Predictors of analgesic efficacy of neurolytic celiac plexus block in patients with unresectable pancreatic cancer: the importance of timing

Long-Term Analgesic Efficacy of Neurolytic Splanchnic Nerve Block via the Transintervertebral Disc Approach to Retrocrural Space: A Multicenter Retrospective Study

INTRODUCTION

The celiac plexus block is effective for treating intractable cancer pain and has been the focus of many studies. At our affiliated institution, fluoroscopy-guided splanchnic nerve block with a single needle via the transintervertebral disc approach was the first choice of treatment. The short-term efficacy of this technique has been reported, but the long-term efficacy is not clear. In the present study, we investigated the long-term analgesic efficacy of this technique.

METHODS

This multicenter, retrospective, observational study reviewed the medical records of patients who underwent neurolytic splanchnic nerve block (NSNB) via the transintervertebral disc approach for intractable cancer pain at five tertiary hospitals in Japan from April 2005 to October 2020. The primary outcome was the long-term analgesic efficacy of a one-time NSNB via the transintervertebral disc approach.

RESULTS

In total, 76 patients were included in the analysis. The median lowest numerical rating scale (NRS) score was 1 within 14 days. At 1, 2, 3, and 6 months after the nerve block, the median NRS score was also ≤ 2, while the median equivalent oral morphine dose did not show any clinically noticeable increase at those times.

CONCLUSION

The long-term analgesic efficacy of NSNB via the transintervertebral disc approach in patients with intractable cancer pain has been demonstrated.

Role of interventional radiology in pain management in oncology patients

This article reviews the current evidence of interventional radiology procedures for patients suffering with debilitating cancer pain, refractory to conventional therapies. Cancer pain is notoriously difficult to treat. Up to 90% of cancer patients experience pain with 56-82% of cancer pain controlled inadequately. Cancer pain influences a patient's ability to perform normal daily activities, causes higher risk of depression, and reduces quality of life. Pain-free status has been universally voted as a "good death". Alternative minimally invasive options include nerve blocks, neurolysis, bone ablation, spine and peripheral musculoskeletal augmentation techniques, embolisation, and cordotomy with evidence highlighting improved pain control, reduced analgesic requirements, and improved quality of life. Unfortunately, awareness and availability of these procedures is limited, potentially leaving patients suffering during their remaining life. The purpose of this review is to describe the basic concepts of interventional radiology techniques for pain palliation in oncology patients. In addition, emphasis will be given upon the need for an individually tailored approach aiming to augment efficacy and safety.

Opioid withdrawal symptoms after neurolytic splanchnic nerve block in cancer patients

PURPOSE

Few reports on opioid withdrawal (OW) due to opioid tapering in cancer patients have been published. The incidence of and risk factors for OW after neurolytic splanchnic nerve block (NSNB) are unknown. This study aimed to elucidate the incidence of and risk factors for OW among cancer patients who could have reduced opioid doses after NSNB.

METHODS

This was a multicenter, retrospective, observational study. We reviewed the medical charts of patients who underwent NSNB for intractable cancer pain at four tertiary hospitals in Yokohama City from April 2005 to October 2020. We included patients whose opioid dose was reduced by > 5 mg/day (equivalent oral morphine dose) within 14 days after NSNB. We classified the patients into two groups according to the presence or absence of OW symptoms and compared them.

RESULTS

Of the 50 patients who underwent NSNB, 24 were included in the study. OW was observed in five (20.8%) patients. Pain and opioid use duration were significantly longer in OW patients than in non-OW patients (median pain duration 689 vs. 195 days; P < 0.043 and median opioid use duration 486 vs. 136 days; P < 0.030). The opioid tapering dose was significantly larger in patients with OW than in those without OW (median opioid tapering dose 75 vs. 40 mg; P < 0.046).

CONCLUSIONS

OW was observed in 20.8% of the patients in the study. A longer pain and opioid use duration and a larger opioid tapering dose may predispose patients to OW.

