Percutaneous CT-Guided Cryoablation of the Celiac Plexus: A Retrospective Cohort Comparison with Ethanol

Applications of Cryoneurolysis in Chronic Pain Management: a Review of the Current Literature

PURPOSE OF REVIEW

The purpose of this review is to evaluate and summarize the literature investigating cryoneurolysis in the treatment of various chronic pain pathologies.

RECENT FINDINGS

There is an increasing amount of interest in the use of cryoneurolysis in chronic pain, and various studies have investigated its use in lumbar facet joint pain, SI joint pain, post-thoracotomy syndrome, temporomandibular joint pain, chronic knee pain, phantom limb pain, neuropathic pain, and abdominal pain. Numerous retrospective studies and a more limited number of prospective, sham-controlled prospective studies suggest the efficacy of cryoneurolysis in managing these chronic pain pathologies with a low complication rate. However, more blinded, controlled, prospective studies comparing cryoneurolysis to other techniques are needed to clarify its relative risks and advantages.

Multimodal locoregional procedures for cancer pain management: a literature review

Pain is the most common and fearsome symptom in cancer patients, particularly in the advanced stage of disease. In cancer pain management, the first option is represented by analgesic drugs, whereas surgery is rarely used. Prior to considering surgical intervention, less invasive locoregional procedures are available from the wide pain management arsenal. In this review article, comprehensive information about the most commonly used locoregional options available for treating cancer pain focusing on interventional radiology (neurolysis, augmentation techniques, and embolization) and interventional radiotherapy were provided, also highlighting the potential ways to increase the effectiveness of treatments.

Computed tomography-guided single celiac plexus neurolysis analgesic efficacy and safety: a systematic review and meta-analysis

PURPOSE

To perform a systematic review and meta-analysis of published studies to evaluate the analgesic efficacy and safety of computed tomography (CT)-guided single celiac plexus neurolysis (CPN) with the injection of a neurolytic agent into the celiac plexus in one session (CT-guided single CPN).

METHODS

PubMed, the Cochrane Library, and Ichushi-Web were searched for English or Japanese articles published up to February 2022, which reported findings about patients who underwent CT-guided single CPN. The outcome measures assessed in the systematic review and meta-analysis were the pain measurement scales from 0 to 10 before and after the intervention and the rate of minor and major complications.

RESULTS

The pooled pain measurement scales at pre-intervention and 1- or 2-, 7-, 30-, 60-, 90-, and 180-day post-intervention was 6.72 (95% confidence interval [CI], 4.77-9.46, I² = 98%), 2.31 (95% CI 2.31-4.44, I² = 92%), 2.84 (95% CI 1.39-5.79, I² = 95%), 3.36 (95% CI 1.66-6.77, I² = 98%), 3.19 (95% CI 1.44-7.08, I² = 59%), 3.87 (95% CI 1.88-7.97, I² = 0%), and 3.40 (95% CI 3.02-3.83, I² = not applicable), respectively. The pooled minor complication rates of diarrhea, hypotension, nausea or vomiting, and pain associated with the procedure were 18% (95% CI 8-37%, I² = 45%), 16% (95% CI 2-58%, I² = 76%), 6% (95% CI 2-16%, I² = 1%), and 7% (95% CI 2-21%, I² = 17%), respectively. There was no major complication in the included studies.

CONCLUSION

CT-guided single CPN can be performed safely and provides immediate analgesic efficacy although the amount of heterogeneity is characterized as large. Further investigation of its long-term analgesic efficacy is required.

Agents Used for Nerve Blocks and Neurolysis

The recognition of pain and the treatments used for it are vital for all practitioners. Many types of pain can be treated in a locoregional fashion, which has significant implications not just for any individual patient but for society as a whole. These treatments are most effective when performed in a minimally invasive, image-guided fashion. Interventional radiologists should play a central role in providing these lifestyle-limiting treatments. This article describes the medications most typically used for spinal and extra-axial treatments in the management of patients in pain.

Celiac Plexus Cryoneurolysis

Intractable, chronic abdominal pain from upper abdominal malignant and benign diseases is a significant challenge for healthcare providers and burden on the healthcare system. While opioid analgesics are commonly used to provide pain relief, the adverse effects of chronic opioid use cannot be overlooked. Celiac plexus neurolysis via chemical or thermal means represents an alternative minimally invasive approach to provide palliative pain relief and increase patients' quality of life. Through the use of computed tomography guidance, celiac plexus neurolysis can be performed by accurately targeting the celiac plexus, while minimizing risks to adjacent structures. Historically, celiac plexus neurolysis was performed via instillation of ethanol or phenol; however, within the past decade cryoablation has gained increasing use with potentially fewer side effects.

Single-Center Review of Celiac Plexus/Retrocrural Splanchnic Nerve Block for Non-Cancer Related Pain

RATIONALE AND OBJECTIVES

Celiac plexus and retrocrural splanchnic nerve (CP/RSN) blocks are widely used for cancer-related abdominal pain, but there is limited literature on their efficacy for non-cancer related pain. Our aim was to determine the indications and effectiveness of CT-guided CP/RSN blocks performed on patients with abdominal pain from non-cancer related sources.

