Percutaneous splanchnic nerve radiofrequency ablation for chronic abdominal pain

Percutaneous pulsed radiofrequency treatment of the splanchnic nerves for chronic flank pain secondary to non-obstructive nephrolithiasis

Chronic benign flank pain of unknown etiology presents a significant challenge for pain physicians, especially when interventional treatment options are limited. We report the case of a 26-year-old male with a history of chronic left flank pain, recurrent non-obstructing nephrolithiasis, and a complex urologic background, who was referred to pain management after failing to find relief through previous urologic interventions. Despite the absence of new obstructing stones, the patient's pain persisted. Initial splanchnic nerve blocks using 0.25 % bupivacaine and dexamethasone provided temporary relief, leading to the decision to proceed with pulsed radiofrequency (RF) treatment of the left splanchnic nerves. Under fluoroscopic guidance, the pulsed RF procedure resulted in significant pain reduction, which lasted for four to six months. Over the course of four years, the procedure was repeated six times, providing sustained relief and allowing the patient to resume normal activities, including school and work. This case highlights the potential effectiveness of pulsed RF as a viable option for managing refractory chronic flank pain when other treatments have failed.

Ten-kHz Spinal Cord Stimulation vs Radiofrequency Ablation of Splanchnic Nerves: A Single-Site Retrospective Comparison of 12-Month Outcomes

OBJECTIVES

A prospective study on 10-kHz spinal cord stimulation (SCS) for various causes of chronic abdominal pain (CAP) showed robust improvements in subjects' pain and function. Radiofrequency ablation of splanchnic nerves (snRFA) has been used in advanced pain management treatment algorithms for CAP. This analysis was designed to provide what we believe is the first comparison of the efficacy of these two therapies. Propensity-score matched analysis (PMA) was performed to compare pain relief and decrease in medication usage in snRFA and SCS for treating refractory CAP.

MATERIALS AND METHODS

Medical records were extracted for consecutive patients with CAP treated from June 2015 to June 2021 who underwent either snRFA or SCS at the Carolinas Pain Institute after positive diagnostic splanchnic block. The patients' diagnoses included gastroparesis, chronic pancreatitis, postsurgical CAP, and other dysmotility syndromes. PMA was performed to produce matched pairs in terms of baseline clinical status, reported pain, and opioid use over 12 months, after treatment was compared in the groups.

RESULTS

PMA produced two well-balanced groups (n = 31) for SCS and snRFA. Analysis showed significant improvement in pain scores in both groups through 12 months, but the mean reduction in reported numerical rating scale points was significantly greater for the SCS group, averaging 4.7 vs 3.0 points for the snRFA group (p < 0.01). Responder rates (≥50% pain relief) similarly diverged at 12 months, with 67.7% vs 30.0% responders in the SCS and snRFA groups, respectively (p = 0.017). Opioid usage did not change in the snRFA group but was reduced in the SCS group at 12 months (p = 0.004).

CONCLUSIONS

SCS provided longer pain relief than did snRFA in this propensity-matched study. Pain scores and opioid usage were significantly less at 12-month follow-up when SCS was used for control of CAP.

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

Context

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.

Aims

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.

Settings and Design

Retrospective analysis of all patients with chronic pancreatitis who received bilateral SPN over the last 4 years.

Methods and Materials

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.

Statistical Analysis Used

Quantitative data for change in pre- to post-block VAS score was collected using the non-parametric Wilcoxon signed ranks test.

Results

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.

Conclusions

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.

Open Thoracic Cordotomy for Cancer Pain with Intraoperative Neuromonitoring: A Case Series and Critical Review of the Literature

OBJECTIVE

Cordotomy is a viable option for patients with intractable cancer pain and limited survival. Open thoracic cordotomy is offered when patients are not candidates for percutaneous cordotomy. After the open procedure, traditionally performed purely based on anatomic landmarks, up to 22% of patients experience postoperative limb weakness. The objective of this study is to report our experience with neurophysiology-guided open cordotomy along with a critical review of the literature.

METHODS

Between 2019 and 2022, 5 open thoracic cordotomies were performed in our center. Intraoperative neurophysiologic monitoring was used in all cases to guide the lesion and standard single-level laminectomy or hemilaminectomy was performed for exposure. Outcome measures were retrospectively reviewed focusing on pain control and neurologic status. Existing literature on cordotomy was critically reviewed.