Efficacy and Safety of Neurolytic Splanchnic Nerve Block via Transintervertebral Disc Approach to Retrocrural Space: A Multicenter Retrospective Study

INTRODUCTION

Celiac plexus block is effective for treating intractable cancer pain and has been the focus of many studies. Several guiding techniques such as fluoroscopy, computed tomography, and endoscopy have been devised, and the target of the block has varied in previous studies as both the celiac plexus and splanchnic nerve, which is the main origin of the celiac plexus, have been targeted. At our affiliated institution, fluoroscopy-guided splanchnic nerve block with a single needle via transintervertebral disc approach is the first choice. However, there have been few reports on the use of this technique. This study investigated the efficacy and safety of this technique.

METHODS

This multicenter retrospective observational study reviewed the medical records of patients who underwent neurolytic splanchnic nerve block (NSNB) via transintervertebral disc approach for intractable cancer pain at five tertiary hospitals in Japan from April 2005 to October 2020. The primary outcome was the clinical success ratio of NSNB, and the secondary outcome was the incidence ratio of NSNB-related adverse events.

RESULTS

In total, 103 patients were included in the analysis. Of these, 77 patients met the definition of clinical success, with a ratio of 74.8%. The incidence ratio of NSNB-related adverse events was 40.8% (hypotension, 21.4%; alcohol intoxication, 13.6%; diarrhea, 11.7%; and vascular puncture, 3.9%; duplicates were present). All adverse events improved with observation and symptomatic treatment only. No patient had infection or serious adverse events such as organ or nerve damage.

CONCLUSIONS

The clinical success ratio of this technique was 74.8%. Although the incidence of adverse events was 40.8%, all events were mild and no serious adverse events were observed. The findings demonstrate the efficacy and safety of our NSNB in patients with intractable cancer pain.

Is the Erector Spinae Plane Block Effective for More than Perioperative Pain? A Retrospective Analysis

Introduction: The thoracic Erector Spinae Plane Block (ESPB) is an ultrasound-guided block that has gained popularity and is widely used in acute pain setups. However, data regarding its role in chronic and cancer-related pain are anecdotal. Material and Methods: The study is a retrospective analysis of patients who underwent ESPB. The cohort was divided into subgroups based on three determinants: etiology, pain type, and chronicity. Results: One hundred and ten patients were included, and genders were affected equally. The average age was 61.2 ± 16.1 years. The whole group had a statistically significant reduction in a numerical rating scale (NRS) (7.4 ± 1.4 vs. 5.0 ± 2.6, p-value > 0.001). NRS reduction for 45 patients (41%) exceeded 50% of the pre-procedural NRS. The mean follow-up was 7.9 ± 4.6 weeks. Baseline and post-procedure NRS were comparable between all subgroups. The post-procedural NRS was significantly lower than the pre-procedural score within each group. The proportion of patients with over 50% improvement in NRS was lower for those with symptom duration above 12 months (p-value = 0.02). Conclusions: Thoracic ESPB is a simple and safe technique. The results support the possible role of ESPB for chronic as well as cancer-related pain.

Splanchnic nerve neurolysis via the transdiscal approach under fluoroscopic guidance: a retrospective study

Background

Neurolytic celiac plexus block (NCPB) is a typical treatment for severe epigastric cancer pain, but the therapeutic effect is often affected by the variation of local anatomical structures induced by the tumor. Greater and lesser splanchnic nerve neurolysis (SNN) had similar effects to the NCPB, and was recently performed with a paravertebral approach under the image guidance, or with the transdiscal approach under the guidance of computed tomography. This study observed the feasibility and safety of SNN via a transdiscal approach under fluoroscopic guidance.

Methods

The follow-up records of 34 patients with epigastric cancer pain who underwent the splanchnic nerve block via the T11-12 transdiscal approach under fluoroscopic guidance were investigated retrospectively. The numerical rating scale (NRS), the patient satisfaction scale (PSS) and quality of life (QOL) of the patient, the dose of morphine consumed, and the occurrence and severity of adverse events were recorded preoperatively and 1 day, 1 week, 1 month, and 2 months after surgery.

Results

Compared with the preoperative scores, the NRS scores and daily morphine consumption decreased and the QOL and PSS scores increased at each postoperative time point (P < 0.001). No patients experienced serious complications.

Conclusions

SNN via the transdiscal approach under flouroscopic guidance was an effective, safe, and easy operation for epigastric cancer pain, with fewer complications.