MATERIALS AND METHODS

CT-guided CP/RSN blocks for non-cancer related abdominal pain from 2011-2020 were retrospectively reviewed for patient demographics, procedure details, duration of pain relief, and complications. Effective blocks were defined as patient-reported pain relief or decrease in opioid use lasting 2 or more days for temporary blocks and 14 or more days for permanent blocks.

RESULTS

Of 72 CT-guided CP/RSN blocks for non-cancer related abdominal pain, 48 (67%) were effective for a mean of 51 days (median 14, range 2-700). Of the 18 permanent blocks, 9 (50%) were effective for a mean of 111 days (median 90, range 14-390). Of the 54 temporary blocks, 39 (72%) were effective for a mean of 37 days (median 9, range 2-700). Indications included postural orthostatic tachycardia syndrome/dysautonomia (77% effective, 20/26), pancreatitis (86% effective, 12/14), postsurgical pain (62% effective, 8/13), median arcuate ligament syndrome (70% effective, 7/10), chronic pain syndrome (20% effective, 1/5), gastroparesis (80% effective, 4/5), and renal cystic disease (33% effective, 1/3). For postural orthostatic tachycardia syndrome /dysautonomia, pancreatitis, post-surgical pain, and MALS, there were no statistically significant differences in effectiveness between celiac vs. splanchnic blocks in groups matched by indication and intended duration (temporary/permanent).

CONCLUSIONS

CT-guided CP/RSN blocks can effectively manage non-cancer related abdominal pain, though there is discrepancy in efficacy between temporary and permanent blocks.

A Technical Report on the Performance of Percutaneous Cryoneurolysis of Splanchnic Nerves for the Treatment of Refractory Abdominal Pain in Patients with Pancreatic Cancer: Initial Experience

PURPOSE

To report our preliminary results upon feasibility, efficacy and safety of percutaneous splanchnic nerves cryoneurolysis for the treatment of abdominal pain refractory to conservative medication in patients with pancreatic cancer MATERIALS METHODS: Institutional database research (retrospective review of prospectively collected data from April 2019 till August 2020) identified 5 patients with pancreatic cancer and pain refractory to conservative medication who underwent percutaneous cryoneurolysis of splanchnic nerves. In all patients, percutaneous cryoneurolysis was performed with posterolateral paravertebral approach using a 17 Gauge cryoprobe under computed tomography guidance and local anesthesia. Self-reported pain scores were assessed before and at the last follow-up using a pain inventory with visual analog scale (VAS) units.

RESULTS

Mean patient age was 63.81 years (male-female: 3-2). Mean pain score prior to cryoanalgesia of splanchnic nerves was 9.4 VAS units. This score was reduced to a mean value of 2.6, 2.6 and 3 VAS units at 1, 3 and 6 months of follow-up, respectively. All patients reported significantly reduced analgesic usage. No complication was reported according to the CIRSE classification system. The mean procedure time was 44.4 min (range 39-50 min), including local anesthesia, cryoprobe(s) placement, ablation and post-procedural CT evaluation.

CONCLUSION

Percutaneous cryoanalgesia of the splanchnic nerves is a minimally invasive, safe and effective procedure for pancreatic cancer pain relief. A larger, randomized trial is justified to substantiate these findings.

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.

Percutaneous cryoanalgesia for pain palliation: Current status and future trends

Cryoanalgesia, otherwise termed cryoneurolysis, refers to application of extreme cold upon peripheral nerves for palliation of pain associated to nerve lesions or biomechanical syndromes of neoplastic and non-neoplastic substrate. Application of cryoanalgesia initiates a cascade of pathophysiologic events interrupting nerve conduction of painful stimuli without irreversible nerve damage. Cryoanalgesia is considered a safe procedure with minimal risk of complications when performed with percutaneous approaches under imaging guidance. In the era of an opioid overdose crisis, cryoanalgesia can be proposed as an alternative aiming at controlling pain and improving life quality. Imaging guidance has substituted open surgical and nerve stimulation approaches in nerve identification, significantly contributing to the minimally invasive character of percutaneous approaches. Ultrasound or computed tomography can serve as low cost, ideal guiding techniques due to their abilities for precise anatomic delineation, high spatial resolution and good tissue contrast. The purpose of this review is to become familiar with the most common imaging guided percutaneous cryoanalgesia indications, to learn about different technical considerations during performance providing the current evidence. Controversies concerning products will be addressed.

Interventional Cryoneurolysis: An Illustrative Approach

The application of advanced imaging guidance and the interventional radiology skill set has expanded the breadth of nerve and nerve plexus targets in the body for potential cryoneurolysis. Advancement of the basic science supporting cryoneurolysis has further solidified proceduralists' confidence and ability to select and manage patients clinically. As these procedures continue to evolve, a structured approach to the wide variety of indications is necessary.