Neurolytic Caudal Epidural Block for Rectal Tenesmus: A Case Report

Rectal tenesmus is a very uncomfortable symptom. Though antiarrhythmic drugs and nerve blocks have been proposed as a treatment for rectal tenesmus, none is well-established. We report a 68-year-old female who undertook surgery for uterine cervical cancer and underwent chemotherapy. She got a bilateral nephrostomy and bowel obstruction during the chemotherapy because of recurrence. She decided to stop chemotherapy and to receive palliative care. She had a symptom of rectal tenesmus, which was refractory to medications. The clinical sign was severe and uncomfortable, making her very nervous. We planned to treat the rectal tenesmus with a nerve block. A ganglion impar block was insufficient to remove the symptom, and the saddle block failed due to epidural lipomatosis. We finally succeeded in alleviating the sign with a neurolytic caudal epidural block. Relief of tenesmus made her hope to spend her final period at home. She could stay at home with her family for seven days before death without recurrence of the symptom. Though there is no report about the effectiveness of neurolytic caudal epidural block for rectal tenesmus, we consider the block appropriate for the symptom.

Effectiveness of the superior hypogastric plexus neurolytic block in the management of pelvic abdominal pain in adult patients diagnosed with cancer: A systematic literature review / Efectividad del bloqueo neurolítico del plexo hipogástrico superior en el manejo del dolor abdominopélvico en pacientes adultos con diagnóstico de cáncer. Revisión sistemática de la literatura

INTRODUCTION: Severe oncological pain occurs in up to 60% of pelvic abdominal cáncer patients, being refractory to medical management in up to 30% of cases. In 1990, the superior hypogastric plexus neurolytic block (SHPB) was described for the control of pain in these patients. This study aimed to evaluate the effectiveness of this technique for the control of oncological pain. METHODOLY: Studies that evaluated the effectiveness of the SHPB using the classic or transdiscal approach in adult patients with oncological abdominal-pelvic pain were systematically reviewed. A search was conducted in PubMed, EMBASE and Scopus from January 1, 1990, to August 31, 2019, without a language restriction. The visual analog scale (VAS), morphine milligram equivalents (MME) per day, quality of life and presence of complications were recorded. The quality of the studies was evaluated using the Jadad and Ottawa-Newcastle scales. RESULTS: Eight studies met the inclusión criteria: 6 were descriptivo longitudinal studies, and 2 were controlled clinical trials, comprising 316 patients (75% female and 25% male; average age 53.2 years); the most frequent diagnoses were gynecological (65%) cancer. An average VAS reduction of 55%-60.8% was obtained as well as a MME reduction of 40%-60%. Three studies evaluated the quality of life using the (QLQ-C30), (PSS) and Zubrod scale all with positive results. Complications were reported in 18% of cases, pain related to the puncture was the most frequent. CONCLUSIONS: The SHPB may be an effective for the control of severe oncological abdominal-pelvic pain, decreasing the VAS and MME and improving the quality of life of patients.

INTRODUCCIÓN: El dolor oncológico severo se presenta hasta en el 60% de los pacientes con cáncer abdominopélvico, siendo refractario al manejo médico hasta en el 30% de los casos. En 1990, se describió el bloqueo del plexo hipogástrico superior (BPHS) para el control de dolor en estos pacientes. Nuestro objetivo en este estudio fue evaluar la efectividad de esta técnica. METODOLOGÍA: Se realizó una revisión sistemática de estudios que evaluaron la efectividad del BPHS técnicas guiadas por fluoroscopio en pacientes adultos con dolor oncológico abdominopélvico. Se realizó una búsqueda en Pubmed, EMBASE y Scopus desde el 1de enero de 1990 hasta el 31 de agosto de 2019, sin restricción de idioma. Se evaluó la escala visual análoga, el consumo de opioides: dosis equivalente de morfina día, calidad de vida, presencia de complicaciones y se evaluó la calidad de los estudios mediante escalas Jadad y Ottawa- Newcastle. RESULTADOS: Ocho estudios cumplieron los criterios de inclusión, 6 fueron longitudinales descriptivos y 2 ensayos clínicos controlados, con un total de 316 pacientes, 75% femenino y 25% masculino; edad promedio 53,2 años; diagnóstico más frecuente: Cáncer ginecológico (65%). Se logró una reducción de la escala visual análoga (EVA) de 55%-60,8% y reducción de la dosis equivalente de miligramos de morfina oral día (DEMO) del 40%-60%. Tres estudios evaluaron la calidad de vida con las escalas QLQ-C30, PSS y Zubrod, mostrando mejoría en todas. Se reportaron complicaciones en 18% de los casos, siendo el dolor en el sitio de punción la más frecuente.CONCLUSIONES: El BPHS puede ser efectivo en el control de dolor oncológico de origen abdominopélvico, disminuyendo escala visual análoga (EVA), dosis equivalente de miligramos de morfina oral día (DEMO) y mejorando la calidad de vida. Sin embargo, se requieren de estudios adicionales para dar una recomendación con alta calidad de evidencia.

