Intercostal Nerve Block and Neurolysis for Intractable Cancer Pain

Management of intractable cancer-associated chest wall pain is difficult once patients have reached dose-limiting side effects of opioids and coanalgesic medications. This case series describes 11 patients with intractable cancer-associated chest wall pain who were treated with a diagnostic intercostal nerve block. Six patients subsequently received chemical neurolysis with phenol using the same approach. No serious adverse events were observed. Radiopaque contrast dye spread into the paravertebral space in all 11 patients, and in 1 patient contrast dye spread into the epidural space. Seven of 11 patients experienced pain relief from the diagnostic blockade. Four of six patients experienced pain relief from the neurolytic blockade. The principal reportable finding from this case series is the observation that contrast dye spread liberally from the intercostal space into other anatomic spaces, even though very small volumes of injectate (less than 5 mL) were used. Definitive evidence of safety and efficacy of intercostal nerve block and neurolysis for cancer pain will require a prospective randomized clinical trial.     

CT引导内脏与腹腔神经丛阻滞治疗上腹癌痛的比较

目的：观察CT引导下内脏与腹腔神经丛毁损性阻滞对上腹癌痛的镇痛效果比较。方法：48例顽固性上腹部癌症重度疼痛患者，随机分两组，在CT引导下分别行腹腔神经丛（Ｆ组）或内脏神经丛（Ｎ组）无水乙醇毁损阻滞治疗。观察两组镇痛效果、疼痛缓解程度及不良反应。结果：治疗后即刻全部患者疼痛减轻或消失。在治疗后第3、7、15、30、60、90天，患者的疼痛评分、疼痛程度均明显改善，两组间无显著差异，治疗过程中和治疗后未发生严重并发症。结论：内脏神经丛阻滞可取得与腹腔神经丛阻滞一致的效应，操作方便、疗效确切、安全性高，可供临床选择。     

CT引导下腹腔神经丛毁损术治疗慢性顽固性腹部癌痛

目的：观察CT引导下腹腔神经丛毁损性阻滞对顽固性腹部癌痛的镇痛效果及患者生活质量的影响。方法：74例顽固性腹部癌症疼痛患者，在CT引导监视下经背侧入路经皮穿刺腹腔神经丛无水乙醇阻滞治疗。结果：治疗后一周内全部患者疼痛减轻或消失。在治疗后第7、14、30、60天，患者的疼痛评分、疼痛缓解率、生活质量均明显改善，大多数患者临终前无痛或仅轻度疼痛。治疗过程中和治疗后未发生严重并发症。结论：CT引导下腹腔神经丛阻滞治疗顽固性腹部癌痛的疗效确切，安全性高．     

右美托咪定联合罗哌卡因用于胸椎旁神经阻滞对胆总管切开取石术后镇痛效果的影响

目的:探讨盐酸右美托咪定联合罗哌卡因用于胸椎旁神经阻滞对胆总管切开取石术后镇痛效果的影响。方法:选择择期行胆总管切开取石术的患者40例,性别不限,年龄22~72岁,ASA分级I或II级,采用电脑生成随机数字表法分为D组(n=20)和C组(n=20)。两组均于麻醉前左侧卧位超声引导下行右侧胸7平面椎旁神经阻滞并置管。麻醉苏醒后,D组给予0.5%罗哌卡因+1μg/kg右美托咪定20 mL,C组给予0.5%罗哌卡因20 mL。两组术毕均连接静脉自控镇痛泵(含舒芬太尼1.0μg/mL,地佐辛0.1 mg/mL,昂丹司琼16 mg,0.9%氯化钠稀释至100 mL),作为补充镇痛并用于爆发性疼痛时的补救镇痛。术后入PACU持续监测有创血压、心电图、呼吸、脉搏血氧饱和度。记录拔管后2,4,8,12 h的VAS及Ramsay评分,术后额外镇痛药使用情况及不良反应发生情况。结果:术后2,4,8 h D组VAS评分明显低于C组,术后4,8,12 h A组Ramsay评分明显低于B组(P<0.05);D组额外镇痛药使用次数少于C组(P<0.05);两组不良反应发生情况无明显差异(P>0.05)。结论:右美托咪定联合罗哌卡因胸椎旁神经阻滞用于胆总管切开取石术有较好的镇痛效果。     