CT-Guided Coeliac Plexus Neurolysis in Patients with Intra-Abdominal Malignancy: A Retrospective Evaluation of 52 Palliative In-Patients

INTRODUCTION

Prevalence rates of chronic abdominal pain (CAP) and breakthrough cancer pain (BTcP) are high in patients with intra-abdominal malignancies. As part of a multimodal approach, CT-guided coeliac plexus blockade (CPB) and CT-guided coeliac plexus neurolysis (CPN) are commonly used pain management strategies. The aim of this study was to evaluate pain outcomes among patients with intra-abdominal malignancies who underwent CPB and/or CPN.

METHODS

Patients with intra-abdominal malignancies who underwent CPB and/or CPN for pain control at the general hospital Klagenfurt am Wörthersee from 2010 to 2019 were enrolled.

RESULTS

A total of 84 procedures (24 CPB and 60 CPN) were performed on 52 patients; 62% of these patients had pancreatic cancer. CPN led to significant pain reduction and decreased BTcP intensity. Patients receiving repeated CPN showed higher individual pain reduction. Higher pre-procedural pain intensity was correlated with higher pain reduction. No difference in pain reduction in patients receiving a diagnostic CPB prior to CPN compared to patients without a diagnostic CPB was found. Higher pain reduction after CPN led to longer-lasting pain relief. The time frame from diagnosis to CPN was 472 (± 416) days. Patients experienced a mean duration of pain prior to CPN of 330 (± 53) days. The time frame from diagnosis to CPN was shorter in patients with pancreatic cancer compared to other intra-abdominal malignancies. In 58% of patients pain medication was stable or was reduced after CPN; 16% of patients complained about pain during the procedure; no major complications occurred. There was no correlation between median survival after CPN and pain outcomes.

CONCLUSIONS

In patients with intra-abdominal malignancy-related CAP, CPN is a safe and effective procedure which can provide long-lasting significant relief of background pain and BTcP. As part of a multimodal approach, CPN should be considered as an earlier option for pain management in these patients.

Celiac plexus neurolysis for abdominal cancers: going beyond pancreatic cancer pain

Celiac plexus neurolysis is primarily used for pancreatic cancer pain, but other symptoms and other cancers may also benefit from this intervention.

Introduction:

Celiac plexus neurolysis (CPN) has been verified for mitigating pancreatic cancer pain. However, information regarding CPN's use beyond this remains limited.

Objectives:

Identify which cancers benefit from CPN, which symptoms improve, and when symptoms improve.

Methods:

Retrospective analysis was conducted on 173 patients who received CPN for pain caused by various malignancies. Mean symptom changes on the MD Anderson Symptom Inventory (MDASI) from baseline to 2 weeks, 1 month, and 2 months after CPN were analyzed overall and then by cancer type: pancreatic (all stages and stages III–IV), hepatobiliary, and nonpancreatic, nonhepatobiliary gastrointestinal (NPNH-gastrointestinal).

Results:

Eighty-two pancreatic, 43 NPNH-gastrointestinal, 14 hepatobiliary, and 34 patients with other cancers met inclusion criteria. Statistically significant changes included decrease in the pain score at 1 month by 1.01 points for all cancers, 1.65 points for all pancreatic cancers, and 1.88 points for late-stage pancreatic cancers. At 2 months, pain decreased by 1.50 points for all cancers, 1.68 points for all pancreatic cancers, 2.37 points for late-stage pancreatic cancers, and 1.50 points in NPNH-gastrointestinal cancers. At 2 months, quality of life improved by 1.07 points for all cancers and 1.53 points for all pancreatic cancers. Sleep improved at 2 months for all cancers by 0.73 points and 1.60 points in late-stage pancreatic cancers. At 2 months, pancreatic cancer patients improved in general activity by 0.93 points, walking by 1.00 points, and working by 1.12 points.

Conclusion:

Celiac plexus neurolysis can decrease cancer symptom burden beyond pain including quality of life and sleep for pancreatic and nonpancreatic cancers, as well as general activity for pancreatic cancers.

A New Solution to an Old Problem: Ultrasound-guided Cervical Retrolaminar Injection for Acute Cervical Radicular Pain: Prospective Clinical Pilot Study and Cadaveric Study

STUDY DESIGN

Prospective clinical pilot study and cadaveric study.

OBJECTIVE

The aim of this study was to evaluate the spread of an ultrasound-guided interfascial plane blocks (UGIPBs) and its potential efficacy for cervical radiculopathy.