Advances in pancreatic cancer pain and its treatment / 复旦学报（医学版）

Pancreatic cancer is a malignant digestive system tumor.The incidence of pancreatic cancer is rising,the prognosis is very poor,the mortality rate is extremely high (almost 100％),and the 5-year survival rate is less than 5％.One of the main symptoms of this tumor is pain and mostly neuropathic origin,which significantly decreases the quality of life and the impacts on patient's functional activity.The most common pain treatment for pancreatic cancer is drug analgesia therapy,which is based on the WHO analgesic ladder rule.However,it is not always effective,and many side effects reduce the quality of life of patients.Invasive treatment of pain in pancreatic cancer mainly includes neurolytic celiac plexus block and splanchnicectomy,which can significantly reduce the level of pain and help to improve the quality of life.Invasive remedies should not be applied at the final stage and should be considered in the early stages of the disease (such as the first or second step of the WHO analgesic ladder).This paper comprehensively analyzes the current clinical treatment of pancreatic cancer pain and evaluates its effectiveness,and hopes to provide more information on the treatment of pain in patients with pancreatic cancer.

Postoperative early stress response alleviated by celiac plexus block after partial hepatectomy in rats / 局解手术学杂志

Objective To investigate the effects of neurolytic celiac plexus block(NCPB) on stress response during the early stage of partial hepatectomy(PH) postoperation in rats.Methods Thirty healthy SPF-grade male Sprague-Dawley rats were randomly divided into control group and NCPB group,and then were constructed the 70％ PH model.NCPB group received NCPB with 0.5 ％ lidocaine before closing abdominal,and control group received the same procedures,but 0.9％ physiological saline was injected instead of 0.5 ％ lidocaine.The serum concentration of CRP,GC,ACTH,NA and AD,and the levels of serum TNF-α and IL-1β were determined at 6 hours,12 hours and 24 hours after PH.The western blot assay was performed to examine the expression of GR in the peripheral blood mononuclear cells (PBMCs).Results The obvious stress response was produced within 24 hours after PH in rats,postoperative serum CRP,GC,ACTH,NA and AD concentrations increased in the different extent,but the NCPB group were significantly lower than those in the control group in the corresponding time point (P ＜0.01 or P ＜0.05).The expression levels of GR in PBMCs in the control group were significantly decreased after PH,and markedly lower than those in the NCPB group in the corresponding time point(P ＜ 0.01).The serum TNF-o and IL-1β levels were gradually increased in the control group and NCPB group within 24 hours after PH.But at the respective time points,the levels in the NCPB group were significantly lower than those in control group(P ＜ 0.01 or P ＜ 0.05).Conclusion Intraoperation NCPB can effectively inhibit postoperative stress response at the early stage after PH,and thereby help to reduce the degree of systemic inflammatory response.

Invasive treatment to control neuropathic pain / Tratamento invasivo para o controle da dor neuropática

ABSTRACT BACKGROUND AND OBJECTIVES: Distress, allied to neuropathic pain persistence and its refractory nature, often leads patients to accept invasive procedures. Neuropathic pain control is a major medical challenge requiring approaches and decisions especially based on effectiveness, risks and costs. This study aimed at reviewing these aspects related to major invasive procedures. CONTENTS: Major invasive procedures to control neuropathic pain are presented. Initially, classically reversible anesthetic blocks; then invasive neuromodulation techniques using electric current application and the magnetic field generated by it becomes a target to be stimulated, inhibited or modified in the nervous system (central, peripheral or autonomic); and, finally, ablative procedures including anesthetic methods administering neurolytic agents rather than anesthetics and neurosurgeries using different methods to injure the nervous system to control painful neuropathic discomfort. CONCLUSION: Patients eligible to invasive procedures to control neuropathic pain have, in addition to pain itself, a mixed distress including the collection of repeated delusions at every treatment failure. They have reserved prognosis with regard to total cure and, unfortunately, relieve obtained with invasive treatment in general does not reach persistent and high rates. In such adverse situation, these partial results of decreasing original pain intensity may be interpreted as acceptable, provided the impact on final quality of life is positive. Maybe, the rare exceptions are good results obtained with typical idiopathic/cryptogenic neuralgias ironically excluded from the stricter interpretation of the new pathophysiologic classification of neuropathic pains.

