Cancer Pain – Quality Assurance For Interventional Pain Management Procedures!

Cancer Pain – Quality Assurance For Interventional Pain Management Procedures!

6jMV92a

By Dr. Neeraj Jain, Pain Management

“The neurosignature of pain experience is determined by the synaptic architecture of the neuromatrix”

There have been many advances in the understanding & usefulness of an intervention at right time in selective patients producing excellent results. Interventional pain procedures scores over both medicine and surgery, as they do not have side effects like medicines. Surgeries for pain now have limited indications & usually as a last resort.

The interventional pain procedures produce immediate pain relief, can be performed with ease by pain physicians without anesthesia as outpatient or daycare and adequate duration of pain relief is obtained and they are suitable for surgically unfit, unwilling & debilitated patients, procedures can be repeated safely if required.

With the advancement of technology and science, we have unveiled many aspects of the pain and its treatment. We have to work hard to spread the knowledge of interventional pain techniques. Our goal is to help people suffering from pain, make them productive human being for the society and increase their self esteem so that they can live life as normal individuals.

Unfortunately, awareness about pain management among medical professionals is very limited. In contrast to USA and other developed countries Indian medical community is not aware of interventional pain management techniques which can be helpful for many patients suffering from intractable chronic pain.

Pain treatment is tailor-made & no single treatment fits all.

PERCUTANEOUS LEAST INVASIVE INTERVENTIONAL PAIN MANAGEMENT OF LBP:-       
It has both diagnostic & therapeutic relevance( as there are significant false positive & negative imaging studies not correlating to symptoms). Better results are obtained if treatment is started early.

  1. LESI-lumbar epidural steroid injections::
    • interlamminar or transforaminal or caudal approach
  2. SNRB- selective nerve root block
  3. Epidural adenolysis or percutaneous decompressive neuroplasty
  4. Trigger point injection
  5. Botox paraspinal muscle injection
  6. Facet joint or pericapsular injection
  7. Spine Prolotherapy & manipulation
  8. Facet RF thermal neurolysis
  9. SI joint injection or denervation
  10. Piriformis  muscle block
  11. Diagnostic provocative discography
  12. Intradiscal procedures:-Ozone Discolysis/ Chemonucleolysis
    • Dekompressor disc debulking
    • IDET-intradiscal electrothermal therapy
    • Coblation nucleoplasty
    • Laser percutaneous discectomy
  13. Vertebroplasty & kyphoplasty
  14. Intrathecal pump neuraxial implants
  15. Augmentation or neuromodulation spinal cord stimulation
  16. Lumbar/cervicothoracic sympathetic blocks / neurolysis
  17. Stellate /splanchnic/ celiac plexus/ hypogastric/ impair neurolysis
  18. Paravertebral/psoas compartment blocks
  19. Intrathecal/ Epidural neurolysis
  20. Cranial nerves blocks / neuroablations
  21. Trigeminal gangliolysis
  22. Pituitary chemoadenolysis
  23. Botox chemodenervation
  24. Laser lessioning / radiofrequency (RF) neuroablations

ONCE THE CONSERVATIVE TREATMENT FAILS:- 
Early aggressive treatment plan of pain has to be implemented to prevent peripherally induced CNS changes that may intensify or prolong pain making it a complex pain syndrome. Only 5% of total LBP patients would need surgery & 20% of discal rupture or herniation would need surgery. Nonoperative treatment is sufficient in most of the patients, although the patient selection is important even then.

Depending on the diagnosis one can perform & combine properly selected percutaneous fluoroscopic guided procedures with time spacing depending upon pt`s pathology & response to treatment.

Using precision diagnostic & therapeutic blocks in chronic LBP, isolated facet joint pain in 40%, discogenic pain in 25%(95% in L4-5&L5S1), segmental dural or nerve root pain in 14% & sacroiliac joint pain in 15% of the patients. This article describes successful interventions of these common causes of LBP after conservative treatment has failed.

