CT-guided neurolysis for cancer-related abdominal and pelvic pain

doi:10.1017/CBO9781107338555.030

30 - CT-guided neurolysis for cancer-related abdominal and pelvic pain

from Section X - Specialized interventional techniques in cancer care

Published online by Cambridge University Press: 05 September 2016

Ashraf Thabet

Edited by

Jean-Francois H. Geschwind and

Michael C. Soulen

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Ashraf Thabet: Affiliation:
Department of Radiology
Jean-Francois H. Geschwind: Affiliation:
Yale University School of Medicine, Connecticut
Michael C. Soulen: Affiliation:
Department of Radiology, University of Pennsylvania Hospital, Philadelphia

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Summary

Introduction

Cancer-related abdominal and pelvic pain is unfortunately common. For instance, up to 70–80% of patients with pancreatic cancer suffer from substantial pain. The treatment of cancer-related pain is challenging, with systemic analgesic therapy being, in general, the first-line treatment.

Unfortunately, for up to one-third of patients with pancreatic cancer, pain is not well controlled by such analgesics. Compounding this challenge is the side-effect profile of opiates – including nausea, vomiting, constipation, and sedation – that can paradoxically degrade quality of life. Managing cancer-related pain refractory to such analgesic therapy requires additional strategies that demand a multidisciplinary approach, including surgery, radiation oncology, pain medicine, and interventional radiology.

Image-guided neurolysis represents an important strategy in battling cancer-related abdominal and pelvic pain. Celiac plexus neurolysis (CPN) is the most common type and can be a very effective adjunctive therapy; it may have a lasting effect in 70–90% of patients with pain related to abdominal malignancy. The keys to treatment success with image-guided neurolysis are to: (1) review cross-sectional imaging, usually computed tomography (CT); (2) understand the relevant anatomy; (3) inject sufficient volume of neurolytic agent; and (4) ensure adequate spread of neurolytic agent.

Although the terms have been used interchangeably, a neurolysis procedure should be distinguished from a “block.” Neurolysis refers to permanent disruption of neural pathways that mediate pain, usually with agents such as ethanol or phenol, whereas a block refers to temporary disruption with local anesthetics or steroids. Neurolytic effects, however, may last no more than 3–6 months due to neural regeneration and tumor growth.

Ethanol at a 95–100% concentration is a commonly used neurolytic agent. One disadvantage is transient pain experienced during instillation; lidocaine or bupivacaine may be instilled first or mixed with ethanol to reduce intraprocedural pain. Alternatively, phenol may be used as a neurolytic agent. It has a local anesthetic effect and so intraprocedural pain is less common. However, it is a less potent neurolytic and is more viscous than ethanol, which limits mixing with contrast material. As such, ethanol is the more commonly used agent.

Various modalities for imaging guidance have been described, including fluoroscopy, CT, and endoscopic ultrasound. CPN may be performed using CT guidance or CT fluoroscopy given the excellent delineation of anatomic structures as well as spread of contrast agent afforded by CT at the time of neurolysis.

Type: Chapter
Information: Interventional Oncology
Principles and Practice of Image-Guided Cancer Therapy
, pp. 315 - 322

DOI: https://doi.org/10.1017/CBO9781107338555.030 [Opens in a new window]

Publisher: Cambridge University Press

Print publication year: 2016

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References

1. Kambadakone, A, Thabet, A, Gervais, DA, Mueller, PR, Arellano, RS. CT-guided celiac plexus neurolysis: a review of anatomy, indications, technique, and tips for successful treatment. Radiographics 2011; 31: 1599–1621.Google Scholar

2. Oliveira, R de, Reis, MP dos, Prado, WA. The effects of early or late neurolytic sympathetic plexus block on the management of abdominal or pelvic cancer pain. Pain 2004: 110: 400–408.Google Scholar

3. Staats, PS, Hekmat, H, Sauter, P, Lillemoe, K. The effects of alcohol celiac plexus block, pain, and mood on longevity in patients with unresectable pancreatic cancer: a double-blind, randomized, placebo-controlled study. Pain Med 2001; 2: 28–34.Google Scholar