RESULTS

There was satisfactory pain relief with preservation of motor function in all 5 cases. Temperature sensation was preserved in all but 1 patient, who lost it after the previous ipsilateral percutaneous cordotomy (PCC). No procedural complications were experienced. We found that the neurophysiology monitoring lesion was guided anterior compared with what would have been lesioned on an anatomic basis.

CONCLUSIONS

Open thoracic cordotomy is a safe and effective procedure for intractable cancer-related pain. Technical advancements significantly reduced mortality and major morbidity of PCC. Our series suggests that neurophysiology monitoring alters the location of the lesion and may help better targeting of pain fibers within the spinothalamic tract and preserve other long tracts. The safety profile of open cordotomy with neurophysiology compares favorably with the PCC.

Radiofrequency Ablation for Thoracic and Abdominal Chronic Pain Syndromes

Chronic thoracic pain and chronic abdominal pain are common conditions that can significantly affect quality of life. Pain syndromes encompassing a variety of causes, including cancer pain, neuritis, and postsurgical pain, are traditionally managed by the use of pharmacologic therapy; however, many cases are refractory to these conservative methods. Radiofrequency ablation (RFA) has been increasingly used as a tool to treat resistant, chronic pain of both thoracic and abdominal origin. Multiple cases and trials have been reported that show the efficacy of RFA in the treatment of these chronic pain conditions.

Ultrasound-Guided Subcostal TAP Block with Depot Steroids in the Management of Chronic Abdominal Pain Secondary to Chronic Pancreatitis: A Three-Year Prospective Audit in 54 Patients

BACKGROUND

Chronic pancreatitis is a common cause of recurrent chronic abdominal pain that utilizes significant health care resources. Pain in chronic pancreatitis can be of two types. Visceral pain occurs during ongoing pancreatic inflammation. Once pancreatic inflammation subsides, the pain generator can move to the abdominal wall as a result of viscerosomatic convergence and present as abdominal myofascial pain syndrome. Subcostal transversus abdominis plane block is an abdominal plane block that has been proven effective in upper abdominal pain of somatic origin.

DESIGN

The authors discuss the two distinct types of chronic abdominal pain as a result of pancreatitis and present a prospective audit of a management pathway.

METHODS

Over a three-year period, 54 patients with chronic abdominal pain as a result of pancreatitis were prospectively audited at a tertiary care university hospital. Patients were offered bilateral subcostal transversus abdominis plane block with depot steroids as the primary interventional treatment in the pathway.

RESULTS

In patients with myofascial pain secondary to chronic pancreatitis, the block was effective in producing clinically significant pain relief at three months (95%, 20/21) and durable pain relief lasting six months (62%, 13/21). In patients with visceral pain, the block produced a transient benefit lasting two to three weeks in one-third (six of 17).

CONCLUSIONS

Subcostal transversus abdominis plane block may be an option in the management of abdominal myofascial pain syndrome secondary to chronic pancreatitis. The block is ineffective in producing clinically significant pain relief in the presence of ongoing pancreatic inflammation.

Interventional Radiofrequency Treatment for the Sympathetic Nervous System: A Review Article

Introduction

Interventional techniques such as radiofrequency (RF) treatment can be used to interrupt pain signals transmitted through the sympathetic nervous system (SNS). RF treatments including the pulsed (PRF) and continuous (CRF) modalities show enhanced control over lesion size and enhanced ability to confirm accurate positioning compared to other interventional methods. PRF also acts to reduce the area of the lesion. In this article, we characterize the currently available evidence supporting the use and efficacy of RF treatments in sympathetically mediated pain (SMP) conditions.

Study Design

A comprehensive literature review.

Methods

A PubMed and Cochrane Library database search was performed for human studies applying RF treatment at sympathetic sites (sphenopalatine ganglion, stellate ganglion, cervical, thoracic, or lumbar sympathetic ganglia, celiac plexus, splanchnic nerves, superior hypogastric plexus, and ganglion impar) between January 1970 to May 2020. Data were extracted, summarized into tables, and qualitatively analyzed.

Results

PRF and CRF both show promise in relieving SMP conditions, such as complex regional pain syndrome (CRPS), pain in the perineal region, headache and facial pain, and oncologic and non-oncologic abdominal pain, in addition to other types of pain, with minimal complications. Furthermore, in most comparative studies, outcomes using RF treatments exceeded other interventional techniques, such as anesthetic block and chemical neurolysis.