Nerve Stimulator-Guided Repetitive Paravertebral Block for Thoracic Myofascial Pain Syndrome

▪ Abstract:   Myofascial pain syndrome (MPS) may persist for many years and is often refractory to traditional therapeutic approaches including pharmacotherapy, focal tenderness infiltration by local anesthetic and corticosteroids, physical therapy and behavioral modification. This report describes three cases of MPS following coronary artery bypass graft, inadequate positioning during abdominal hysterectomy, and excessive physical effort refractory to conventional therapeutic approaches. Three patients were successfully treated with repeated nerve stimulator-guided paravertebral block using a mixture of bupivacaine and clonidine.
Physical examinations including a complete neurological assessments were unremarkable. Relevant diagnostic imaging (X-ray, magnetic resonance imaging, computed tomography) and laboratory evaluations also failed to demonstrate any significant structural disorders or systemic diseases that might have been responsible for their pain. Nerve stimulator-guided paravertebral block was performed at the dermatomes corresponding to the thoracic myofascial pain region. Each point was injected with 4 mL of the local anesthetic solution. If the pain returned, a second paravertebral block was performed. The three patients were pain-free over a follow-up period up to 2 years. Our report suggests that nerve stimulator-guided paravertebral blockade could be a useful treatment for MPS refractory to traditional therapeutic approaches. ▪     

Celiac plexus block: evaluation of injectate spread by three-dimensional computed tomography

We describe a case of pancreatic cancer in which the spread pattern of injectate during neurolytic celiac plexus block was evaluated by three-dimensional helical computed tomography. Three-dimensional images provide excellent visualization of the spread patterns of injectate in a target site, which appears to provide patients with effective relief from intractable pain.     

Abstracts of selected papers from the current literature

We describe a case of pancreatic cancer in which the spread pattern of injectate during neurolytic celiac plexus block was evaluated by three-dimensional helical computed tomography. Three-dimensional images provide excellent visualization of the spread patterns of injectate in a target site, which appears to provide patients with effective relief from intractable pain.     

胸腔镜下椎旁间隙置管镇痛在胸腔镜肺叶切除手术中的应用

目的评价胸腔镜下椎旁间隙置管持续椎旁神经阻滞在胸腔镜肺叶切除手术后镇痛中的应用价值。方法选取胸腔镜肺叶切除手术患者68例,根据置管方式不同分为实验组(胸腔镜下椎旁间隙置管镇痛组) 35例和对照组(超声引导下椎旁间隙置管镇痛组) 33例。置管成功后,两组均经导管注入0.5%罗哌卡因20 mL作为负荷量,术后以2 mL/h的速度持续泵入0.15%罗哌卡因。比较两组术后不同时间点的疼痛程度、镇痛副作用及肺部并发症发生情况。结果在静止状态及咳嗽时,两组术后2、4、6、8、12、24和48 h的视觉模拟评分(VAS)比较,差异均无统计学意义(P 0.05)。两组均有患者出现头晕嗜睡、恶心呕吐和低血压等镇痛相关副作用,但两组比较,差异无统计学意义(P 0.05)。两组肺部并发症比较,差异无统计学意义。没有观察到与麻醉镇痛相关的严重并发症。结论胸腔镜下椎旁间隙置管用于术后持续椎旁神经阻滞镇痛中,安全、有效、可行,且并发症发生率低,操作简单易学,无需超声设备辅助。     