SUMMARY OF BACKGROUND DATA

Cervical radiculopathy is a common disorder, potentially leading to severe pain and disability. Conservative treatment with cervical epidural steroid injections (ESI) is limited by concerns regarding their safety. UGIPBs are used in cervical surgical procedures as part of the multimodal postoperative analgesia regimen however, were not described for cervical radiculopathy.

METHODS

Twelve patients with acute cervical radicular pain who failed conservative treatment and were candidates for surgery were offered a cervical retrolaminar injection. A solution of 4 mL lidocaine 0.5% and 10 mg dexamethasone was injected, assisted by ultrasound guidance, at the posterior aspect of the cervical lamina corresponding to the compressed nerve root level. Additionally, a cadaver study was carried to evaluate the contrast spread and infiltration into near structures, both anatomically and radiographically.

RESULTS

Twelve patients underwent the procedure, with a mean follow-up time of 14.5 weeks. Average numerical rating scale improved from 7.25 at baseline to 2.83 following the injection (P < 0.001). Three patients received 2 to 3 injections without significant improvement and were eventually operated. No adverse events were reported.In the cadaver study, fluoroscopy demonstrated contrast spread between T1 and T3 caudally, C2 to C5 cranially and facet joints laterally. Anatomically, the dye spread was demonstrated up to C2 cranially, T1 caudally, the articular pillars of C4 to C7, and the neural foramen of C6 laterally.

CONCLUSION

A solution injected into the cervical retrolaminar plane can diffuse in the cranial-caudal axis to C2-T3 and laterally to the facet joints and the cervical neural foramen. Our pilot study confirmed the feasibility of our study protocol. Future studies are needed to support our early results.Level of Evidence: 4.

Endoscopic ultrasound-guided neurolysis in advanced pancreatic cancer: current status

Pancreatic cancer has a very poor prognosis with patients often presenting with locally advanced, inoperable or metastatic disease. A significant proportion of patients have visceral pain due to perineural infiltration or coeliac plexus involvement by the tumour. This pain is difficult to control and may become refractory to conventional pain management. Therefore, coeliac plexus neurolysis (CPN) has been proposed to ablate the neuronal transmission pathway of pain permanently. CPN is recommended for those who have uncontrolled pain, are experiencing unacceptable opioid adverse effects or are receiving escalating doses of analgesics. It is not known whether CPN performed at diagnosis as the first-line treatment ('early') would impact short-term and long-term pain control and quality of life. NICE has recommended (2018) a randomised trial comparing early endoscopic ultrasound-guided coeliac plexus neurolysis (EUS-CPN) with on-demand EUS-CPN in pancreatic cancer. In this context, we will review the current evidence on its clinical benefits.

Factors associated with successful response to neurolytic celiac plexus block in patients with upper abdominal cancer-related pain: a retrospective study

Background

Prior studies have reported that 40%-90% of the patients with celiac plexus-mediated visceral pain benefit from the neurolytic celiac plexus block (NCPB), but the predictive factors of response to NCPB have not been evaluated extensively. This study aimed to identify the factors associated with the immediate analgesic effectiveness of NCPB in patients with intractable upper abdominal cancer-related pain.

Methods

A retrospective review was performed of 513 patients who underwent NCPB for upper abdominal cancer-related pain. Response to the procedure was defined as (1) a decrease of ≥ 50% or ≥ 4 points on the numerical rating scale (NRS) in pain intensity from the baseline without an increase in opioid requirement, or (2) a decrease of ≥ 30% or ≥ 2 points on the NRS from the baseline with simultaneously reduced opioid consumption after NCPB. Logistic regression analysis was performed to determine the factors associated with successful responses to NCPB.

Results

Among the 513 patients included in the analysis, 255 (49.8%) and 258 (50.2%) patients were in the non-responder and responder group after NCPB, respectively. Multivariable logistic regression analysis showed that diabetes (odds ratio [OR] = 0.644, P = 0.035), history of upper abdominal surgery (OR = 0.691, P = 0.040), and celiac metastasis (OR = 1.496, P = 0.039) were the independent factors associated with response to NCPB.