Conclusions

RF treatments can be effective in carefully selected patients who are refractory to conservative management. However, further randomized controlled studies are needed prior to implementing it into common practice.

Radiofrequency Ablation of the Splanchnic Nerve and Superior Hypogastric Plexus for Chronic Abdominal Pain Status Post-Abdominal Surgery

Gastrointestinal cancers, such as malignant carcinoid tumor and pancreatic cancer, are responsible for excruciating and debilitating abdominal pain. Too often, patients are placed on chronic high-dose opioids, but the pain remains poorly controlled. It is incumbent on the medical team to approach the patient's debilitating pain in a thorough multi-modal fashion. Opioids may play an important role, but they make up only a portion of available invasive and noninvasive management. We present a case of a patient who was serendipitously diagnosed with malignant carcinoid tumor after endoscopic polypectomy and Whipple procedure for pancreatic cancer. Her abdominal pain was refractory to opioid and non-opioid medications, and therefore we proposed radiofrequency ablation (RFA) of the splanchnic nerve and superior hypogastric plexus. This technique was preceded by a diagnostic block of these nerves. She experienced significant pain relief and an improved quality of life, and was able to stop all opioid medications. The preferred approach to pain management is a multi-modal one. This includes physical therapy, pharmacological management, and minimally invasive procedures such as RFA. The medical team must consider all available pain management modalities to provide the patient with proper care of such debilitating pain as that described in our case presentation. A systematic approach is important, as demonstrated by our team by first performing diagnostic blocks of the superior hypogastric plexus and splanchnic nerve to test the likelihood of a successful RFA. Only after achieving favorable results, we decided to proceed with RFA treatment of those same nerves. Ultimately, our RFA technique provided significant pain relief for our patient and she did not require any opioid medications.

Radiofrequency Ablation and Alcohol Neurolysis of the Splanchnic Nerves for a Patient With Abdominal Pain From Pancreatic Cancer

Abdominal pain related to gastrointestinal malignancy can be notoriously difficult to manage and can lead to significant morbidity and suffering. The blockade of the celiac plexus has traditionally been performed for alleviating abdominal pain related to malignancy. Visceral structures that are innervated by these nerves include the pancreas, liver, gallbladder, mesentery, omentum, and the gastrointestinal tract from the stomach to the transverse colon. Alternatively, this pain can be treated by disrupting visceral nociceptive signals at the splanchnic nerves. In this report, we describe our experience of treating a 50-year-old male patient suffering from severe abdominal pain related to pancreatic cancer with multiple liver metastases. The patient failed medication management and had an international normalized ratio of 1.6, which was a concern for performing a celiac plexus block given the proximity of major vascular structures. The patient instead underwent radiofrequency ablation (RFA) as well as alcohol neurolysis of the bilateral splanchnic nerves and obtained significant relief from the procedure.

Pain Relieving Effect of Intraoperative Chemical Splanchnicectomy of Celiac Ganglions in Patients with Resectable Pancreatic or Gastric Masses: A Randomized Clinical Trial

Background

Trials of intraoperative chemical splanchnicectomy during resection of pancreatic and gastric masses resulted in significant difference in a patient's postoperative pain. This study aims to determine if splanchnicectomy by alcohol neurolysis can relieve postoperative pain after gastrectomy and Whipple surgery. The study explores differences in outcomes at first four months after surgery.

Methods

Fifty-eight patients with gastric and 60 patients with pancreatic resectable masses were included (28 were lost to follow-up). Each randomized in control and intervention subgroups. Intervention subgroups underwent chemical blockage of celiac ganglions by ethanol injection at both sides of suprapancreatic aorta. Participants were asked to report their pain intensity according to the Visual Analogue Scale (VAS) at specific times.

Result

The overall postoperative pain of injected Whipple and gastrectomy subgroups was lower than the noninjected Whipple and gastrectomy subgroups (p < 0.001). The pain-modifying effect of the injection was not different between Whipple and gastrectomy groups (p=0.125).

Conclusion

Splanchnicectomy is recommended for pain reduction after abdominal operations. Perspective. This article presents positive effect of intraoperative chemical splanchnicectomy during resection of pancreatic and gastric masses on postoperative pain. This is an easy, effective, safe, and inexpensive procedure recommended for all operable gastric or pancreatic masses to palliate the pain degree.