超声引导下的胸椎旁神经阻滞对肺结核患者开胸手术后细胞免疫功能的影响

目的探讨超声引导下胸椎旁神经阻滞对肺结核患者开胸手术细胞免疫功能的影响。方法60例择期行开胸手术肺结核患者,随机分为单纯全麻组（G组）和全麻复合超声引导下胸椎旁神经阻滞组（P组）,30例/组。P组患者麻醉诱导前在超声引导下行单次胸椎旁神经阻滞,两组患者均采用静吸复合全麻维持麻醉,术毕行静脉自控镇痛。记录两组患者手术时间及失血量;记录两组患者术后6 h（T1）、12 h（T2）、24 h（T3）和72 h（T4）安静状态下和咳嗽时的视觉模拟评分;记录两组患者术前1 d和T1、T2、T3、T4的CD3⁺、CD4⁺、CD8⁺的百分率及CD4⁺/CD8⁺比值。结果在安静和咳嗽状态下,P组患者在术后6、12 h视觉模拟评分均低于G组（P < 0.05）;两组患者CD3⁺、CD4⁺、CD8⁺、CD4⁺/CD8⁺在T1、T2、T3、T4时间点较术前均有下降（P < 0.05）;P组患者CD3⁺、CD4⁺、CD8⁺、CD4⁺/CD8⁺在T1、T2时间点较G组患者高（P < 0.05）。结论超声引导下的胸椎旁神经阻滞可以减轻肺结核患者开胸术后早期疼痛,并可减轻患者术后的细胞免疫功能抑制。     

超声引导下胸椎旁神经阻滞在肺结核患者开胸手术中的应用

目的探讨超声引导下胸椎旁神经阻滞在肺结核患者开胸手术中的应用价值。方法选择ASA I~II级,年龄18~60岁择期行开胸手术肺结核患者90例,随机分为单纯全麻组（G组）、全麻复合超声引导下胸椎旁神经阻滞组（P组）和全麻复合硬膜外阻滞组（E组）,每组各30例。P组患者麻醉诱导前在超声引导下行单次胸椎旁神经阻滞,E组患者麻醉诱导前行胸段硬膜外穿刺并留置硬膜外导管。3组患者均采用静吸复合全麻维持麻醉,术毕行静脉自控镇痛。记录患者入手术室时（T0）、诱导插管前（T1）、切皮前（T2）、切皮后5 min（T3）、拔管后（T4）及术后2 h (T5)的MAP及HR;记录患者术中舒芬太尼用量、手术时间及多巴胺使用例数;记录患者术后2、6、12、24、48、72 h安静状态下和咳嗽时VAS评分及镇痛泵的按压次数。结果P组患者MAP在T3、T4时间点较G组患者有下降（P<0.05）,HR在T3、T4、T5时间点较G组患者有下降（P<0.05）;E组患者MAP、HR在T1、T2、T3、T4、T5时间点较G组、P组患者均有下降（P<0.05）;P组及E组患者术中舒芬太尼用量较G组患者少（P<0.05）;E组患者多巴胺使用例数多于G组、P组患者（P<0.05）,而P组患者多巴胺使用例数多于G组患者（P<0.05）;在安静和咳嗽状态下,P组患者在术后2、6、12 h评分低于G组患者（P<0.05）,E组患者在术后2、6 h评分低于G组患者（P<0.05）;P组、E组患者术后镇痛泵按压次数少于G组患者（P<0.05）。结论超声引导下胸椎旁神经阻滞操作成功率高,镇痛效果确切,围术期血流动力学平稳,可减少肺结核患者开胸手术术中阿片类药物用量,增强术后早期镇痛效果,可安全有效地应用于肺结核患者开胸手术麻醉。      

Intermittent interpleural injection of bupivacaine and methylprednisolone for analgesia in metastatic thoracic neoplasm.

Three patients with intractable chest wall pain due to diffusely metastatic thoracic neoplasm were successfully treated with intermittent interpleural steroid injections. Intermittent administration of 0.5% bupivacaine mixed with methylprednisolone suspension (Depo-Medrol) was effective in controlling intractable pain due to metastatic cancer. Pain relief with this technique lasted for periods in excess of 3 weeks between injections. Intermittent interpleural block may be a useful addition to the therapeutic armamentarium in dealing with chronic pain due to metastatic neoplasm.     

