Percutaneous cryoanalgesia for pain palliation: Current status and future trends

Cryoneurolysis versus radiofrequency ablation outcome on pain experience in chronic low back pain (COPE): a single-blinded randomised controlled trial

OBJECTIVE

A comparison of cryoneurolysis or radio frequency (RF) with placebo in patients with facetogenic chronic low back pain (LBP) for patient global impression of change (PGIC), pain intensity, function and quality of life, with 1-year follow-up.

DESIGN

Single-centre, single-blinded placebo-controlled randomised controlled trial.

SETTING

Single-centre study.

PARTICIPANTS

Inclusion from March 2020 to September 2022: consenting adults over 18 years of age, LBP>3 months, average Numeric Rating Scale LBP≥4 average last 14 days and a positive response to a diagnostic medial branch block (>50% pain reduction after 60 min).

INTERVENTIONS

120 patients were block randomised 1:1:1 to cryoneurolysis, RF or placebo of the medial branch nerves. Physical therapy was added after 4 weeks for all groups.

MAIN OUTCOME MEASURES

Primary outcome was PGIC 4 weeks after the intervention. Secondary outcomes included pain intensity (Numeric Rating Scale, NRS), quality of life (Short Form 36, EQ-5D-5L), disability (Oswestry Disability Index), depression (Major Depression Inventory) and catastrophising (Pain Catastrophising Scale). Outcomes were measured at 4 weeks, 3, 6 and 12 months.

RESULTS

There was no statistically significant difference in PGIC at 4 weeks between cryoneurolysis and placebo (risk ratio (RR) 2; 95% CI 0.75 to 5.33, p=0.17) and RF and placebo (RR 1.6; 95% CI 0.57 to 4.49, p=0.37), except PGIC for cryoneurolysis at 6-month follow-up (RR 5.1; 95% CI 1.20 to 22.03, p=0.03). No statistically significant differences were found in secondary follow-up endpoints.

CONCLUSIONS

Denervation of the medial branch nerve by either cryoneurolysis or RF compared with placebo did not demonstrate significant improvement in PGIC, pain intensity, function and quality of life in patients with facetogenic chronic LBP at short-term or long-term follow-up.

TRIAL REGISTRATION NUMBER

NCT04786145.

Cryoanalgesia: Review with Respect to Peripheral Nerve

BACKGROUND

 Cryoanalgesia is a tool being used by interventional radiology to treat chronic pain. Within a certain cold temperature range, peripheral nerve function is interrupted and recovers, without neuroma formation. Cryoanalgesia has most often been applied to the intercostal nerve. Cryoanalgesia has applications to peripheral nerve surgery, yet is poorly understood by reconstructive microsurgeons.

METHODS

 Histopathology of nerve injury was reviewed to understand cold applied to peripheral nerve. Literature review was performed utilizing the PubMed and MEDLINE databases to identify comparative studies of the efficacy of intraoperative cryoanalgesia versus thoracic epidural anesthesia following thoracotomy. Data were analyzed using Fisher's exact and analysis of variance tests. A similar approach was used for pudendal cryoanalgesia.

RESULTS

 Application of inclusion and exclusion criteria resulted in 16 comparative clinical studies of intercostal nerve for this review. For thoracotomy, nine studies compared cryoanalgesia with pharmaceutical analgesia, with seven demonstrating significant reduction in postoperative opioid use or postoperative acute pain scores. In these nine studies, there was no association between the number of nerves treated and the reduction in acute postoperative pain. One study compared cryoanalgesia with local anesthetic and demonstrated a significant reduction in acute pain with cryoanalgesia. Three studies compared cryoanalgesia with epidural analgesia and demonstrated no significant difference in postoperative pain or postoperative opioid use. Interventional radiology targets pudendal nerves using computed tomography imaging with positive outcomes for the patient with pain of pudendal nerve origin.

CONCLUSION

 Cryoanalgesia is a term used for the treatment of peripheral nerve problems that would benefit from a proverbial reset of peripheral nerve function. It does not ablate the nerve. Intraoperative cryoanalgesia to intercostal nerves is a safe and effective means of postoperative analgesia following thoracotomy. For pudendal nerve injury, where an intrapelvic surgical approach may be difficult, cryoanalgesia may provide sufficient clinical relief, thereby preserving pudendal nerve function.