LESI: LUMBAR EPIDURAL STEROID INJECTION
Indicated in  -  Acute radicular pain due to irritation or inflammation.
-  Symptomatic herniated disc with failed conservative therapy
-  Acute exerbation of discogenic pain or pain of spinal stenosis
-  Neoplastic infiteration of roots
-  Epidural fibrosis
-  Chronic LBP with acute radicular symptoms

ESI  TREATMENT PLAN:
Compared to interlaminar approach better results are found with a transforaminal approach where drugs (steroid+ LA/saline +/- hyalase) are injected into anterior epidural space & neural foramen area where herniated disc or offending nociceptors are located. Whereas in interlaminar approach most of drug is deposited in posterior epidural space. Drugs are injected total 6-10 ml at lumbar, 3-6 ml at cervical & 20+ ml if caudal approach is selected. Lumbar ESI is performed close to the level of radiculopathy, often using paramedian approach to target the lateral aspect of the epidural space on involved side. Cervical epidural is performed at C7-T1 level.

SNRB- SELECTIVE NERVE ROOT BLOCK. 
Fluoroscopically performed it is a good diagnostic & therapeutic procedure for radiculopathy pain if

  1. There is minimal or no radiological finding.
  2. Multilevel imaging abnormalities
  3. Equivocal neurological examination finding or discrepancy between clinical & radiological signs
  4. Postop patient with unexplainable or recurrent pain
  5. Combined canal & lateral recess stenosis.
  6. To find out the pathological dermatome for more invasive procedures, if needed
    • Sciatica- Selective Nerve Root Block

EPIDURAL ADENOLYSIS  OR PERCUTANEOUS DECOMPRESSIVE NEUROPLASTY  for EPIDURAL FIBROSIS OR ADHESIONS IN FAILED BACK SURGERY SYNDROMES (FBSS)

A catheter is inserted in epidural space via caudal/ interlaminar/ transforaminal approach.

After epidurography testing volumetric irrigation with normal saline/ L.A./ hyalase/ steroids/ hypertonic saline in different combinations is then performed along with mechanical adenolysis with spring loaded or stellated catheters or under direct vision with EPIDUROSCOPE.

FACET SYNDROME:-  FACET JOINT INJECTION OR
RF MEDIAL BRANCH NEUROTOMY

It is due to mechanical stress on the Zygapophysial joints or traumatic/anatomical derangement & degenerative facet arthropathy. It is commoner in the male of younger age group during active careers. CT/ MRI/ Bone scan show structural pathology, but diagnosis is confirmed by relief of pain with joint injection (1ml of LA+ 20 mg triamcinolone) which has therapeutic value also.After effective facet joint block, fluoroscopic percutaneous radiofrequency(RF) thermal rhizotomy of two-level medial branches of dorsal ramus is a safe, effective & long-term treatment.

Facet RF Neuroablation

Bartilotti Syndrome Treatment

SACROILIAC JOINT INJECTION & DENERVATION: 
The only way to make a definitive diagnosis is pain relief with image guided joint injection of depo-steroid with L.A..This can be followed by joint denervation of L4-5 S1-3 branches to this joint providing long term pain relief.

SI Joint Block
INTRADISCAL PROCEDURES::
PROVOCATIVE DISCOGRAPHY: coupled with CT

A diagnostic procedure & prognostic indicator for surgical outcome is necessary in the evaluation of patients with suspected discogenic pain, its ability to reproduce pain(even with normal radiological finding), to determine type of disc herniation /tear, finding surgical options & in assessing previously operated spines

Discography

PERCUTANEOUS DISC DECOMPRESSION (PDD)
After diagnosing the level of painful offending disc various percutaneous intradiscal procedures can be employed:–

OZONE-CHEMONEUCLEOPLASTY: Ozone Discectomy a revolutionary least invasive safe & effective alternative to spine surgery is the treatment of choice for prolapsed disc (PIVD) done under local anaesthesia in a daycare setting. This procedure is ideally suited for cervical & lumbar disc herniation with radiculopathy. Total cost of the procedure is much less than that of surgical discectomy. All these facts have made this procedure very popular in European countries. It is also gaining popularity in our country due to high success rate, less invasiveness, fewer chances of recurrences, remarkably fewer side effects meaning high safety profile, short hospital stay, no post-operative discomfort or morbidity and low cost.

