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The Combination of Superior Hypogastric Plexus Block and the Block of the Ganglium Impair in a Patient With Abdominal and Perineal Pain Poorly Responsive to Opioids

Open ArchivePublished:April 15, 2019DOI:https://doi.org/10.1016/j.jpainsymman.2019.04.001
      Dear Editor
      More than 10 million people worldwide are diagnosed with cancer. About two-thirds of them will experience pain during the course of the disease.
      • van den Beuken-van Everdingen M.H.J.
      • van Kuijk S.M.J.
      • Janssen D.J.A.
      • Joosten E.A.J.
      Treatment of pain in cancer: towards Personalised Medicine.
      The management of cancer pain requires an appropriate multidisciplinary approach involving consideration of the pain's physiopathology, analgesic pharmacology, and the patient's psychosocial concerns. Drug therapy with the use of opioids and adjuvants is successful in 70% to 90% of patients with varied types of cancer pain.
      • Mercadante S.
      Managing difficult pain conditions in the cancer patient.
      Standards for the management of cancer pain have been recently released.
      • Bennett M.I.
      • Eisenberg E.
      • Ahmedzai S.H.
      • et al.
      Standards for the management of cancer-related pain across Europe-A position paper from the EFIC Task Force on cancer pain.
      About 10% of patients with cancer pain do not have a good response to drug therapy. An interventional pain treatment may be indicated when drugs do not provide sufficient analgesia or when adverse effects become intolerable.
      • Candido K.D.
      • Kusper T.M.
      • Knezevic N.N.
      New cancer pain treatment options.
      According to recent recommendations of the European Association for Palliative Care, the evidence supporting these procedures is weak for most neurolytic blocks.
      • Kurita G.P.
      • Benthien K.S.
      • Nordly M.
      • Mercadante S.
      • Klepstad P.
      • Sjøgren P.
      European Palliative Care Research Collaborative (EPCRC). The evidence of neuraxial administration of analgesics for cancer-related pain: a systematic review.
      • Klepstad P.
      • Kurita G.P.
      • Mercadante S.
      • Sjøgren P.
      Evidence of peripheral nerve blocks for cancer-related pain: a systematic review.
      • Mercadante S.
      • Klepstad P.
      • Kurita G.P.
      • Sjøgren P.
      • Pigni A.
      • Caraceni A.
      Minimally invasive procedures for the management of vertebral bone pain due to cancer: the EAPC recommendations.
      • Mercadante S.
      • Klepstad P.
      • Kurita G.P.
      • Sjøgren P.
      • Giarratano A.
      European Palliative Care Research Collaborative (EPCRC). Sympathetic blocks for visceral cancer pain management: a systematic review and EAPC recommendations.
      However, in some specific conditions, an interventional approach may produce spectacular improvements in analgesia. As the face of cancer pain management has changed in considerable ways, interventional procedures have become an integral part of providing multimodal analgesia for selected patients.
      • Candido K.D.
      • Kusper T.M.
      • Knezevic N.N.
      New cancer pain treatment options.
      Neurolysis of retroperitoneal sympathetic ganglia, which are transit points for visceral afferents as well as sympathetic efferents, has minimal complications and is easy to perform. We report a patient who underwent complex opioid strategies unsuccessfully and then had clear clinical improvement using a combination of two sympathetic ganglia blocks—the superior hypogastric plexus block and the block of the ganglion impair.
      • Plancarte R.
      • de Leon-Casasola O.A.
      • El-Helaly M.
      • Allende S.
      • Lema M.J.
      Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer.