Efficacy and Safety of Cryoablation Compared with Cooled Radiofrequency Ablation of Genicular Nerves in Advanced Osteoarthritis of the Knee: A Study Protocol of Single-Centric, Assessor-Blinded, Randomized, Parallel-Group, Non-inferiority Study

PURPOSE

In patients with symptomatic osteoarthritis knee (OAK), cryoneurolysis (CRYO) and cooled radiofrequency ablation (C-RFA) are reported to be effective and safe; however, they have not been compared directly. The objective of this study is to compare CRYO and C-RFA of the genicular nerve (GN) in terms of efficacy and safety profile in patients with Kellgren and Lawrence (KL) grade ≥ 3 OAK.

METHODS

This single-centric, assessor-blinded, randomized, parallel-group, non-inferiority study will include 80 patients with KL grade ≥ 3 OAK. The patients with ≥ 50% pain relief on diagnostic block of three GNs will be randomized to one of the two groups, i.e., CRYO (n = 40) or C-RFA (n = 40). The three target GNs for the interventions will include: superior medial, superior lateral, and inferior medial. The primary outcome will be efficacy of CRYO or C-RFA at 2, 12, and 24 weeks post-procedure based on the 11-point Numerical Pain Rating Scale. The secondary outcomes will be functional improvement based on 12-item Oxford Knee Score and safety of both the procedures. The study is registered in the Clinical Trials Registry-India.

CONCLUSION

CRYO and C-RFA provide pain relief and improve functional outcome by preventing transmission of pain signals, though by distinct mechanisms. While C-RFA is an established treatment modality, recent evidence supports CRYO in patients with OAK. This study intends to demonstrate non-inferiority of CRYO against C-RFA, thereby supporting the use of CRYO as an additional treatment modality in patients with KL grade ≥ 3 OAK.

Computed tomography-guided percutaneous cryoablation and microwave ablation in the treatment of perivascular hepatocellular carcinoma: A comparative study with propensity score matching

OBJECTIVE

To evaluate the safety and efficacy of cryoablation (CYA) and microwave ablation (MWA) in the treatment of patients with perivascular hepatocellular carcinoma (HCC).

METHODS

Patients with perivascular HCC who underwent computed tomography (CT)-guided percutaneous CYA or MVA treatment in our hospital from August 2009 to March 2019 were included. Propensity score matching (PSM) was performed to adjust for potential baseline differences in the two groups. The technical success rate (TS), complications, and visual analog scale (VAS) were analyzed. The overall survival (OS) was evaluated using Kaplan-Meier curves and Cox proportional hazards models.

RESULTS

After PSM, 32 patients from each group were selected. The technical success rate was 94 % for CYA and 91 % for MWA, and 13 patients developed recurrence (CYA, n = 5, 2 local, 3 distant; MWA, n = 8, 6 local, 2 distant). There were no significant differences in OS (36-months OS: CYA 53.1 % vs, MWA 40.6 %; P = 0.191). No intraoperative deaths or complication-related deaths were observed, and 19 patients (CYA, n = 8; MWA, n = 11) experienced complications (P = 0.435). The VAS in the MWA group (5.38 ± 1.21) was significantly higher than that in the CYA group (2.22 ± 0.87; P < 0.001).

CONCLUSIONS

While CYA has equal safety and high primary efficacy as MWA in the treatment of perivascular HCC, it is associated with less periprocedural pain.

Pain Control during the Treatment of Primary Palmar Hyperhidrosis with Botulinum Toxin A by a Topical Application of Liposomal Lidocaine: Clinical Effectiveness

Primary palmar hyperhidrosis (PPH) constitutes a debilitating condition that profoundly impacts the social, functional, and occupational aspects of individuals. The intradermal administration of botulinum toxin type A (BoNT-A) stands as an established therapeutic approach for PPH, albeit one frequently accompanied by considerable pain, posing challenges for patient tolerance. Our study aimed to assess the efficacy of combining cryoanalgesia spray (CA) with topical anesthesia utilizing a cream containing liposomal lidocaine at a concentration of 40 mg/g, with the objective of mitigating the pain associated with intradermal BoNT-A injection for PPH treatment. Nineteen participants, aged ≥18 years and afflicted with severe PPH, were enrolled in a double-blind randomized vehicle-controlled trial. Patient-perceived pain during the procedure was quantified using the Numeric Rating Scale (NRS). Statistical analysis was applied to the collected data. The combination of CA and the topical application of liposomal lidocaine during BoNT-A treatment for PPH resulted in diminished pain compared to CA alone and the combination of CA with the application of a basic cream. Topical anesthesia through the application of a liposomal lidocaine-containing cream emerged as a facile, secure, and efficacious approach for alleviating the pain associated with intradermal BoNT-A injection in PPH treatment. Furthermore, it demonstrated compatibility with CA, thereby offering a comprehensive strategy for pain management during BoNT-A administration.