Lumbar Ozone Injection

  1. DEKOMPRESSOR: A mechanical percutaneous nucleotome cuts & drills out the disc material somewhat like morcirator debulking the disc reducing nerve compression.
  2. Disc – drill decompression in progress
  3. Disc Extracted on DeKompressor
  4. Ganglion of Impar Block for Coccydynia & Perineal Cancer Pain

Piriformis Syndrome Injection
INTRATHECAL (SPINAL) PUMP IMPLANTS:   
Opted when oral narcotics provide insufficient pain relief or side effects are troublesome in intractable cancer & chronic pain patients. It delivers drug via an implanted catheter directly into CSF needing a very small dose (1/300 of oral dose). The programmable pump is implanted in ant. lower abdomen. It delivers the drug as per the patients needs. More powerful analgesia & spasticity control is achieved using lower doses, constant relief & fewer side effects as with oral doses eg. Somnolence, mental clouding, constipation, euphoria with decreased chances of drug addiction or misuse.

NEUROMODULATION TECHNIQUES:
SPINAL CORD STIMULATION (SCS) IMPLANTS : 

Done for FBSS( failed back surgery syndrome) & CRPS(complex regional pain syndromes) in USA. In Europe, it is done for chronic intractable angina &  pain of peripheral vascular diseases (PVD). The indications are expanding further in chronic pain states. A set of electrodes is placed in epidural space & connected to a pulse generator ( like a cardiac pacing device) that is implanted in upper buttock. Low level of electric impulses replace pain signals to the brain with mild tingling sensation. A trial stimulation is done before permanent SCS lead implant.

PERCUTANEOUS VERTEBROPLASTY / KYPHOPLASTY:  
A NEWER APPROACH TO MANAGEMENT OF VERTEBRAL BODY FRACTURES  
As life expectancy is increasing so is the incidence of vertebral body (VB) # now being the commonest # of the body. PVP is an established interventional technique in which PMMA bone cement is injected under L.A. via a needle into a # VB with imaging guidance providing increased bone strength, stability, pain relief, decreased analgesics, increased mobility with improved QOL and early return to work.

Started in 1984 by Galibert PVP is done in the host of INDICATIONS:
Senile osteoporotic compression # remains the commonest Indication. Other indications are  Metastatic VB #,  Multiple myeloma VB #, VB haemangioma,  Vertebral osteonecrosis & for strengthening VB before major spinal surgery. The benefit has been extended to the traumatic stable uncomplicated VB compression # (VCF)   which is commoner in younger age group with active life profile and prime of their career where strict bed rest and acute or chronic pain are unacceptable and they are more demanding for proactive treatment approach so as to be back to work ASAP.

Discovering the fact that # VB is the commonest # of body, its incidence >the # hip, it becomes imperative to take it more seriously. With increasing life span there is more of aged osteoporotic population, more so due to sedentary indoor lifestyle and postmenopausal osteoporosis.  Diabetics, smokers & alcoholics are at higher risk of developing osteoporosis. I have seen such alcoholic patient developing six spine fractures in just three months time from a single fracture being on complete bed rest.

Quick fix of fracture spine makes patient walk back same day instead of bed rest of months together avoiding morbidity & mortality of prolonged bed rest, making bedridden patient walk, in a way bringing patient back to normal life.

In this era of MAS replacing open surgeries, PVP is a novel procedure & should be in the first line of management in place of conservatism or major spine surgery for painful uncomplicated compression.

OUTCOME:

  1. PVP is a novel procedure with high benefit to risk ratio, which is highly underutilized in relation to the high prevalence of the vertebral #.
  2. Different studies show an immediate pain relief in (85 – 90)% of patients with low complication rate ranging from (1-5)% depending upon the type of lesion.
  3. PVP does augment height of VB but ideal would be kyphoplasty.
  4. The patient is either off medicine or on reduced doses.
  5. The patient feels so well that he almost forgets if he had VB #.

Trigeminal Neuralgia: If medication fails to relieve pain or produces intolerable side effects such as excess fatigue, Interventional Pain Treatment is recommended done on an outpatient basis in which TN is blocked by Neurolytic drug or Radiofrequency with good results.

Cancer Pain: 
Pain is a major symptom of cancer and occurs at all stages of the disease. In addition, pain is usually a hallmark of progression or metastatic spread, and 65 to 85 percent of people with cancer have pain when they develop advanced disease. In 10 to 20 percent of cancer cases, pain is difficult to treat, frustrating, and poorly controlled. Currently, opioid pharmacotherapy is the principal weapon in the fight against cancer pain; but when less invasive treatments are unsuccessful, invasive interventions should be added to optimize pain relief. Interventional pain procedures target neural and non-neural pain generators and neural blockade techniques provide excellent pain relief for neuropathic, sympathetic, nociceptive somatic, or visceral pain. Neural blockade techniques are broadly categorized into non-neurolytic and neurolytic blocks.