Splanchnic block at T11 provides a longer relief than celiac plexus block from nonmalignant, chronic abdominal pain

Aim: Neural blockade at the celiac plexus is less specific compared with splanchnic nerve block. This retrospective study compares duration and potency of celiac versus splanchnic block. Patients & methods: Analyzed were data of 16 consecutive patients with visceral abdominal nonmalignant pain treated using both celiac plexus and T11 splanchnic block. Results: Improvement in pain scores was from 7.24 ± 1.0 to 4.1 ± 2.1 for celiac, and 7.8 ± 0.8 to 2.9 ± 2.1 for splanchnic at 4 weeks. Duration of the splanchnic nerve block was superior, median of 56 days versus only 21 days for celiac plexus block. Conclusion: T11 bilateral splanchnic block provided significantly longer relief from chronic nonmalignant abdominal pain, than celiac plexus block (p = 0.001). Reduction in pain severity was more with splanchnic compared with celiac block (p = 0.029).

EUS-guided celiac ganglion radiofrequency ablation versus celiac plexus neurolysis for palliation of pain in pancreatic cancer: a randomized controlled trial (with videos)

BACKGROUND AND AIMS

Although EUS-guided celiac plexus neurolysis (EUS-CPN) is frequently performed, its efficacy for palliation of pain in pancreatic cancer is suboptimal. Recently, EUS-guided radiofrequency ablation (EUS-RFA) has been proposed as a palliative treatment option for pancreatic neoplasms. We performed a single-blind, randomized trial to compare the effectiveness of EUS-CPN and EUS-RFA for palliation of pain in pancreatic cancer.

METHODS

Patients with abdominal pain because of locally advanced or metastatic pancreatic cancer underwent EUS-CPN (n = 14) or EUS-RFA (n = 12). EUS-RFA was performed using a 1F monopolar probe passed via a 19-gauge FNA needle, by targeting the area of celiac plexus or visualized ganglia. Primary outcome was pain severity as measured by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire pancreatic cancer module (PAN26) administered pretreatment and at 2 and 4 weeks post-treatment. Secondary outcome measures were comparison of quality of life as determined by the PAN26 and EORTC Quality of Life Questionnaire core questionnaire (C30) and opioid analgesia use between the 2 groups.

RESULTS

Both the PAN26 (49.0 vs 57.0, P < .001) and C30 (51.9 vs 64.4, P = .032) revealed less pain for EUS-RFA than for EUS-CPN. Also, the EUS-RFA cohort experienced significantly less-severe GI symptoms, were able to plan more for the future, and had better emotional functioning compared with the EUS-CPN group.

CONCLUSIONS

Compared with EUS-CPN, EUS-RFA provided more pain relief and improved the quality of life for patients with pancreatic cancer. (Clinical trials registration number: NCT03152487.).

Comparison between radiofrequency ablation and chemical neurolysis of thoracic splanchnic nerves for the management of abdominal cancer pain, randomized trial

BACKGROUND

Radiofrequency ablation (RFA) of the splanchnic nerves has been reported as a predictable and safe technique for abdominal pain management. We compare between RFA and chemical neurolysis of bilateral thoracic splanchnic nerves in the management of refractory cancer pain.

METHODS

The study was conducted on 60 patients aged ≥18 years who suffered from abdominal pain (visceral pain, VAS ≥4) due to upper abdominal cancers. Participants were randomized into two groups. Group I (RF): 30 participants received a bilateral splanchnic nerve block at T10 and T11 levels using RFA. Group II (alcohol): 30 participants received a bilateral splanchnic nerve block at T11 using alcohol. Pain relief was assessed using VAS (0-10) and total daily oral opioid consumption (primary outcome).

RESULTS

Significant reductions of VAS and global perceived effect satisfaction scores (GPES) were observed in both groups compared to baseline levels (p < 0.001); Group I had the largest reduction. MST consumption and QOL scores improved significantly in both groups (p < 0.001). Oral opioid consumption started to reduce at the end of the first post-interventional week for Group I, 0.00 (0-45 mg), and at the end of the second post-interventional week for Group II, 20.00 (0-135 mg). No major complications were recorded in either group.

CONCLUSION

Simultaneous bilateral pain block of splanchnic nerves at the levels of T10 and T11 using RFA is more effective than using alcohol at a single level of T11 in cancer patients presenting with upper abdominal pain. The RFA intervention acted faster, provided longer duration analgesia, worked in a higher proportion of patients and had a better safety profile than the alcohol intervention.