Safety and Effectiveness of Stellate Ganglion Cryoablation in Complex Regional Pain Syndrome

This was a retrospective, observational, descriptive study to evaluate the safety and 6-month effectiveness of percutaneous cryoablation of the stellate ganglion for the treatment of complex regional pain syndrome (CRPS). Eight patients with CRPS diagnosed by Budapest criteria were treated with this procedure. CRPS symptom severity was assessed prior to the procedure and at 3-month intervals after the procedure using a novel CRPS scoring system-the Budapest score-created by the authors. The mean Budapest score prior to and 6 months (187 days, SD ± 43) after stellate ganglion cryoablation was 7.0 (SD ± 2.0) (n = 6) and 3.8 (SD ± 2.3) (n = 6), respectively, showing a decrease of 3.2 (SD ± 1.7) (n = 6; P = .006). There were no major adverse events due to the procedure, and there was only 1 minor adverse event. Stellate ganglion cryoablation is a feasible, safe, and minimally invasive procedure that may represent an efficacious adjunct treatment option for select patients with CRPS.

Cryotherapy in Postoperative Shoulder Surgery: A Systematic Review

Cryotherapy, a therapeutic technique involving localized cooling of the body, has gained popularity for postsurgical rehabilitation. It induces a reduction in cellular metabolism, vasoconstriction, and pain relief, making it an attractive option for managing postoperative (PO) shoulder pain. This systematic review aimed to assess the effectiveness of cryotherapy in PO shoulder patients, focusing on pain, range of motion, functionality, and temperature changes. The review included six randomized clinical trials, involving a total of 233 patients who underwent various shoulder surgeries. Cryotherapy was applied using different methods, including Cryo/Cuff, Cryoton®, Polar Care 300, and ice packs. Results indicated that cryotherapy was generally effective in reducing PO shoulder pain. However, one study found no significant difference in pain outcomes between the cryotherapy group and control group. Furthermore, three studies demonstrated a decrease in intra-articular and skin temperatures with cryotherapy application. A risk of bias analysis revealed some concerns in the overall risk of bias for five studies, with one study considered to have a high risk of bias. Although publication bias assessment was not conducted due to the limited number of included studies, it was noted that the studies exhibited heterogeneity in terms of population, intervention methods, and outcome measures. In conclusion, cryotherapy appears to be a promising adjunctive treatment for PO shoulder pain, although the existing evidence has some limitations, including small sample sizes and methodological concerns. More high-quality studies are needed to establish the full extent of cryotherapy's effectiveness in PO shoulder rehabilitation, especially regarding its impact on functionality and range of motion.

Vapocoolant Analgesia for Breast Lymphoscintigraphy: A Prospective Clinical Trial

Breast lymphoscintigraphy is commonly performed before initial surgical intervention and surgical staging in the setting of breast cancer. Breast lymphoscintigraphy injections can often be quite painful and are routinely performed without any anesthesia or analgesia, thus representing a significant unmet need for the breast cancer population. Although vapocoolants have been previously available, they have typically been used on intact skin and not been recommended for sterile procedures. Methods: Thirty consecutive patients were enrolled in our prospective study of which 29 received vapocoolant analgesia in the setting of breast lymphoscintigraphy. Patients were given a postinjection questionnaire that included a self-reported pain score and boolean question regarding whether they would recommend vapocoolant for future patients. Results: The lymposcintigraphy procedure was successful in 100% of cases with an ipsilateral axillary node identified on average within 2.4 h of injection (median, 1 h; range 1-4.5 h). The average self-reported pain score was 1.98 (median, 1; range, 1-10). Conclusion: Vapocoolant analgesia in the setting of breast lymphoscintigraphy is feasible, does not appear to compromise lymphoscintigraphy, and appears to be associated with generally low self-reported pain scores.