Non-Neurolytic Blocks
Local anesthetic and corticosteroid blocks are used to treat a variety of pain syndromes. They can also predict how a patient will respond to neurolytic blocks. A good response to non-neurolytic interventions usually means the patient will benefit from neurolytic procedures as well. Fluoroscopic guidance improves the accuracy of these blocks and minimizes complications. Somatic, sympathetic, and neuropathic pain respond to local anesthetic injections or the continuous administration of anesthetic drugs through a catheter. Intercostal nerve blocks or intrapleural analgesia are indicated in post-thoracotomy chest wall pain/intercostal neuralgia, and radiculopathy requires selective nerve root blocks or transforaminal epidural injections when non-invasive treatments fail. Sympathetic blocks and other regional anesthetic techniques are employed in sympathetically maintained pain states, ischemic pain, postherpetic neuralgia, and radiation plexopathy.

Neurolytic Blocks
Alcohol and phenol are the preferred agents for neurolytic procedures because they cause axonal degeneration within minutes and effectively interrupt the central transmission of pain impulses. Chemical neurolysis can result in immediate and total pain relief in selected patients with localized or regional pain. Opioid requirements decrease sharply, and patients on high doses of opioids will require careful tapering to avoid respiratory depression. Other indications for neurolysis are costopleural syndrome and sympathetically maintained pain in Pancoast’s syndrome. Unfortunately, potentially unacceptable side effects limit the utility of neurolytic blocks; but neurolytic blocks are still preferred over standard opioid analgesia to control intractable abdominal, pelvic, and perineal pain.

The following four criteria must be met before a nerve block is considered appropriate:

  1. Limited lifespan of three to six months
  2. A favorable risk to benefit ratio (i.e., the block will not impair bladder or bowel function or cause limb paralysis)
  3. A poor response to primary antitumor treatment, which has not been able to reduce the tumor burden
  4. A good analgesic response and acceptable side effects with prognostic blocks.

Advantages:

The neurolytic blocks have the following advantages in home care by relatives of patients particularly in rural area of India:

1). Neurolytic blocks provide longer duration of pain relief.

2).Drugs and inexpensive equipment required are readily available.Elaborate equipment is not mandatory.

3). Long-term indoor ward treatment is avoided, repeated visits to the urban pain center are not required.

4). Patient can remain at home painfree even in rural areas where medical help is scarce.

Neurolytic Block
Neurolytic Celiac Plexus Blocks (NCPB) And Splanchnic Nerve Blocks (SNB) are routinely performed (and are preferred over standard analgesic therapies) for patients with intractable pain from pancreatic and upper gastrointestinal cancer. NCPBs provide immediate and substantial pain relief in 70 to 90 percent of cases, improve the patient’s quality of life, and significantly reduce opioid intake. The procedure can be repeated in three to six months if the effect of the initial block wears off. NCPBs are performed percutaneously or intraoperatively. Under radiologic guidance, 50 to 100 percent alcohol is instilled anterior to the aorta at the level of the L1 vertebral body. Injection site pain, diarrhea, and temporary hypotension are transient adverse effects. A low complication rate is observed, since the risk of the neurolytic agent spreading to the somatic nerves supplying the lower limbs, bladder, and bowel is minimal

Superior Hypogastric Plexus Blocks (SHPB) are indicated for unrelenting pain from cancer of the pelvic viscera. This plexus lies in front of the L5 and S1 vertebrae in the prevertebral space. A spinal needle is placed percutaneously in this space from the back under radiologic guidance. Excellent analgesia is reported by 70 percent of patients after a SHPB. Reductions in pain scores and opioid consumption are reported to be significant, even in patients with advanced disease. No major complications have been reported following SHPBs, although a potential risk exists for the spread of neurolytic agents to the nerve fibers controlling micturition, bowel motility, and sexual function. The SHPB block can be repeated if pain recurs. Patients who fail two consecutive attempts are candidates for intraspinal opioid analgesia.

Ganglion Impar Neurolytic Blocks relieve perineal pain from cancer of the cervix, endometrium, bladder, and rectum. The ganglion is a single, midline structure ventral to the sacrococcygeal junction and can be accessed by a midline trans-sacral approach.

