for binary data. Results: The ODI and VAS scores as well as the success rates for ODI vs VAS were significantly better 3, 6, and 12 months in the lysis group vs the control group. The ODI in the lysis group improved from 55.3 ± 11.6 to 26.4 ± 10.8 after 3 months. The placebo group improved from 55.4 ± 11.5 to 41.8 ± 14.6 (P &lt; 0.01). VAS improved from 6.7 ± 1.1 to 2.9 ± 1.9 in the active group and from 6.7 ± 1.1 to 4.8 ± 2.2 (P &lt; 0.01) after placebo. Twelve month follow-up shows further improvement, the differences remain significant. In multiple linear regression, forward and backward variable selection methods resulted in the same covariate model confirming the univariate result for group comparison in the primary analysis. No severe side effects occurred but minor transient neurological effects such as partial sensomotoric deficits did. One dura puncture and one catheter displacement were found. Limitations: Specific effects of single treatment components cannot be specified because there was no imaging examination after treatment. Conclusion: Based on the findings of our study as well as other studies, we believe the minimally invasive percutaneous adhesiolysis procedure should be the first choice treatment option for patients with chronic lumbosacral radicular pain who present with clinical history and findings similar to those of the patients enrolled in our study. Key words: Lysis, low back pain, randomized controlled trial (RCT), placebo, epidural, radiculopathy, outcome, evidence-based medicine

Musculoskeletal Pain as a Novel Complication After Posterior Tibial Nerve Block in Stroke and Traumatic Brain Injury Patients

Percutaneous neurolysis of the posterior tibial nerve is a known treatment for spasticity that causes equinovarus deformity. Although dysesthesia is a known complication of phenol nerve blocks, this case series describes 3 cases of musculoskeletal foot pain that developed as a novel complication of posterior tibial nerve blocks and was successfully treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and foot arch enhancement of the patients’ ankle-foot orthosis (AFO).

Neurolysis for Pancreatic Cancer Pain: Same Song, Different Verse?

Since Kappis first performed percutaneous neurolysis in 1914, investigators have employed innumerable technical variations in an effort to enhance the efficacy. Similar efforts have been underway by endosonographers since Wiersema performed the first endoscopic ultrasound (EUS)-guided celiac plexus neurolysis in 1996. Although such efforts are important, the availability of multiple procedural options is indicative of the controversy and lack of meaningful progress. If one particular method was clearly superior, the other techniques would have become obsolete. Sakamoto et al. present a new method of EUS-guided neurolysis in an attempt to improve the outcomes. Although their data are promising, we eagerly await rigorously designed studies that may validate their findings.

Dangers anatomiques de la section percutanée du ligament inter-métatarsien dans le traitement du névrome de Morton

Certain authors have proposed percutaneous neurolysis of Morton's neuroma. We conducted a human anatomy study to assess the reliability and the iatrogenic effect of percutaneous section of the ligament. Percutaneous section of the inter-metatarsal ligament was performed on 16 fresh cadaver specimens via a dorsal approach. The plantar dissection demonstrated that the section was not complete, without associated lesion, in only six cases. Analyzing these failures, we determined the necessary procedure for correct section.

Radiofréquence bipolaire et cimentoplastie dans le traitement des métastases osseuses

Bone metastases are the most common cause of pain in cancer patients. Pain management in cancer patients, often revealing the disease and always present at advanced stages, is an important and difficult task. Pain is not always properly controlled by high doses of specific medication, radiation therapy or chemotherapy. When these therapies do not provide adequate pain relief, percutaneous neurolysis, infiltrations, alcoholizations and cementoplasty may be considered. More recently RF ablation has been proposed. On weight-bearing bones, RF can be combined with acrylic cement injection. The authors present here this very effective new technique which is complementary to classical pain management techniques.