超声引导下胸椎旁神经阻滞对肺癌患者血流动力学、应激反应、术后痛敏反应和复苏质量的影响

目的探讨超声引导下胸椎旁神经阻滞对肺癌患者血流动力学、术后痛敏反应和复苏质量的影响。方法前瞻性选取2019年5月至2021年5月在首都医科大学大兴教学医院住院治疗的行肺癌根治术患者100例,根据随机数字表法分为对照组和观察组,每组各50例。对照组患者采用单纯全身麻醉方式,观察组采用在超声引导下胸椎旁神经阻滞后行全身麻醉方式。对比两组患者的临床资料及进入手术室后5分(T0)、麻醉诱导后5分(T1)、切皮即刻(T2)、切皮后(T3)、手术结束即刻(T4)的血流动力学指标情况;比较诱导前或神经阻滞前30 min(t0)、切皮后1 h(t1)、术后2 h(t2)、术后24 h(t3)两组患者麻醉前后应激反应情况;比较两组患者的术后视觉模拟量表(VAS)评分、Ramsay镇静评分(RSS)、术后苏醒情况及术后并发症情况。结果观察组中的MAP和心率在T2～T4时显著低于对照组,差异均有统计学意义(P <0.05)。观察组中去甲肾上腺素、肾上腺素、血管紧张素Ⅱ和β内啡肽水平在t1、t2、t3时显著低于对照组,差异均有统计学意义(P <0.05)。观察组中的VAS疼痛评分低于对照组,差异有...     

超声引导下胸神经阻滞技术应用于肩胛骨骨折手术的镇痛效果观察

目的:探讨超声引导下胸神经阻滞技术对肩胛骨骨折手术患者的镇痛效果。方法:选取我院2018年1月至2019年11月间行肩胛骨骨折择期手术140例患者进行回顾性分析,共分为3组:气管插管全麻32例(G组),全麻联合臂丛阻滞55例(B组),全麻联合臂丛+胸神经阻滞53例(S组)。其中S组分为3个亚组:胸椎旁阻滞19例(S1组),竖脊肌阻滞16例(S2组),椎板阻滞18例(S3组)。分析术中舒芬太尼追加剂量、苏醒室内的视觉模拟评分法(visual analogue scale,VAS)疼痛评分和追加镇痛药物需求率。结果:在术中追加舒芬太尼用量、苏醒室中VAS评分和追加镇痛需求率方面,S组最低,B组和S组显著低于G组,差异具有统计学意义(P<0.05)。3个S亚组之间,差异无统计学意义。结论:肩胛骨骨折手术中,胸神经阻滞可以在全麻联合臂丛阻滞的基础上,进一步增强镇痛效果,3种胸神经阻滞技术镇痛效果相似。     

Preoperative vs. Postoperative Bilateral Paravertebral Blocks for Laparoscopic Cholecystectomy: A Prospective Randomized Clinical Trial

Background: The aim of this clinical trial was to determine the potential analgesic effect of preoperative paravertebral blockade in patients undergoing laparoscopic cholecystectomy. Methods: Sixty patients scheduled for laparoscopic cholecystectomy were randomized to one of two groups with 30 patients each: bilateral nerve stimulator guided paravertebral blockade at the T5 to T6 level either prior to induction of general anesthesia (Group 1) or blockade immediately postoperatively (Group 2). Results: The preoperative paravertebral block group had significantly lower visual analog scale scores compared with the postoperative paravertebral block group both at rest 12 hours postoperatively (1.06 vs. 1.89; P < 0.05), on movement 12 hours postoperatively (1.89 vs. 3.00; P < 0.001) and on coughing 12 hours postoperatively (2.24 vs. 3.17; P < 0.01). The consumption of analgesics as well as the duration of hospital stay was significantly reduced in patients receiving preoperative paravertebral blocks (P < 0.05). [Correction added after online publication 27th May 2011: visual analog scores were amended] Conclusion: Bilateral paravertebral blockade performed prior to general anesthesia for laparoscopic cholecystectomy can provide early discharge and better postoperative pain management.     