      Case Description

      A 48-year-old woman with a history of ovarian cancer was admitted to the main regional center for pain relief and supportive care. She had undergone surgery and multiple courses of chemotherapy and a course of pelvic radiotherapy. She had additional interventions to remove pelvic lymph nodes after relapse and needed a ureteral stent. She provided consent for description of her case for scientific purposes.
      The patient developed persistent abdominal pain in the right inferior quadrant and perineal pain. She had been treated with several opioid regimens and before admission was receiving transdermal fentanyl 3.6 mg/day (150 mcg/h), ibuprofen 800 mg/day, and subcutaneous morphine 10 mg as needed, administered four to six times a day for episodes of breakthrough pain. Her Karnofsky Performance Status score was 60 and she did not have cognitive disturbances, as assessed by Memorial Assessment Delirium scale (3/30). Pain intensity was 7/10 on a numerical 0–10 scale, with peaks of breakthrough pain of 10/10 occurring four to six times a day. The principal symptoms indicated on the Edmonton Symptom Assessment Scale (ESAS) were insomnia (9/10), weakness (8/10), and poor well-being (9/10) (Fig. 1). Imaging studies showed a pelvic mass constituted principally by lymph nodes.
      Figure thumbnail gr1
      Fig. 1a) ESAS before performing the blocks (see text); b) ESAS on the day after the blocks. P = pain; D = dyspnea; A = anxiety; De = depression; I = insomnia; D = drowsiness; N = nausea; A = appetite; W = weakness; WB = well-being; ESAS = Edmonton Symptom Assessment Scale. The gray area is the breakthrough pain intensity.
      Fentanyl was switched to methadone in doses of 90 mg/day orally, divided into three doses, without reporting any clinical benefit. Pain oscillated between 8/10 and 10/10. Hydration and other supportive measures were provided. A ketamine burst of 100 mg/day and midazolam 30 mg/day for two days was uneventful and had no effect on the patient, who indicated the same intensity levels of ESAS items. A further increase in the methadone dose, intravenously, and the addition of tapentadol up to 300 mg/day and amitriptyline 30 mg/day did not improve her clinical condition.
      Neurolysis of the superior hypogastric plexus and the ganglion impair was proposed to the patient as an alternative to improve her reported misery. The patient approved and provided written consent. After premedication and under light anesthesia with propofol, the patient was placed in prone position. Under fluoroscopy, a 22-gauge needle was inserted at 7 cm bilateral to the midline at level of L4-5 interspace, with the needle bevel directed to midline. The needle was advanced laterally to the body of the L5 vertebra until the needle tip was in the anterolateral space. Biplanar fluoroscopy was used to verify needle placement. The injection of contrast medium confirmed the accuracy of placement. Alcohol 75%, 6–8 mL, was injected bilaterally. With the patient in the same position, a needle, bent to form a 30° angle, was then advanced under fluoroscopic guidance in the midline over the anococcygeal ligament. It was directed anteriorly toward the coccyx until its tip reached the sacrococcygeal junction. The injection of contrast medium under fluoroscopy showed the typical image resembling an apostrophe. Alcohol 75%, 5 mL, was injected. The patient was then transferred to the unit for strict observation, monitoring for the possibility that the methadone may require prompt tapering.
      The day after pain intensity was 0/10, and most items of ESAS were clearly reduced. Methadone doses were progressively reduced to 45 mg/day orally. The patient was discharged with no pain and a low level of symptom distress (Fig. 1).
      This case illustrates the use of neurolysis of the lower sympathetic ganglia to dramatically resolve a difficult case of pain that was poorly responsive to different types of opioid therapy, a burst of ketamine and midazolam, and other treatments used to desensitize patients receiving high doses of opioids unsuccessfully or for assisting opioid switching in some difficult cases of opioid-induced hyperalgesia.
      • Mercadante S.
      • Caruselli A.
      • Casuccio A.
      The use of ketamine in a palliative-supportive care unit: a retrospective analysis.
      Interruption of sympathetic structures, such as the superior hypogastric plexus and the ganglion impair, has been used for a variety of pelvic and perineal pains, respectively. These techniques lack evidence of efficacy in the literature
      • Mercadante S.
      • Klepstad P.
      • Kurita G.P.
      • Sjøgren P.
      • Giarratano A.
      European Palliative Care Research Collaborative (EPCRC). Sympathetic blocks for visceral cancer pain management: a systematic review and EAPC recommendations.
      but can be individually chosen on the basis of specific clinical conditions. In our case, the patient complained of both lower abdominal pain and perineal pain. These areas are the main target for the two blocks used in this patient: The superior hypogastric plexus carries afferents from the viscera of the lower abdomen and pelvis and the ganglion impair innervates the perineum, distal rectum, anus, distal urethra, vulva, and distal third of the vagina. The neurolysis of these sympathetic structures provided excellent analgesia, allowed reduction of opioid doses, and reduced the intensity level of associated symptoms.
      The combination of these two neurolytic techniques by using transdiscal and transsacrococcygeal approaches has been described to be effective in a case series.
      • Ahmed D.G.
      • Mohamed M.F.
      • Mohamed S.A.
      Superior hypogastric plexus combined with ganglion impar neurolytic blocks for pelvic and/or perineal cancer pain relief.
      Although other approaches, such as opioid rotation, are usually considered when there is insufficient pain relief or substantial adverse effects, interventional approaches should be considered when systemic pharmacologic treatment and other noninvasive therapies fail. For our patient, it was possible to manage a very difficult pain situation by blocking the lower retroperitoneal sympathetic ganglia.
      Complex pain syndromes refractory to conventional pharmacologic treatments require prompt, albeit judicious, delivery of unorthodox treatment options that may not be included in conventional guidelines and standard practices.
      • Candido K.D.
      • Kusper T.M.
      • Knezevic N.N.
      New cancer pain treatment options.
      A stepwise and a meaningful approach to clinical problems may be helpful in the treatment of conditions otherwise considered intractable and should be considered after appropriate trials of pharmacological treatments. Careful patient selection is mandatory when performing these techniques, rather than using them extensively.
      A combined neurolytic superior hypogastric plexus block and ganglion impair block may be an effective treatment for reducing pain in individual cancer patients presenting with pelvic and/or perineal pain who are not responsive to intensive opioid treatment. These techniques are easy to perform under fluoroscopy guidance and have rare serious complications.