Painful input from somatic and visceral structures can produce sympathetically maintained pain (SMP) that may be visceral or neuropathic in nature. Sympathetic Ganglion Neurolysis relieves SMP and improves blood flow and is used to treat pain from radiation plexopathy, phantom pain, herpes zoster, vascular insufficiency secondary to malignancy, and complex regional pain syndromes (reflex sympathetic dystrophy and causalgia), with little risk of motor or sensory loss or deafferentation pain.The trigeminal nerve receives sensory input from the skin of the face, anterior two-thirds of the tongue, and oronasal mucosa. Anesthetic Blockade Or Chemical Rhizolysis of the trigeminal ganglion or its individual branches is indicated in orofacial malignancies with intractable head and face pain.

Neurolytic Spinal Blockade can produce profound segmental analgesia. Nociceptive input is interrupted by selectively destroying the dorsal roots and rootlets between the spinal cord and the dorsal root ganglia. The procedure is reserved for terminally ill patients with cancer who have a short life expectancy and unilateral somatic pain localized to a few adjacent dermatomes, ideally in the trunk and distant from sphincter or limb innervation. Combined with a unilateral cordotomy, subarachnoid phenol blocks effectively control pain in costopleural syndrome, which is caused by invasion of the pleural cavity and thoracic wall. Adverse effects include PDPH, meningitis (rarely), persistent numbness and paresthesia, loss of motor function due to the unintended neurolysis of ventral rootlets, and sphincter and limb weakness.

Trans-sphenoid Pituitary Neuroablation: Chemical Hypophysectomy 
Very useful simple intervention with 70-80% success rate in diffuse cancers of advanced stage with multiple bony & spinal metastasis especially hormone dependent cancers not responding to all other measures.
Intraspinal Opioid Therapy
Continued administration of opioids intrathecally or epidurally with or without dilute concentration of local anesthetic& adjuvant drugs is an important option for patients with thoracic, abdominal or pelvic cancer pain that is refractory to conventional pharmacologic management.  Advantages include profound analgesia, often at a much lower opioid dose without the motor, sensory, or sympathetic block. However combinations of low-dose opioids given epidurally with a local anesthetic act synergistically to produce effective analgesia while decreasing the side effects. Administration can be carried out using a variety of drug-delivery systems ranging from a temporary percutaneous epidural catheter to a totally implanted system. The effectiveness of preimplantation procedure and reversibility of effect makes this an attractive treatment option.

Conclusion
The management of patients with cancer pain can be a challenging task, even for physicians trained in cancer pain management Effectively relieving pain in cancer patients requires a range of treatment alternatives, including neural blockade when the patient’s pain no longer responds to opioid analgesia. The type of neural block selected is determined by the location and mechanism of the pain, the physical status of the patient, the extent of tumor spread, and the technical skill and experience of the person performing the intervention. Non-neurolytic blocks can provide safe and effective analgesia for the less serious conditions indicated above. Neurolytic blocks, with their potential for complications, are reserved for select patients who are unresponsive to standard analgesic pharmacotherapy and/or are at a more advanced stage of disease. However, few would question that aggressive intervention is often appropriate. Neurolytic nerve blocks offer an excellent option for the physician in the fight to control cancer pain. Such blocks can be easily utilized to help provide cancer pain relief in most of patients at the utmost needed times.

“Pain is real & treatable — There is no merit in suffering!”

Pain is a major symptom of cancer and occurs at all stages of the disease. In addition, pain is usually a hallmark of progression or metastatic spread, and 65 to 85 percent of people with cancer have pain when they develop advanced disease. In 10 to 20 percent of cancer cases, pain is difficult to treat, frustrating, and poorly controlled. Currently, opioid pharmacotherapy is the principal weapon in the fight against cancer pain; but when less invasive treatments are unsuccessful, invasive interventions should be added to optimize pain relief. Interventional pain procedures target neural and non-neural pain generators and neural blockade techniques provide excellent pain relief for neuropathic, sympathetic, nociceptive somatic, or visceral pain. Neural blockade techniques are broadly categorized into non-neurolytic and neurolytic blocks.