4. Wong, GY, Schroeder, DR, Carns, PE, et al. Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer: a randomized controlled trial. JAMA 2004; 291: 1092–1099.Google Scholar

5. Wyse, JM, Chen, Y-I, Sahai, AV. Celiac plexus neurolysis in the management of unresectable pancreatic cancer: when and how? World J Gastroenterol 2014; 20: 2186–2192.Google Scholar

6. Yan, BM, Myers, RP. Neurolytic celiac plexus block for pain control in unresectable pancreatic cancer. Am J Gastroenterol 2007; 102: 430–438.Google Scholar

7. Miguel, R. Interventional treatment of cancer pain: the fourth step in the World Health Organization analgesic ladder? Cancer Control 2000; 7: 1490156.Google Scholar

8. Shulman, M, Harris, JE, Lubenow, TR, Nath, HA, Ivankovich, AD. Comparison of epidural butamben to celiac plexus neurolytic block for the treatment of pain of pancreatic cancer. Clin J Pain 2000; 16: 304–309.Google Scholar

9. Arcidiacono, PG, Calori, G, Carrara, S, McNicol, ED, Testoni, PA. Celiac plexus block for pancreatic cancer pain in adults. Cochrane Database Syst Rev 2011; 16: CD007519.Google Scholar

10. Tam, A, Ahrar, K. Palliative interventions for pain in cancer patients. Semin Intervent Radiol 2007; 24: 419–429.Google Scholar

11. Rathmell, JP. Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medicine. 2nd edn. Philadelphia, PA: Lippincott Williams and Wilkins, 2012.

12. Eisenberg, E, Carr, DB, Chalmers, TC. Neurolytic celiac plexus block for treatment of cancer pain: a meta-analysis. Anesth Analg 1995; 80: 290–295.Google Scholar

13. Penman, D. Celiac plexus neurolysis. Best Pract Res Clin Gastroenterol 2009; 23: 761–766.Google Scholar

14. Noble, M, Gress, FG. Techniques and results of neurolysis for chronic pancreatitis and pancreatic cancer. Curr Gastroenterol Rep 2006; 8: 99–103.Google Scholar

15. Soweid, AM, Azar, C. Endoscopic ultrasound-guided celiac plexus neurolysis. World J Gastroenterol Endosc 2010; 2: 228–231.Google Scholar

16. Mercadante, S,Nicosia, F. Celiac plexus block: a reappraisal. Reg Anesth Pain Med 1998; 23: 37–48.Google Scholar

17. Wang, PJ, Shang, MY, Qian, Z, et al. CT-guided percutaneous neurolytic celiac plexus block technique. Abdom Imaging 2006; 31: 710–718.Google Scholar

18. Titton, RL, Lucey, BC, Gervais, DA, Boland, GW, Mueller, PR. Celiac plexus block: a palliative tool underutilized by radiologists. Am J Roentgenol 2002; 179: 633–636.Google Scholar

19. Erdek, MA, Halpert, DE, Gonzalez-Fernandez, M, Cohen, SP. Assessment of celiac plexus block and neurolysis outcomes and technique in the management of refractory visceral cancer pain. Pain Med 2010; 11: 92–100.Google Scholar

20. Loukas, M, Klaassen, Z, Merbs, W, et al. A review of the thoracic splanchnic nerves and celiac ganglia. Clin Anat 2010; 23: 512–522.Google Scholar

21. Bonica, JJ. The role of the anaesthetist in the management of intractable pain. Proc R Soc Med 1954; 47: 1029–1032.Google Scholar

22. Erdine, S. Celiac ganglion block. Agri 2005; 17: 14–22.Google Scholar

23. Cicco, M de, Matovic, M, Fracasso, A, et al. Single-needle celiac plexus block: is needle tip position critical in patients with no regional anatomic distortions? Anesthesiology 1997; 87: 1301–1308.Google Scholar

24. Zhang, XM, Zhao, QH, Zeng, NL, et al. The celiac ganglia: anatomic study using MRI in cadavers. Am J Roentgenol 2006; 186: 1520–1523.Google Scholar