Musculoskeletal Interventional Oncology: A Contemporary Review

Musculoskeletal interventional oncology is an emerging field that addresses the limitations of conventional therapies for bone and soft-tissue tumors. The field's growth has been driven by evolving treatment paradigms, expanding society guidelines, mounting supportive literature, technologic advances, and cross-specialty collaboration with medical, surgical, and radiation oncology. Safe, effective, and durable pain palliation, local control, and stabilization of musculoskeletal tumors are increasingly achieved through an expanding array of contemporary minimally invasive percutaneous image-guided treatments, including ablation, osteoplasty, vertebral augmentation (with or without mechanical reinforcement via implants), osseous consolidation via percutaneous screw fixation (with or without osteoplasty), tumor embolization, and neurolysis. These interventions may be used for curative or palliative indications and can be readily combined with systemic therapies. Therapeutic approaches include the combination of different interventional oncology techniques as well as the sequential application of such techniques with other local treatments, including surgery or radiation. This article reviews the current practice of interventional oncology treatments for the management of patients with bone and soft-tissue tumors with a focus on emerging technologies and techniques.

Selective MR neurography-guided lumbosacral plexus perineural injections: techniques, targets, and territories

The T12 to S4 spinal nerves form the lumbosacral plexus in the retroperitoneum, providing sensory and motor innervation to the pelvis and lower extremities. The lumbosacral plexus has a wide range of anatomic variations and interchange of fibers between nerve anastomoses. Neuropathies of the lumbosacral plexus cause a broad spectrum of complex pelvic and lower extremity pain syndromes, which can be challenging to diagnose and treat successfully. In their workup, selective nerve blocks are employed to test the hypothesis that a lumbosacral plexus nerve contributes to a suspected pelvic and extremity pain syndrome, whereas therapeutic perineural injections aim to alleviate pain and paresthesia symptoms. While the sciatic and femoral nerves are large in caliber, the iliohypogastric and ilioinguinal, genitofemoral, lateral femoral cutaneous, anterior femoral cutaneous, posterior femoral cutaneous, obturator, and pudendal nerves are small, measuring a few millimeters in diameter and have a wide range of anatomic variants. Due to their minuteness, direct visualization of the smaller lumbosacral plexus branches can be difficult during selective nerve blocks, particularly in deeper pelvic locations or larger patients. In this setting, the high spatial and contrast resolution of interventional MR neurography guidance benefits nerve visualization and targeting, needle placement, and visualization of perineural injectant distribution, providing a highly accurate alternative to more commonly used ultrasonography, fluoroscopy, and computed tomography guidance for perineural injections. This article offers a practical guide for MR neurography-guided lumbosacral plexus perineural injections, including interventional setup, pulse sequence protocols, lumbosacral plexus MR neurography anatomy, anatomic variations, and injection targets.

Ischiorectal Approach to Cryoablation of the Pudendal Nerve Using a Handheld Device: A Report of Two Cases

The pudendal nerve is situated deep within the pelvis and is a challenge to target for pain interventions due to the theoretical risk of incontinence with manipulation. The management of pudendal neuralgia using cryoablation is currently limited as it has historically required computed tomography (CT) guidance by interventional radiologists. Through this report, we describe a safe, reproducible, ischiorectal fossa approach to pudendal nerve cryoablation with a handheld device utilizing anatomical landmarks, nerve stimulation, and fluoroscopy. Two patients with longstanding pelvic pain and positive response to diagnostic pudendal nerve blocks underwent bilateral cryoablation of the pudendal nerves. This procedure was performed with the patients in prone positioning and percutaneous insertion of a cryoablation probe medial to the ischial tuberosity and lateral to the rectum. Correct positioning on the pudendal nerve was achieved with nerve stimulation eliciting visible anal sphincter contraction, and fluoroscopic imaging of the probe relative to the ischial spine. The probe was set to -88 Celsius for 108 seconds and a total of two cycles were performed. Pain reduction was reported for 3-4 months and repeat cryoablation was similarly efficacious with no evidence of incontinence. This technique, we believe minimizes risks and simplifies cryoablation to be performed on an outpatient basis by more pain physicians.

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.

Ultrasound-Guided Percutaneous Cryoanalgesia for Pectus Excavatum: When Should It be Applied?

INTRODUCTION

 The addition of ultrasound-guided percutaneous cryoanalgesia (PCr) for pain management after pectus excavatum (PE) surgery offers a new and advantageous approach. Our aim is to describe our experience with PCr applied on the same day, 24 hours, and 48 hours prior to PE surgery.

MATERIAL AND METHODS

 Prospective pilot study in patients undergoing ultrasound-guided PCr (2019-2022) was divided into three groups: PCr on the same day of surgery (PCrSD), PCr 24 hours before (PCr24), and PCr 48 hours before (PCr48). We describe the application of technique and data obtained by comparing the three groups.