CT-guided neurolysis. Status of the technique and current results

Both thoracic and lumbar sympathectomy and celiac ganglion block could be established as effective methods; side effects are rarely reported. Only the high accuracy of CT-guided positioning can make this possible. Severe side effects are merely sporadic if the proper technique is applied. We used 21G or 22G fine needles. All CT-guided percutaneous neurolysis methods require a proper blood coagulation. Most common CT scanners are suitable for neurolysis if there is enough room for maintaining sterile conditions. All neurolysis methods involve sterile puncture of the ganglia under local anesthesia, a test block with anesthetic and contrast agent to assess the clinical effect and the definitive block with a mixture of 96% ethanol and local anesthetic. This allows us to correct the position of the needle if we see improper distribution of the test block or unwanted side effects. Though inflammatory complications of the peritoneum due to puncture are rarely seen, we prefer the dorsal approach whenever possible. Seven of 20 legs showed at least transient clinical improvement after CT-guided lumbar sympathectomies; 13 legs had to be amputated. Results of the methods in the literature differ. For lumbar sympathectomy, improved perfusion is reported in 39-89%, depending on the pre-selection of the patient group. It was recently proved that sympathectomy not only improves perfusion of the skin but also of the muscle. The hypothesis of a steal effect after sympathectomy towards skin perfusion was disproved. Modern aggressive surgical and interventional treatment often leaves patients to sympathectomy whose reserves of collateralization are nearly exhausted. We presume this is the reason for the different results we found in our patient group. For thoracic sympathectomy the clinical treatment depends very much on the indications. Whereas palmar hyperhidrosis offers nearly 100% success, only 60-70% of patients with disturbance of perfusion have benefited. Results in celiac ganglia block also differ. Patients with carcinoma of the pancreas and other organs of the upper abdomen benefit in 80-100% of all cases, patients with chronic pancreatitis in 60-80%.

Percutaneous neurolysis of the celiac plexus via the anterior approach with sonographic guidance.

The purpose of this study was to evaluate the usefulness of sonographically guided percutaneous neurolysis of the celiac plexus in patients with abdominal tumors or chronic pancreatitis in whom systemic analgesics were ineffective. Neurolysis of the celiac plexus was performed in 38 patients, 34 with neoplastic disease and four with chronic pancreatitis. Under sonographic guidance, a 22-gauge needle was advanced by the anterior route to the area above the celiac plexus, and 30-40 ml of 50% alcohol was injected. Pain relief was assessed 1 week, 6 months, and 1 year after the procedure. Patients subjectively rated the pain after treatment as totally relieved, partially relieved, or unchanged. At 1 week and at 6 months after treatment, pain was totally relieved in 61% of patients, partially relieved in 31%, and unchanged in 8%. After 1 year, pain was totally relieved in 39%, partially relieved in 52%, and unchanged in 9%. The complications observed were five cases of mild diarrhea and one case of retroperitoneal pain, which subsided with conservative treatment. The anterior, sonographically guided approach appears to be as successful as other percutaneous techniques for neurolysis of the celiac plexus.

Trigeminal Neuralgia

The treatment of trigeminal neuralgia (TN), which is resistant to medical therapy, has benefited from many surgical techniques. It is not possible, in light of the present level of knowledge, to establish exactly which method is the most suitable. It does, however, seem significant that certain side effects appear, in varying percentages, in all kinds of operations. In 13 years, 2,094 patients suffering from TN have been treated by the authors with percutaneous Gasserian neurolysis, 128 patients with radiofrequency trigeminal neurolysis, and 1,966 with selective ethanolic trigeminal neurolysis (SETN). Our experience treating TN with controlled increments of ethanol by means of a needle introduced through the oval foramen in the Gasserian ganglion is related here. The tip of the needle is accurately placed among the roots desired under fluoroscopic control. The clinical effects on the conscious patient of a prognostic block with local anesthetics are evaluated before producing the neurolysis. Follow-up has been long enough to show that SETN is a highly selective procedure, which shouldn't be underrated in the centers that use it routinely.