Increasing the efficacy of a celiac plexus block in patients with severe pancreatic cancer pain.

The purpose of this study was to evaluate the technical possibilities of placing a catheter near the celiac plexus for performance of a celiac plexus block, and to study the efficacy of repeated neurolytic celiac plexus blocks with alcohol in patients with advanced pancreatic cancer pain resistant to opioid treatment. In 12 patients, a neurolytic celiac plexus block with alcohol, administered via an indwelling celiac catheter, was performed. To evaluate the efficacy, visual analog scale scores were recorded every day. Quality of life scores were registered before and 4 weeks following the procedure. Alterations in opioid consumption, and the time between the diagnosis of pancreatic cancer and the performance of the block, were registered. All patients were followed until they died. Two patients remained without pain after the first neurolytic celiac plexus block. In all other patients a second block was administered which provided only temporary relief. Additional intermittent administration of bupivacaine through the catheter was necessary to provide adequate pain relief in these patients. Quality of life increased significantly during the treatment. Opioid consumption decreased significantly in all patients. Our study indicates that a neurolytic celiac plexus blockade with alcohol results in a significant but short-lasting analgesic effect. The use of a celiac catheter improves the long-term management of pancreatic cancer pain.     

Neurolytic celiac plexus block: a better alternative to opioid treatment in upper abdominal malignancies: an Indian experience

The majority of patients with advanced upper abdominal malignancies suffer from moderate to severe pain due to unavailability of morphine in developing world. This study was undertaken to evaluate the role of neurolytic celiac plexus block on pain and quality of life in this patient subpopulation. One hundred consecutive patients receiving opioids for their pain relief were divided in two groups. Group I (control) patients received oral morphine & NSAIDS and group II (study) patients underwent neurolytic celiac plexus block (NCPB) to compare their effects on pain relief, morphine consumption, quality of life (QOL), Karnofsky and performance scores up to one month. NCPB provided statistically significant better pain relief and reduced morphine consumption at one month (P = 0.000). Superior Karnofsky and performance scores also favored NCPB group (P = 0.000); however the difference in overall QOL was not statistically significant (P = 0.24). Patients in oral morphine group had more side effects (94% vs. 58%) as compared to NCPB (P = 0.000). NCPB is an effective tool to reduce opioid requirement and the drug-related adverse effects. It is a rewarding technique, especially when morphine availability and its easy accessibility to the deserving patient is poor.     

Ultrasound-guided paravertebral nerve block anesthesia on the stress response and hemodynamics among lung cancer patients