RESULTS

 We present 42 patients (25 PCrSD, 11 PCr24, 6 PCr48). PCr24 had a shorter procedure duration than PCrSD (65.8 vs. 91.2 minute; p = 0.048). Related to analgesia, PCr24 and PCr48 showed lower opioid consumption than PCrSD in PCA volume (48.5 and 49.6 vs. 75.1 mL; p = 0.015) and PCA time (23.3 and 23.8 vs. 34.3 hours; p = 0.01). Degree of pain (VAS scale) on the day of surgery and on the second postoperative day was lower in PCr24 and PCr48 than in PCrSD (4 and 2 vs. 5; p = 0.012; 0 and 1 vs. 2; p = 0.01, respectively) as well as shorter hospital stay (3 and 3.5 vs. 5 days; p = 0.021). In addition, PCr24 showed lower opioid consumption and hospital stay than PCr48 (p > 0.05). The greatest savings in hospital costs were obtained in the PCr24 group.

CONCLUSION

 PCr48 and PCr24 prior to PE surgery offers lower opioid consumption, less pain and shorter hospital stay than PCrSD. PCr24 is comparable to PCr48, but seems to show advantages and simpler logistics for the patient and the hospital.

Thermal Protection Strategies and Neuromonitoring during Ablation

Advanced interventional pain management approaches seek to lesion neural targets to achieve desirable analgesia; however, equally important is preservation of motor and sensory function for regional bystander nerves. The topic of neuroprotection is also relevant for thermal ablation of metastatic bone tumors in the vicinity of neural structures. This report aims to provide an IR-directed framework of thermoprotective techniques available during thermal ablation.

Percutaneous Cryoanalgesia: A New Strategy for Pain Management in Pectus Excavatum Surgery

INTRODUCTION

 In recent years, pain protocols for pectus excavatum (PE) have incorporated cryoanalgesia through thoracoscopic approach. Since 2019, ultrasound-guided percutaneous cryoanalgesia (PCr) has been applied at our institution, either on the same day as the Nuss procedure or 48 hours before surgery. We carried out a preliminary retrospective review of patients with PE in whom PCr prior to surgery was performed at our institution between 2019 and 2021.

MATERIALS AND METHODS

 Two groups were evaluated: PCr on the same day (PCrSD) and PCr 48 hours before surgery (PCr48). Despite PCr, patients were treated with "patient-controlled analgesia" (PCA) with opioids for at least 24 hours, switching to conventional intravenous analgesia and oral analgesia in the following days. Demographic, clinical-radiological variables, PCA opioid use, pain grade according to the visual analog scale (VAS), and length of stay (LOS) were compared between the groups. A total of 20 patients were included (12 with PCrSD and 8 with PCr48), without significant differences in demographics or clinical-radiological variables. The overall median time of PCr was 65 minutes (55-127), with no differences between the groups.

RESULTS

 PCr48 group presented with significantly lower median number of hours of continuous PCA (24 vs. 32 hours; p = 0.031), lower median number of rescue boluses (11 vs. 18; p = 0.042), lower median VAS in the early postoperative hours (2 vs. 5.5; p = 0.043), and lower median LOS (3.5 vs. 5 days).

CONCLUSION

 PCr performed 48 hours prior to surgery is more effective in terms of PCA requirements, VAS, and LOS when compared with cryoanalgesia on the same day.

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.

The Role of Percutaneous Ablation in the Management of Colorectal Cancer Liver Metastatic Disease

Approximately 50% of colorectal cancer patients will develop metastases during the course of the disease. Local or locoregional therapies for the treatment of liver metastases are used in the management of oligometastatic colorectal liver disease, especially in nonsurgical candidates. Thermal ablation (TA) is recommended in the treatment of limited liver metastases as free-standing therapy or in combination with surgery as long as all visible disease can be eradicated. Percutaneous TA has been proven as a safe and efficacious therapy offering sustained local tumor control and improved patient survival. Continuous technological advances in diagnostic imaging and guidance tools, the evolution of devices allowing for optimization of ablation parameters, as well as the ability to perform margin assessment have improved the efficacy of ablation. This allows resectable small volume diseases to be cured with percutaneous ablation. The ongoing detailed information and increasing understanding of tumor biology, genetics, and tissue biomarkers that impact oncologic outcomes as well as their implications on the results of ablation have further allowed for treatment customization and improved oncologic outcomes even in those with more aggressive tumor biology. The purpose of this review is to present the most common indications for image-guided percutaneous ablation in colorectal cancer liver metastases, to describe technical considerations, and to discuss relevant peer-reviewed evidence on this topic. The growing role of imaging and image-guidance as well as controversies regarding several devices are addressed.