SIGNIFICANCE

Radiofrequency ablation of the splanchnic nerves is safe and effective for relieving upper abdominal cancer pain.

Novel treatment protocol for ameliorating refractory, chronic pain in patients with autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) patients can suffer from chronic pain that can be refractory to conventional treatment, resulting in a wish for nephrectomy. This study aimed to evaluate the effect of a multidisciplinary treatment protocol with sequential nerve blocks on pain relief in ADPKD patients with refractory chronic pain. As a first step a diagnostic, temporary celiac plexus block with local anesthetics was performed. If substantial pain relief was obtained, the assumption was that pain was relayed via the celiac plexus and major splanchnic nerves. When pain recurred, patients were then scheduled for a major splanchnic nerve block with radiofrequency ablation. In cases with no pain relief, it was assumed that pain was relayed via the aortico-renal plexus, and catheter-based renal denervation was performed. Sixty patients were referred, of which 44 were eligible. In 36 patients the diagnostic celiac plexus block resulted in substantial pain relief with a change in the median visual analogue scale (VAS) score pre-post intervention of 50/100. Of these patients, 23 received a major splanchnic nerve block because pain recurred, with a change in median VAS pre-post block of 53/100. In 8 patients without pain relief after the diagnostic block, renal denervation was performed in 5, with a borderline significant change in the median VAS pre-post intervention of 20/100. After a median follow-up of 12 months, 81.8% of the patients experienced a sustained improvement in pain intensity, indicating that our treatment protocol is effective in obtaining pain relief in ADPKD patients with refractory chronic pain.

Interventional Pain Management Approaches for Control of Chronic Pancreatic Pain

OPINION STATEMENT

Treatment of persistent pain from chronic pancreatitis historically was difficult to treat. For years, focus was on opioid and other analgesics and psychological treatments. Recent studies provided evidence for decrease in analgesic intake and pain scores after properly conducted sympathetic blocks (celiac, splanchnic nerve blocks). These therapies should be considered as parts of a multimodal analgesic strategy. Animal studies suggest that spinal cord stimulation suppresses visceral hyperalgesia. Large case series of spinal cord stimulation demonstrated a significant pain relief in patients with chronic pancreatitis. Given the limitations of conservative and surgical treatments for chronic visceral pain, spinal cord stimulation may be a very useful therapeutic option.

A stepwise approach for effective management of chronic pain in autosomal-dominant polycystic kidney disease

Chronic pain, defined as pain existing for >4-6 weeks, affects >60% of patients with autosomal-dominant polycystic disease (ADPKD). It can have various causes, indirectly or directly related to the increase in kidney and liver volume in these patients. Chronic pain in ADPKD patients is often severe, impacting physical activity and social relationships, and frequently difficult to manage. This review provides an overview of pathophysiological mechanisms that can lead to pain and discusses the sensory innervation of the kidneys and the upper abdominal organs, including the liver. In addition, the results of a systematic literature search of ADPKD-specific treatment options are presented. Based on pathophysiological knowledge and evidence derived from the literature an argumentative stepwise approach for effective management of chronic pain in ADPKD is proposed.

Percutaneous radiofrequency ablation of the splanchnic nerves in patients with chronic pancreatitis: results of single and repeated procedures in 11 patients

BACKGROUND

Pain is a major problem for chronic pancreatitis (CP) patients. Unfortunately, medical therapy often fails. Endoscopic and surgical treatments are invasive, and results vary. Percutaneous radiofrequency ablation of the splanchnic nerves (RFSN) is a relatively new and minimally invasive procedure for treatment of intractable pain in CP patients.

MATERIALS AND METHODS

We retrospectively evaluated 18 RFSN procedures in 11 CP patients, all refractory to analgesics. Five patients underwent a second procedure; two patients underwent a third procedure. NRS pain scores were assessed. Complications, analgesics usage, and length of the pain-free period were recorded.

RESULTS

Radiofrequency ablation of the splanchnic nerves was effective in 15/18 interventions. The mean NRS pain score decreased from 7.7 ± 1.0 to 2.8 ± 2.7 (P ≤ 0.001). The pain-free period lasted for a median period of 45 weeks. The effect of repeated interventions was comparable to the initial procedure. One transient side effect was reported. Four patients reported significantly reduced analgesic usage; 4 patients completely stopped their pain medication.

