Neurolytic techniques have long been used in the treatment of pain. The underlying principle for neurolytic blocks is prolonged relief of intractable pain, most often in patients with malignancies. Pain associated with cancer may be visceral, somatic, and/or neuropathic in origin. Many cancer patients have a combination of these pain types at the time of their diagnosis. Pain is often reported when visceral structures are compressed, invaded, or distended. Visceral pain is often described as vague, dull, deep, constricting, crampy, or colicky in nature. Empirical data suggests that visceral sympathetically-mediated pain responds more favorably to neurolytic therapy than neuropathic pain.1
Neurolysis, or destruction of neural tissue, was once performed surgically under direct visualization. As advancements in imaging and ablative techniques continued to progress, these procedures can now be done percutaneously2 chemically, thermally with radiofrequency, or by freezing via cryoneurolysis.
The indications for chemical neurolysis include3:
Severe, intractable pain that persists after less invasive treatments
Intolerable side effects of analgesic therapy
Intrathecal catheter, with or without a pump, is not a viable option
Advanced or terminal malignancy
Pain well localized:
Primary somatic pain mechanism
Absence of intraspinal tumor spread
Pain relieved with prognostic local anesthetic block
No undesirable effects after local anesthetic block
Realistic expectations by patient and family
Informed consent clearly explains potential complications
BASIC CONCERNS AND CONTRAINDICATIONS
Risks and benefits should always be weighed prior to undergoing any intervention. Extensive communication with the patient is necessary before proceeding.
Potential risk for infection in immunocompromised patients
Metastatic cancer spread to the region
Thrombocytopenia secondary to chemotherapy
Difficulty in positioning due to tumor and pain location
Absolute contraindications for injection include:
Relative contraindications include:
Autonomic nervous system no longer the main transmission of the pain source for visceral pain (eg, carcinoma of the pancreas that has begun to invade the body wall)
Distorted or complicated anatomy (eg, large aortic aneurysm)
Visceral neurolytic blocks are particularly effective for cancer-related pain. The paravertebral sympathetic chain consists of sympathetic neural tissue from several sympathetic plexuses that run along the paravertebral region of the body (Figure 78-1). There are several sites for neurolytic blockade of the sympathetic nervous system for the treatment of cancer pain (Table 78-1).1 These axial sympathetic chains include the cervical, thoracic, and lumbar sympathetic ganglia.
Sympathetic nervous system sites for neurolysis.
TABLE 78-1.Sympathetic Nervous System with Corresponding Anatomic ...
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