BACKGROUNDThoracic surgery for radical resection of lung tumor requires deep anesthesia which can lead to an adverse inflammatory response, loss of hemodynamic stability, and decreased immune function. Herein, we evaluated the feasibility and benefits of ultrasound-guided paravertebral nerve block anesthesia, in combination with general anesthesia, for thoracic surgery for lung cancer. The block was performed by diffusion of anesthetic drugs along the paravertebral space to achieve unilateral multi-segment intercostal nerve and dorsal branch nerve block. AIMTo evaluate the application of ultrasound-guided paravertebral nerve block anesthesia for lung cancer surgery to inform practice. METHODSThe analysis was based on 140 patients who underwent thoracic surgery for lung cancer at our hospital between January 2018 and May 2020. Patients were randomly allocated to the peripheral + general anesthesia (observation) group (n = 74) or to the general anesthesia (control) group (n = 66). Patients in the observation group received ultrasound-guided paravertebral nerve block anesthesia combined with general anesthesia, with those in the control group receiving an epidural block combined with general anesthesia. Measured outcomes included the operative and anesthesia times, as well as the mean arterial pressure (MAP), heart rate (HR), and blood oxygen saturation (SpO₂) measured before surgery, 15 min after anesthesia (T1), after intubation, 5 min after skin incision, and before extubation (T4).RESULTSThe dose of intra-operative use of remifentanil and propofol and the postoperative use of sufentanil was lower in the observation group (1.48 ± 0.43 mg, 760.50 ± 92.28 mg, and 72.50 ± 16.62 mg, respectively) than control group (P < 0.05). At the four time points of measurement (T1 through T4), MAP and HR values were higher in the observation than control group (MAP, 90.20 ± 9.15 mmHg, 85.50 ± 7.22 mmHg, 88.59 ± 8.15 mmHg, and 90.02 ± 10.02 mmHg, respectively; and HR, 72.39 ± 8.22 beats/min, 69.03 ± 9.03 beats/min, 70.12 ± 8.11 beats/min, and 71.24 ± 9.01 beats/min, respectively; P < 0.05). There was no difference in SpO₂ between the two groups (P > 0.05). Postoperative levels of epinephrine, norepinephrine, and dopamine used were significantly lower in the observation than control group (210.20 ± 40.41 pg/mL, 230.30 ± 65.58 pg/mL, and 54.49 ± 13.32 pg/mL, respectively; P < 0.05). Similarly, the postoperative tumor necrosis factor-α and interleukin-6 levels were lower in the observation (2.43 ± 0.44 pg/mL and 170.03 ± 35.54 pg/mL, respectively) than control group (P < 0.05). There was no significant difference in the incidence of adverse reactions between the two groups (P > 0.05).CONCLUSIONUltrasound-guided paravertebral nerve block anesthesia improved the stress and hemodynamic response in patients undergoing thoracic surgery for lung cancer, with no increase in the rate of adverse events.     

悬吊运动训练对颈源性头痛的疗效

目的观察悬吊运动训练治疗颈源性头痛的临床疗效。方法颈源性头痛患者60 例,按就诊顺序分为两组。Ⅰ组(n=30)行C2椎旁阻滞,每周1 次;Ⅱ组(n=30)在颈椎旁阻滞基础上配合悬吊运动训练,悬吊运动训练每周3 次。均治疗4 周。观察治疗前与治疗后1 个月、3 个月、6 个月的疼痛视觉模拟评分(VAS)、每月疼痛发作次数及临床疗效。结果治疗后VAS评分,Ⅰ组治疗后1 个月、3 个月,Ⅱ组治疗后1 个月、3 个月、6 个月均较治疗前显著改善(P<0.001);治疗后3 个月、6 个月,Ⅱ组较Ⅰ组改善更显著(P<0.001)。治疗后疼痛发作次数,Ⅰ组治疗后1 个月、3 个月,Ⅱ组治疗后1 个月、3 个月、6 个月均较治疗前减少(P<0.05);治疗后3 个月、6 个月,Ⅱ组较Ⅰ组减少更明显(P<0.05)。治疗后Ⅰ组优良率33.3%,Ⅱ组73.3% (P<0.01)。结论配合悬吊运动训练治疗颈源性头痛优于单一采用颈椎旁阻滞,远期效果更佳。     

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.     

Regional head and face pain relief following lower cervical intramuscular anesthetic injection

BACKGROUND: Although cervical trigger point intramuscular injections are commonly used to relieve localized neck pain, regional head pain relief from lower cervical paravertebral injections has not been reported previously. PURPOSE: To evaluate the safety and efficacy of such injections in a selected group of patients with intractable head or face pain. METHODS: In a series of patients with chronic head or face pain, local anesthetic was injected into the lower cervical spine paravertebral musculature approximately 1 to 2 inches lateral to the seventh cervical spinous process. RESULTS: In addition to producing rapid relief of palpable scalp or facial tenderness (mechanical hyperalgesia and allodynia pain), this lower cervical intramuscular injection technique alleviated associated symptoms of nausea, photophobia, and phonophobia in patients with migrainous headache. CONCLUSION: Our results suggest that lower cervical intramuscular anesthetic injection may be an effective treatment for head or face pain.