Neck Cancer

Cancer spreading to spine
The management of patients with cancer pain can be a challenging task, even for physicians trained in cancer pain management Effectively relieving pain in cancer patients requires a range of treatment alternatives, including neural blockade when the patient’s pain no longer responds to opioid analgesia. The type of neural block selected is determined by the location and mechanism of the pain, the physical status of the patient, the extent of tumor spread, and the technical skill and experience of the person performing the intervention. Non-neurolytic blocks can provide safe and effective analgesia for the less serious conditions indicated above. Neurolytic blocks, with their potential for complications, are reserved for select patients who are unresponsive to standard analgesic pharmacotherapy and/or are at a more advanced stage of disease. However, few would question that aggressive intervention is often appropriate. Neurolytic nerve blocks offer an excellent option for the physician in the fight to control cancer pain. Such blocks can be easily utilized to help provide cancer pain relief in most of patients at the utmost needed times.

Cancer Pain: Effective Pain Management
Pain is a major symptom of cancer and occurs at all stages of the disease. In addition, pain is usually a hallmark of progression or metastatic spread, and 65 to 85 percent of people with cancer have pain when they develop advanced disease. In 10 to 20 percent of cancer cases, pain is difficult to treat, frustrating, and poorly controlled. Currently, opioid pharmacotherapy is the principal weapon in the fight against cancer pain; but when less invasive treatments are unsuccessful, invasive interventions should be added to optimize pain relief. Interventional pain procedures target neural and non-neural pain generators and neural blockade techniques provide excellent pain relief for neuropathic, sympathetic, nociceptive somatic, or visceral pain. Neural blockade techniques are broadly categorized into non-neurolytic and neurolytic blocks.
The management of patients with cancer pain can be a challenging task, even for physicians trained in cancer pain management Effectively relieving pain in cancer patients requires a range of treatment alternatives, including neural blockade when the patient’s pain no longer responds to opioid analgesia. The type of neural block selected is determined by the location and mechanism of the pain, the physical status of the patient, the extent of tumor spread, and the technical skill and experience of the person performing the intervention. Non-neurolytic blocks can provide safe and effective analgesia for the less serious conditions indicated above.
Neurolytic blocks, with their potential for complications, are reserved for select patients who are unresponsive to standard analgesic pharmacotherapy and/or are at a more advanced stage of disease. However, few would question that aggressive intervention is often appropriate. Neurolytic nerve blocks offer an excellent option for the physician in the fight to control cancer pain. Such blocks can be easily utilized to help provide cancer pain relief in most of patients at the utmost needed times.

Cancer Liver Advance Stage
Neurolytic Celiac Plexus Blocks (NCPB) And Splanchnic Nerve Blocks (SNB) are routinely performed (and are preferred over standard analgesic therapies) for patients with intractable pain from pancreatic and upper gastrointestinal cancer. NCPBs provide immediate and substantial pain relief in 70 to 90 percent of cases, improve the patient’s quality of life, and significantly reduce opioid intake. The procedure can be repeated in three to six months if the effect of the initial block wears off. NCPBs are performed percutaneously or intraoperatively. Under radiologic guidance, 50 to 100 percent alcohol is instilled anterior to the aorta at the level of the L1 vertebral body. Injection site pain, diarrhea, and temporary hypotension are transient adverse effects. A low complication rate is observed, since the risk of the neurolytic agent spreading to the somatic nerves supplying the lower limbs, bladder, and bowel is minimal.

Celiac Block
Superior Hypogastric Plexus Blocks (SHPB) are indicated for unrelenting pain from cancer of the pelvic viscera. This plexus lies in front of the L5 and S1 vertebrae in the prevertebral space. A spinal needle is placed percutaneously in this space from the back under radiologic guidance. Excellent analgesia is reported by 70 percent of patients after a SHPB. Reductions in pain scores and opioid consumption are reported to be significant, even in patients with advanced disease. No major complications have been reported following SHPBs, although a potential risk exists for the spread of neurolytic agents to the nerve fibers controlling micturition, bowel motility, and sexual function. The SHPB block can be repeated if pain recurs. Patients who fail two consecutive attempts are candidates for intraspinal opioid analgesia.

Cancer Hypogastric Plexus Block
Ganglion Impar Neurolytic Blocks relieve perineal pain from cancer of the cervix, endometrium, bladder, and rectum. The ganglion is a single, midline structure ventral to the sacrococcygeal junction and can be accessed by a midline trans-sacral approach.

Painful input from somatic and visceral structures can produce sympathetically maintained pain (SMP) that may be visceral or neuropathic in nature. Sympathetic Ganglion Neurolysis relieves SMP and improves blood flow and is used to treat pain from radiation plexopathy, phantom pain, herpes zoster, vascular insufficiency secondary to malignancy, and complex regional pain syndromes (reflex sympathetic dystrophy and causalgia), with little risk of motor or sensory loss or deafferentation pain.