Conclusions

Celiac plexus metastases, absence of diabetes, and absence of prior upper abdominal surgery may be independently associated with better response to NCPB for upper abdominal cancer-related pain.

Reasons for failure to perform interventional pain procedures in cancer patients: an analysis of pain clinic consultations

Background

Interventional pain procedures (IPPs) may be necessary for some cancer patients when conservative treatment fails. However, many IPPs are often delayed or cancelled for cancer patients who are referred to the pain clinic.

Methods

We retrospectively analyzed the reasons for such cancellations to identify clinically avoidable causes of the delay in IPP.

Results

We enrolled 350 cancer patients who were referred to our pain clinic for an IPP between March 2016 and February 2018. There were 213 (60.9%) cases that were cancelled, among which 115 (54%) cases were potentially avoidable and 98 (46%) were unavoidable. The most common reasons for cancellation were patient-derived factors, which accounted for 85 (39.9%) cases. Patient refusal was a common reason for cancellation, with 33 (15.5%) cases attributed to this cause. The primary avoidable causes of cancellation were a recommendation that the patient continue with their current pharmacological pain treatment, conflict with another planned treatment, and pain characteristics that were not suitable for an IPP. Together, these accounted for 76.5% of all avoidable cancellations.

Conclusions

Comprehensive and accurate pain assessments before IPP may result in more favorable outcomes for the efficient use of medical resource and effective pain relief in cancer patients.

Tailoring of neurosurgical ablative procedures in the management of refractory cancer pain

INTRODUCTION

Neurosurgical ablative procedures can offer immediate and effective pain relief for patients suffering from refractory cancer pain. However, choosing the appropriate procedure for each patient may not be straightforward and warrants an interdisciplinary approach. The purpose of the current study was to evaluate the outcome of patients with cancer who were carefully selected for neurosurgical intervention by a dedicated interdisciplinary team composed of a palliative physician and nurse practitioner, a pain specialist and a neurosurgeon.

METHODS

A retrospective review was carried out on all patients who underwent neurosurgical ablative procedures in our institute between March 2015 and September 2019. All patients had advanced metastatic cancer with unfavorable prognosis and suffered from intractable oncological pain. Each treatment plan was devised to address the patients' specific pain syndromes.

RESULTS

A total of 204 patients were examined by our service during the study period. Sixty-four patients with localized pain and nineteen patients with diffuse pain syndromes were selected for neurosurgical interventions, either targeted disconnection of the spinothalamic tract or stereotactic cingulotomy. Substantial pain relief was reported by both groups immediately (cordotomy: Numerical Rating Scale (NRS) 9 ≥1, p=0.001, cingulotomy: NRS 9 ≥2, p=0.001) and maintained along the next 3-month follow-up visits.

CONCLUSIONS

An interdisciplinary collaboration designated to provide neurosurgical ablative procedures among carefully selected patients could culminate in substantial relief of intractable cancer pain.

TRIAL REGISTRATION NUMBER

IR0354-17.

Pain Outcomes After Celiac Plexus Block in Children and Young Adults with Cancer

Purpose: The use of celiac plexus block (CPB) for abdominal pain has been extensively reported in adults. However, pediatric literature is limited to three single case reports and a series of three cases. This study evaluated the effectiveness of CPB in children and young adults (aged 8-20 years) with abdominal malignancies. Methods: Pain outcomes after CPB were evaluated in four children and young adults with cancer. Mean daily pain score (PS, 0-10) and morphine consumption (intravenous morphine equivalent daily [MED], mg/kg/day) before and after CPB were used to assess effectiveness. Results: Mean daily PS reduced after CPB in all patients. In one patient, this reduction was sustained up to 6 months of follow-up, and analgesics were discontinued 1 week after CPB. The other three patients had limited survival (6, 16, and 37 days) after CPB. One patient had a PS of 0 over the last few days of life, but the MED was escalated from 0.74 before the block to 5.4 mg/kg/day at the end of life. In the other two patients, MED was lower during the first week after CPB than that before CPB (4.55 vs. 1.59 and 2.88 vs. 1.51 mg/kg/day, respectively). As these two patients had disease progression during their last days of life, the MED was increased to 4.75 and 263.9 mg/kg/day, respectively. Conclusions: Our results suggest that CPB may contribute to reducing PS and MED. We observed the use of CPB rather late in the disease trajectory.