CONCLUSION

Radiofrequency ablation of the splanchnic nerves is a minimally invasive, effective procedure for pain relief. After the effect has subsided, RFSN can be successfully repeated. RFSN might become an alternative treatment in a selected group of CP patients. A larger, randomized trial is justified to substantiate these findings.

The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment)

Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

Radiofrequency thermocoagulation of the thoracic splanchnic nerve in functional abdominal pain syndrome -A case report-

The thoracic splanchnic nerve block has been used in managing abdominal pain, especially for pains arising from abdominal cancers. A 27-year-old male patient who had a constant abdominal pain was referred to our clinic for pain management but had no organic disease. The numeric rating scale (NRS) for pain scored 7/10. We applied a diagnostic thoracic splanchnic nerve block under the diagnosis of functional abdominal pain syndrome. Since the block reduced the pain, we applied a radiofrequency thermocoagulation at the T11 and T12 vertebral level. Thereafter, his symptoms improved markedly with pain decreasing to an NRS score of 2-3/10. Hereby, we report a successful management of functional abdominal pain via radiofrequency thermocoagulation of the thoracic splanchnic nerves.

Palliative interventions for pain in cancer patients

Pain is a debilitating problem that is common to most patients with cancer at some time during the course of their disease. Conventional therapies such as opiate analgesics and radiation therapy provide suboptimal and limited relief. Novel image-guided interventions have made a significant impact in the management of this difficult problem. This article reviews some of the most promising image-guided techniques for relieving bone and visceral pain in patients suffering from cancer.

26. Pain in chronic pancreatitis

Chronic pancreatitis is defined as a progressive inflammatory response of the pancreas that has lead to irreversible morphological changes of the parenchyma (fibrosis, loss of acini and islets of Langerhans, and formation of pancreatic stones) as well as of the pancreatic duct (stenosis and pancreatic stones). Pain is one of the most important symptoms of chronic pancreatitis. The pathogenesis of this pain can only partly be explained and it is therefore often difficult to treat this symptom. The management of pain induced by chronic pancreatitis starts with lifestyle changes and analgesics. For the pharmacological management, the three-step ladder of the World Health Organization extended with the use of co-analgesics is followed. Interventional pain management may consist of radiofrequency treatment of the nervi splanchnici, spinal cord stimulation, endoscopic stenting or stone extraction possibly in combination with lithotripsy, and surgery. To date, there are no randomized controlled trials supporting the efficacy of radiofrequency and spinal cord stimulation. The large published series reports justify a recommendation to consider these treatment options. Radiofrequency treatment, being less invasive than spinal cord stimulation, could be tested prior to considering spinal cord stimulation. There are several other treatment possibilities such as endoscopic or surgical treatment, pancreatic enzyme supplementation and administration of octreotide and antioxidants. All may have a role in the management of pain induced by chronic pancreatitis.

Permanent percutaneous splanchnic nerve neuromodulation for management of pain due to chronic pancreatitis: a case report

INTRODUCTION

  The management of pain in chronic benign pancreatitis is complex. Celiac plexus neurolysis provides pain relief of variable duration. Neuromodulation of splanchnic nerves with electrodes and an implantable pulse generator system is an alternative to producing long-term pain relief with minimal complications in selected cases.

METHODS

  A 36-year-old lady with intractable abdominal pain for five years from chronic benign pancreatitis presented to our pain clinic. Multiple pharmacotherapy regimens, surgery, and interventions produced temporary pain relief of variable duration and intensity. Following a successful trial of celiac plexus stimulation, neuromodulation of the splanchnic nerves was achieved with two permanently implanted octopolar leads at the T11/T12 area connected to an implantable pulse generator.

RESULTS

  Eighteen months following the implant, the patient continues to derive satisfactory pain relief without any device related complications. Her opiate use is significantly reduced from 225 (486 mg morphine per day) to 12.5 (27 mg morphine per day) micrograms/h fentanyl patches and the fentanyl lozenges were stopped with an increase in appetite and of more than 8 kg in weight gain. The initial pain score visual analogue scale (VAS) 8-9/10 was reduced to VAS 0/10 since implantation.

DISCUSSION

  The pain of chronic pancreatitis has both visceral and somatic components as evidenced by the lack of complete pain relief from celiac plexus block alone and the knowledge that in chronic disease, the pathology extends to extra pancreatic somatic tissues, particularly the retro-peritoneum. We postulate that the electrical field generated by the dual octrode system extends to include splanchnic nerves and other somatic innervation of the pancreas.