The trigeminal nerve receives sensory input from the skin of the face, anterior two-thirds of the tongue, and oronasal mucosa. Anesthetic Blockade Or Chemical Rhizolysis of the trigeminal ganglion or its individual branches is indicated in orofacial malignancies with intractable head and face pain.

Coccyx Impar Block
Neurolytic Spinal Blockade can produce profound segmental analgesia. Nociceptive input is interrupted by selectively destroying the dorsal roots and rootlets between the spinal cord and the dorsal root ganglia. The procedure is reserved for terminally ill patients with cancer who have a short life expectancy and unilateral somatic pain localized to a few adjacent dermatomes, ideally in the trunk and distant from sphincter or limb innervation. Combined with a unilateral cordotomy, subarachnoid phenol blocks effectively control pain in costopleural syndrome, which is caused by invasion of the pleural cavity and thoracic wall. Adverse effects include PDPH, meningitis (rarely), persistent numbness and paresthesia, loss of motor function due to the unintended neurolysis of ventral rootlets, and sphincter and limb weakness.

Intraspinal Opioid Therapy
Continued administration of opioids intrathecally or epidurally with or without dilute concentration of local anesthetic& adjuvant drugs is an important option for patients with thoracic, abdominal or pelvic cancer pain that is refractory to conventional pharmacologic management. Advantages include profound analgesia, often at a much lower opioid dose without the motor, sensory, or sympathetic block. However combinations of low-dose opioids given epidurally with a local anesthetic act synergistically to produce effective analgesia while decreasing the side effects. Administration can be carried out using a variety of drug-delivery systems ranging from a temporary percutaneous epidural catheter to a totally implanted system. The effectiveness of preimplantation procedure and reversibility of effect makes this an attractive treatment option.

Pain is a major symptom of cancer and occurs at all stages of the disease. In addition, pain is usually a hallmark of progression or metastatic spread, and 65 to 85 percent of people with cancer have pain when they develop advanced disease. In 10 to 20 percent of cancer cases, pain is difficult to treat, frustrating, and poorly controlled. Currently, opioid pharmacotherapy is the principal weapon in the fight against cancer pain; but when less invasive treatments are unsuccessful, invasive interventions should be added to optimize pain relief. Interventional pain procedures target neural and non-neural pain generators and neural blockade techniques provide excellent pain relief for neuropathic, sympathetic, nociceptive somatic, or visceral pain. Neural blockade techniques are broadly categorized into non-neurolytic and neurolytic blocks.

Non-Neurolytic Blocks
Local anesthetic and corticosteriod blocks are used to treat a variety of pain syndromes. They can also predict how a patient will respond to neurolytic blocks. A good response to non-neurolytic interventions usually means the patient will benefit from neurolytic procedures as well. Fluoroscopic guidance improves the accuracy of these blocks and minimizes complications. Somatic, sympathetic, and neuropathic pain respond to local anesthetic injections or the continuous administration of anesthetic drugs through a catheter. Intercostal nerve blocks or interpleural analgesia are indicated in post-thoracotomy chest wall pain/intercostal neuralgia, and radiculopathy requires selective nerve root blocks or transforaminal epidural injections when non-invasive treatments fail. Sympathetic blocks and other regional anesthetic techniques are employed in sympathetically maintained pain states, ischemic pain, postherpetic neuralgia, and radiation plexopathy

Neurolytic Blocks
Alcohol and phenol are the preferred agents for neurolytic procedures because they cause axonal degeneration within minutes and effectively interrupt the central transmission of pain impulses. Chemical neurolysis can result in immediate and total pain relief in selected patients with localized or regional pain. Opioid requirements decrease sharply, and patients on high doses of opioids will require careful tapering to avoid respiratory depression. Other indications for neurolysis are costopleural syndrome and sympathetically maintained pain in Pancoast’s syndrome. Unfortunately, potentially unacceptable side effects limit the utility of neurolytic blocks; but neurolytic blocks are still preferred over standard opioid analgesia to control intractable abdominal, pelvic, and perineal pain.