25. Cicco, M de, Matovic, M, Bortolussi, R, et al. Celiac plexus block: injectate spread and pain relief in patients with regional anatomic distortions. Anesthesiology 2001; 94: 561–565.Google Scholar

26. Penman, ID, Gilbert, D. Basic technique for celiac plexus block/neurolysis. Gastroenterol Endosc 2009; 69: S163–S165.Google Scholar

27. Wang, ZJ, Webb, EM, Westphalen, AC, Coakley, FV, Yeh, BM. Multi-detector row computed tomography appearance of celiac ganglia. J Comput Assist Tomogr 2010; 34: 343–347.Google Scholar

28. Rykowski, JJ, Higler, M. Efficacy of neurolytic celiac plexus block in varying locations of pancreatic cancer. Anesthesiology 2000; 92: 347–354.Google Scholar

29. Ina, H, Kitoh, T, Kobayashi, M, et al. New technique for the celiac plexus block: the transintervertebral disc approach. Anesthesiology 1996; 85: 212–217.Google Scholar

30. Kroll, CE, Schartz, B, Gonzalez-Fernandez, M, et al. Factors associated with outcome after superior hypogastric plexus neurolysis in cancer patients. Clin J Pain 2014; 30: 55–62.Google Scholar

31. der Beuken-van Everdingen, MH Van, Rijke, JM de, Kessels, AG, et al. Prevalence of pain in patients with cancer: a systematic review of the past 40 years. Ann Oncol 2007; 18: 1437–1449.Google Scholar

32. der Beuken-van Everdingen, MH Van, Rijke, JM de, Kessels, AG, et al. High prevalence of pain in patients with cancer in a large population-based study in The Netherlands. Pain 2007; 132: 312–320.Google Scholar

33. Breivik, H, Cherney, N, Collett, B, et al. Cancer-related pain: a pan-European survey of prevalence, treatment, and patient attitudes. Ann Oncol 2009; 20: 1420–1433.Google Scholar

34. Bosscher, H. Blockade of the superior hypogastric plexus block for visceral pelvic pain. Pain Pract 2001; 2: 162–170.Google Scholar

35. Gamal, G, Helaly, M, Labib, YM. Superior hypogastric block: transdiscal versus classic posterior approach in pelvic cancer pain. Clin J Pain 2006; 22: 544–547.Google Scholar

36. Plancarte, R, Leon-Casasola, OA de, El-Helaly, M, Allende, S, Lema, MJ. Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Reg Anesth 1997; 22: 562–568.Google Scholar

37. Erdine, S, Yucel, A, Celik, M, Talu, GK. Transdiscal approach for hypogastric plexus block. Reg Anesth Pain Med 2003; 28: 304–308.Google Scholar

38. Scott-Warren, JT, Hill, V, Rajasekaran, A. Ganglion impar blockade: a review. Curr Pain Headache Rep 2013; 17: 306.Google Scholar

39. Datir, A, Connell, D. CT-guided injection for ganglion impar blockade: a radiologic approach to the management of coccydynia. Clin Radiol 2010; 65: 21–25.Google Scholar

40. Chang-Seok, O, In-Hyuk, C, Hyun-Ju, J, et al. Clinical implications of topographic anatomy on the ganglion impar. Anesthesiology 2004; 101: 249–250.Google Scholar

41. Plancarte, R, Amescua, C, Patt, RB, et al. Presacral blockade of the ganglion of Walther (ganglion impar). Anesthesiology 1990; 73: A751.Google Scholar

42. Foye, PM. New approaches to ganglion impar blocks via coccygeal joints. Reg Anesth Pain Med 2007; 32: 269.Google Scholar

43. Ho, KY, Nagi, PA, Gray, L, et al. An alternative approach to ganglion impar neurolysis under computed tomography guidance for recurrent vulvar cancer. Anesthesiology 2006; 105: 861–862.Google Scholar

44. Foye, PM. Ganglion impar injection techniques for coccydynia (coccyx pain) and pelvic pain. Anesthesiology 2007; 106: 1062–1063.Google Scholar

45. Lin, CS, Cheng, JK, Hsu, YW, et al. Ultrasound-guided ganglion impar block: a technical report. Pain Med 2010; 11: 390–394.Google Scholar