RESUMO JUSTFICATIVA E OBJETIVOS: O sofrimento aliado à persistência e refratariedade da dor neuropática frequentemente leva seu portador a aceitar tratamentos invasivos. O controle da dor neuropática representa um desafio médico importante necessitando adoção de condutas e decisões baseadas, principalmente, em efetividade, riscos e custos. O escopo deste estudo foi a revisão desses aspectos relacionados aos principais procedimentos invasivos CONTEÚDO: São apresentados os principais procedimentos invasivos utilizados para o controle da dor neuropática. Inicialmente, os bloqueios anestésicos, classicamente reversíveis; depois as técnicas de neuromodulação invasiva que utilizam a aplicação de corrente elétrica e o campo magnético por ela gerado em alvos a serem estimulados, inibidos ou modificados, no sistema nervoso (central, periférico ou autônomo); e, finalmente, os procedimentos ablativos que incluem os métodos anestésicos que administram agentes neurolíticos ao invés de anestésicos, e, as neurocirurgias que utilizam métodos diversos de produção de lesões no sistema nervoso para o controle do desconforto doloroso neuropático. CONCLUSÃO: Os pacientes que se apresentam como candidatos a receberem indicações de procedimentos invasivos para controle de dores neuropáticas, possuem além do inerente à própria dor, sofrimento misto, que inclui a coleção de desilusões reiteradas a cada insucesso de tratamento. Possuem prognóstico reservado no que tange a plena cura, e, infelizmente, o alívio obtido com o tratamento invasivo, em geral, não atinge taxas persistentes e elevadas. Nessa situação tão adversa esses resultados parciais de redução da intensidade da dor original possam ser interpretados como aceitáveis desde que o impacto na qualidade de vida final seja positivo. Talvez, as raras exceções, recaiam sobre os bons resultados obtidos com as neuralgias típicas, idiopáticas/criptogenéticas, ironicamente, excluídas da interpretação mais rígida da nova classificação fisiopatológica das dores neuropáticas.

Clinical Identification of the Vertebral Level at Which the Lumbar Sympathetic Ganglia Aggregate

BACKGROUND: The location and the number of lumbar sympathetic ganglia (LSG) vary between individuals. The aim of this study was to determine the appropriate level for a lumbar sympathetic ganglion block (LSGB), corresponding to the level at which the LSG principally aggregate. METHODS: Seventy-four consecutive subjects, including 31 women and 31 men, underwent LSGB either on the left (n = 31) or the right side (n = 43). The primary site of needle entry was randomly selected at the L3 or L4 vertebra. A total of less than 1 ml of radio opaque dye with 4% lidocaine was injected, taking caution not to traverse beyond the level of one vertebral body. The procedure was considered responsive when the skin temperature increased by more than 1℃ within 5 minutes. RESULTS: The median responsive level was significantly different between the left (lower third of the L4 body) and right (lower margin of the L3 body) sides (P = 0.021). However, there was no significant difference in the values between men and women. The overall median responsive level was the upper third of the L4 body. The mean responsive level did not correlate with height or BMI. There were no complications on short-term follow-up. CONCLUSIONS: Selection of the primary target in the left lower third of the L4 vertebral body and the right lower margin of the L3 vertebral body may reduce the number of needle insertions and the volume of agents used in conventional or neurolytic LSGB and radiofrequency thermocoagulation.

Bloqueo neurolítico de neuromas recidivantes guiado por ultrasonografía / Neurolytic blockof recurrent neuromas guided by ultrasound

Los neuromas de muñón son causa de dolor intenso de difícil control. El bloqueo neurolítico es una alternativa en el tratamiento, y el uso de la ultrasonografía se impone para garantizar la efectividad del proceder. En este reporte de caso se describe la realización de la neurolisis con alcohol absoluto de varios neuromas recidivantes en un muñón de miembro superior, guiados por ultrasonido, en un paciente con dolor crónico que no resuelve con tratamiento médico.