      Disclosures and Acknowledgments

      This research received no specific funding/grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest.

      References

        • van den Beuken-van Everdingen M.H.J.
        • van Kuijk S.M.J.
        • Janssen D.J.A.
        • Joosten E.A.J.
        Treatment of pain in cancer: towards Personalised Medicine.
        Cancers (Basel). 2018; 10
        • Mercadante S.
        Managing difficult pain conditions in the cancer patient.
        Curr Pain Headache Rep. 2014; 18: 395
        • Bennett M.I.
        • Eisenberg E.
        • Ahmedzai S.H.
        • et al.
        Standards for the management of cancer-related pain across Europe-A position paper from the EFIC Task Force on cancer pain.
        Eur J Pain. 2018;
        • Candido K.D.
        • Kusper T.M.
        • Knezevic N.N.
        New cancer pain treatment options.
        Curr Pain Headache Rep. 2017; 21: 12
        • Kurita G.P.
        • Benthien K.S.
        • Nordly M.
        • Mercadante S.
        • Klepstad P.
        • Sjøgren P.
        European Palliative Care Research Collaborative (EPCRC). The evidence of neuraxial administration of analgesics for cancer-related pain: a systematic review.
        Acta Anaesthesiol Scand. 2015; 59: 1103-1115
        • Klepstad P.
        • Kurita G.P.
        • Mercadante S.
        • Sjøgren P.
        Evidence of peripheral nerve blocks for cancer-related pain: a systematic review.
        Minerva Anestesiol. 2015; 81: 789-793
        • Mercadante S.
        • Klepstad P.
        • Kurita G.P.
        • Sjøgren P.
        • Pigni A.
        • Caraceni A.
        Minimally invasive procedures for the management of vertebral bone pain due to cancer: the EAPC recommendations.
        Acta Oncol. 2016; 55: 129-133
        • Mercadante S.
        • Klepstad P.
        • Kurita G.P.
        • Sjøgren P.
        • Giarratano A.
        European Palliative Care Research Collaborative (EPCRC). Sympathetic blocks for visceral cancer pain management: a systematic review and EAPC recommendations.
        Crit Rev Oncol Hematol. 2015; 96: 577-578
        • Plancarte R.
        • de Leon-Casasola O.A.
        • El-Helaly M.
        • Allende S.
        • Lema M.J.
        Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer.
        Reg Anesth. 1997; 22: 562-568
        • Mercadante S.
        • Caruselli A.
        • Casuccio A.
        The use of ketamine in a palliative-supportive care unit: a retrospective analysis.
        Ann Palliat Med. 2018; 7: 205-210
        • Ahmed D.G.
        • Mohamed M.F.
        • Mohamed S.A.
        Superior hypogastric plexus combined with ganglion impar neurolytic blocks for pelvic and/or perineal cancer pain relief.
        Pain Physician. 2015; 18: E49-E56