CONCLUSION

  In our opinion, this is the first case of a successful long-term neuromodulation of splanchnic nerves with a permanently implanted device. The potential exists for its use in visceral abdominal pain of varied etiology, once more experience is obtained with this technique.

Pain Challenges at the End of Life - Pain and Palliative Care Collaboration

Pain and symptom management at the end of life remains suboptimal.Pain physicians are uniquely placed to provide interventions for patients with difficult to manage pain.Interventions such as acupuncture, radiofrequency ablation, neurolysis together with regional analgesia including neuraxial techniques and spinal cordotomy may provide the patient with improved analgesia.

A review of the thoracic splanchnic nerves and celiac ganglia

Anatomical variation of the thoracic splanchnic nerves is as diverse as any structure in the body. Thoracic splanchnic nerves are derived from medial branches of the lower seven thoracic sympathetic ganglia, with the greater splanchnic nerve comprising the more cranial contributions, the lesser the middle branches, and the least splanchnic nerve usually T11 and/or T12. Much of the early anatomical research of the thoracic splanchnic nerves revolved around elucidating the nerve root level contributing to each of these nerves. The celiac plexus is a major interchange for autonomic fibers, receiving many of the thoracic splanchnic nerve fibers as they course toward the organs of the abdomen. The location of the celiac ganglia are usually described in relation to surrounding structures, and also show variation in size and general morphology. Clinically, the thoracic splanchnic nerves and celiac ganglia play a major role in pain management for upper abdominal disorders, particularly chronic pancreatitis and pancreatic cancer. Splanchnicectomy has been a treatment option since Mallet-Guy became a major proponent of the procedure in the 1940s. Splanchnic nerve dissection and thermocoagulation are two common derivatives of splanchnicectomy that are commonly used today. Celiac plexus block is also a treatment option to compliment splanchnicectomy in pain management. Endoscopic ultrasonography (EUS)-guided celiac injection and percutaneous methods of celiac plexus block have been heavily studied and are two important methods used today. For both splanchnicectomies and celiac plexus block, the innovation of ultrasonographic imaging technology has improved efficacy and accuracy of these procedures and continues to make pain management for these diseases more successful.

Recent advances in the treatment of pain

Cancer pain and chronic non-malignant pain can be difficult to manage and may not respond satisfactorily to standard analgesics. Sequential empiric analgesic trials are usually done to manage individual patients. Experimental human pain models have helped to clarify mechanisms of opioid and adjuvant analgesic actions. Combinations of opioids and adjuvant analgesics better relieve pain than either opioids or adjuvant analgesics alone, as demonstrated in randomized controlled trials. The analgesic activity of antidepressants is largely dependent upon norepinephrine reuptake and activation of alpha 2 adrenergic receptors. Corticosteroids reduce postoperative orthopedic incident pain, which may allow patients to ambulate earlier and with less pain. Spinal corticosteroids reduce lower hemibody pain. Gabapentinoids as single high doses reduce postoperative pain and certain acute pain syndromes. Individuals who experience flares of pain while on spinal opioids benefit from intrathecal boluses of levobupivicaine or sublingual ketamine. Interventional approaches to pain management are often necessary due to the limitations of systemic analgesics. Electronics stimulators (peripheral, spinal and motor cortex) improve difficult to manage chronic pain syndromes. Pulsed radiofrequency reduces pain without tissue damage, which could be an advantage over chemical or radiofrequency neurotomy. Botulinum toxin A reduces focal neuropathic pain that is durable. Interventional related successes in relieving pain are operator dependent. Most reported benefits of systemic and regional analgesics and interventional approaches to pain relief are not based on randomized trials and are subject to selection bias, sampling error, and placebo responses, which may over-inflate reported benefits. Randomized controlled trials are needed to confirm reported benefits.

Neurolytic blocks revisited

The use of neurolytic blockade is a staple in the management of cancer pain. However, the data on neurolysis for chronic pain are plagued by inconsistencies in patient selection, diagnostic criteria, technical standards, and outcome measures. No one neurolytic agent or technique has been proven superior to another. Current evidence suggests that patients with pain of malignant origin may benefit from a variety of neurolytic techniques, as the benefit of documented short-term pain relief may outweigh risk at the end of life. In the absence of compelling data suggesting low-risk long-term efficacy, neurolysis for chronic benign pain should be cautiously considered, in most cases, only after failure of aggressive multidisciplinary management.