Stump-neuromas cause difficult deep pain control. Neurolytic block is an alternative treatment, and ultrasound guarantee the certainty of the procedure. This case report describes the realization of neurolysis with total alcohol of various stump-neuromas, guided by ultrasound, in a patient with chronic pain that don´t solve with medic treatment.

The effect of neurolytic celiac plexus block on liver inflammatory reaction after partial hepatectomy in rats / 中华肝胆外科杂志

Objective To investigate the effect of neurolytic celiac plexus block (NCPB) on the inflammatory reaction of the remaining liver tissue and liver function after partial hepatectomy (PH) in rats.Methods Thirty male Sprague-Dawley rats of SPF were constructed as a PH model with deligation and ablation operated on their left and middle lobes,respectively.Then,they were randomly divided into two groups:NCPB group and control group.Twelve hours after the surgery,0.5％ lidocaine was given in the NCPB group once a day,while 0.9％ saline was given in the control group.Determination of liver function,generation of the remaining liver,and deposition of IL-β,TNF-α of the pathological section was respectively made on Day 1,3 and 7 after the surgery.Results On Day 1,3 and 7 after surgery,both the aspartate aminotransferase (AST) and the alanine aminotransferase (ALT) levels in NCPB group were,to different degrees,lower than those in the control group (P ＜ 0.05).Strikingly,total bilirubin in NCPB group was lower than that in control group (P ＜ 0.01) on Day 7,while the level of semm albumin was higher than that in control group (P ＜ 0.01).There was no statistically significant difference on the generation of the remaining livers between NCPB and control groups.On Day 3 and 7,the deposition of IL-β,TNF-α in the pathological sections of NCPB group were lower than those in control group.Conclusion NCPB can not only effectively reduce the damage of liver function caused by PH surgery,but also improve the inflammatory reaction of the residual liver.

Bloqueio neurolítico subaracnoideo em paciente com dor oncológica refratária: relato de caso / Subarachnoid neurolytic blockade in patient with refractory cancer pain: case report

JUSTIFICATIVA E OBJETIVOS: O uso de bloqueio neurolítico subaracnoideo no controle de dor tem diminuído nos últimos anos devido à introdução de novas técnicas, mas ainda tem importância no controle de dor oncológica refratária. O objetivo deste estudo foi apresentar um caso de dor oncológica, em que esta técnica foi utilizada para controle da dor. RELATO DO CASO: Paciente do sexo masculino, 45 anos, diagnosticado com carcinoma espinocelular de canal anal localmente avançado e lesão ulcerada em região perineal com presença de fístula retovesical e infecção local. O paciente apresentava dor intensa com escala verbal numérica (EVN) =10 e recebia tratamento farmacológico com doses altas de opioide e adjuvantes sem boa resposta. Foi realizado bloqueio neurolítico subaracnoideo com fenol a 5% e após realização do bloqueio houve melhora significativa do quadro doloroso, tendo paciente referindo alívio de 80% após 20 minutos do procedimento. A melhora permaneceu até o 21º dia após bloqueio quando o paciente foi a óbito devido complicações infecciosas. CONCLUSÃO: O caso ilustrou o uso do bloqueio subaracnoideo com fenol a 5% para controle de dor oncológica. Conclui-se que para casos selecionados, onde a expectativa de vida é limitada, esta técnica pode ser empregada com sucesso.

BACKGROUND AND OBJECTIVES: The use of subarachnoid neurolytic blockade to control pain has decreased in recent years due to the introduction of new techniques, but it is still important to control refractory cancer pain. This study aimed at presenting a case of cancer pain where this technique was used to control pain. CASE REPORT: Male patient, 45 years old, with locally advanced anal canal scamous cell carcinoma and ulcerated lesion in perineal region with enterovesical fistula and local infection. Patient had severe pain with numerical verbal scale (NVS) = 10 and was being pharmacologically treated with high opioid doses and adjuvants without good response. Subarachnoid neurolytic blockade was induced with 5% phenol with significant pain relief; 20 minutes after the procedure patient has referred 80% relief. Improvement has remained for 21 days when patient died due to infectious complications. CONCLUSION: This case has illustrated the use of subarachnoid blockade with 5% phenol to control cancer pain. The conclusion is that for selected cases, where life expectation is limited, this technique may be successfully used.

Advances in the research of neurolytic celiac plexus block / 中国肿瘤临床

Neurolytic celiac plexus block (NCPB) is an effective method used to alleviate upper abdominal pain or back pain caused by pancreatic cancer and other malignancies. NCPB can relieve cancer pain to improve the quality of life and cause fewer side effects than conventional analgesic drugs. This article systemically reviewed NCPB methodology and research progress in clinical appli-cations.

Ejaculatory Failure after Unilateral Neurolytic Celiac Plexus Block

Abdominal pain associated with chronic pancreatitis is often difficult to control with analgesics and can be severely debilitating with significant impairment of quality of life. In these patients, neurolytic celiac plexus block (NCPB) is an effective treatment option with a low complication rate. However, there is a risk of ejaculatory failure after NCPB, which may be a problem in patients with a long life expectancy. We report a case of ejaculatory failure after unilateral NCPB in a patient with chronic pancreatitis.

CT-guided cervical approach neurolytic therapy of glossopharyngeal nerve / 中国微创外科杂志

Objective To investigate the effects of CT-guided cervical approach neurolytic therapy of glossopharyngeal nerve in the treatment of glossopharyngeal neuralgia and intractable pain of glossopharyngeal nerve innervation area. Methods A total of 16 cases of glossopharyngeal neuralgia (Group A) and 12 cases of intractable pain of glossopharyngeal nerve innervation area (Group B) were included in this study. Under the guidance of CT scanning, a percutaneous needle puncture was carried out located on the anterior border of the styloid process at the level of the second cervical vertebra. The 7% phenol glycerin solution was injected after the glossopharyngeal nerve was blocked by the local anesthetic. Results The complete remission rate and the total effective rate in the Group A were 87.5% (14/16) and 100% (16/16), respectively. The corresponding values in the Group B were 50% (6/12) and 83.3% (10/12), respectively. Follow-up observations for 6 months found no recurrence in the Group A and 6 cases (50.0%) of recurrence in the Group B. No severe complications occurred in both of groups. Conclusions CT-guided cervical approach neurolytic therapy of glossopharyngeal nerve is characterized by high reliability, accurate location, good operational safety, and fewer complications.

MR-guided Neurolytic Celiac Plexus Block for Treatment of Upper Abdominal Cancer Pain / 实用放射学杂志

Objective To evaluate the value of MR-guided neurolytic celiac plexus block(NCPB)for treatment of upper abdominal cancer pain.Methods 13 neurolytic celiac plexus blocks were carried out in 12 patients with severe upper abdominal pain caused by malignant tumors.The pain-relieving effect of the block was both evaluated using visual analogue scale(VAS) and analyzed statistically in all cases.Results The placement of the needle MR-guided was easy and accurate,the successful rate of the puncture was 92%.There were no severe complications.The pain before and after the procedure had obvious difference and the pain relief could last for a long time.Conclusion MR-guided NCPB is a simple and effective technique for treatment of upper abdominal cancer pain.

Clinical Experience of Pituitary Injectin of Phenol for Relief of Cancer Pain / 대한마취과학회지

Moriccas technique, neuroadenolysis of the pituitary gland through direct injection of alcohol, was performed 5 times on three cancer patients at chonnam university hospital. Two of the three patients had complete pain relief. During this procedure there was no any severe complications except diabetes insipidus, but it was treated uneventfully with indomethacin and fluid administration. Although several theories including destructiorr of the thalamic and hypothalamic nerve pathway, pituitary hormone and endorphin on the mechanism of pain relief by the neuroadenolysis have been reported, it is still not clearly determined. This technique is considered to be an exceedingly useful method for management of intractable pain in inoperable cancer patients.

Intrathecal Block with 15 % Phenol in Glycerine for Pain of Rectal Cancer / 대한마취과학회지

This patient who was a 42-year-old female had suffered from bearing down sensation and pain on anal region due to metastatic rectal cancer. She was done intrathecal block with 15% phenol in glycerine. The result was exellent to bearing down sensation and pain on anal area. Because lower back pain, pain on lower extremity and generalized painful sensation was not improved, we has done pharmacologic assistance. Urination difficulty became slightly aggrevated but was improved at post-block day 4th. This pain clinic report that intrathecal block with 15% phenol in glycerine was effective to treatment of cancer pain without major complications.