The following four criteria must be met before a nerve block is considered appropriate:

–Limited lifespan of three to six months

–A favorable risk to benefit ratio (i.e., the block will not impair bladder or bowel function or cause limb paralysis)

— A poor response to primary antitumor treatment, which has not been able to reduce the tumor burden

— A good analgesic response and acceptable side effects with prognostic blocks.

Advantages: The neurolytic blocks have the following advantages in home care by relatives of patients particularly in rural area of India: 1). Neurolytic blocks provide longer duration of pain relief. 2).Drugs and inexpensive equipment required are readily available.Elaborate equipment is not mandatory. 3). Long-term indoor ward treatment is avoided, repeated visits to the urban pain center are not required. 4). Patient can remain at home pain free even in rural areas where medical help is scarce.

Table 1. AUTONOMIC NERVE BLOCKS
Neurolytic Block Site/Condition Treated
Stellate ganglion Head Neck or arm pain
Gasserian ganglion Trigeminal neuralgia and facial pain
Interpleural (thoracic sympathetic chain) Upper—head, armsMiddle—thorax, heart, lungLower— abdominal organs, uterus, bladder
Celiac plexus (splanchnic nerves) Pancreatitis, Hepatobiliary Cancer pain, visceral/GIT cancer pain upto trans.Colon.
Lumbar sympathetic Lower limb pain, retroperitoneal pain
Hypogastric plexus Pelvic,  Perineal, urogenital pain
Sacrococcygeal ganglion (impar, Walther) Rectal, uretheral, perineal, vaginal pain

Neurolytic Celiac Plexus Blocks (NCPB) And Splanchnic Nerve Blocks (SNB) are routinely performed (and are preferred over standard analgesic therapies) for patients with intractable pain from pancreatic and upper gastrointestinal cancer. NCPBs provide immediate and substantial pain relief in 70 to 90 percent of cases, improve the patient’s quality of life, and significantly reduce opioid intake. The procedure can be repeated in three to six months if the effect of the initial block wears off. NCPBs are performed percutaneously or intraoperatively. Under radiologic guidance, 50 to 100 percent alcohol is instilled anterior to the aorta at the level of the L1 vertebral body. Injection site pain, diarrhea, and temporary hypotension are transient adverse effects. A low complication rate is observed, since the risk of the neurolytic agent spreading to the somatic nerves supplying the lower limbs, bladder, and bowel is minimal.

Superior Hypogastric Plexus Blocks (SHPB) are indicated for unrelenting pain from cancer of the pelvic viscera. This plexus lies in front of the L5 and S1 vertebrae in the prevertebral space. A spinal needle is placed percutaneously in this space from the back under radiologic guidance. Excellent analgesia is reported by 70 percent of patients after a SHPB. Reductions in pain scores and opioid consumption are reported to be significant, even in patients with advanced disease. No major complications have been reported following SHPBs, although a potential risk exists for the spread of neurolytic agents to the nerve fibers controlling micturition, bowel motility, and sexual function. The SHPB block can be repeated if pain recurs. Patients who fail two consecutive attempts are candidates for intraspinal opioid analgesia.
Ganglion Impar Neurolytic Blocks relieve perineal pain from cancer of the cervix, endometrium, bladder, and rectum. The ganglion is a single, midline structure ventral to the sacrococcygeal junction and can be accessed by a midline trans-sacral approach.

Painful input from somatic and visceral structures can produce sympathetically maintained pain (SMP) that may be visceral or neuropathic in nature. Sympathetic Ganglion Neurolysis relieves SMP and improves blood flow and is used to treat pain from radiation plexopathy, phantom pain, herpes zoster, vascular insufficiency secondary to malignancy, and complex regional pain syndromes (reflex sympathetic dystrophy and causalgia), with little risk of motor or sensory loss or deafferentation pain.

The trigeminal nerve receives sensory input from the skin of the face, anterior two-thirds of the tongue, and oronasal mucosa. Anesthetic Blockade Or Chemical Rhizolysis of the trigeminal ganglion or its individual branches is indicated in orofacial malignancies with intractable head and face pain.

Neurolytic Spinal Blockade can produce profound segmental analgesia. Nociceptive input is interrupted by selectively destroying the dorsal roots and rootlets between the spinal cord and the dorsal root ganglia. The procedure is reserved for terminally ill patients with cancer who have a short life expectancy and unilateral somatic pain localized to a few adjacent dermatomes, ideally in the trunk and distant from sphincter or limb innervation. Combined with a unilateral cordotomy, subarachnoid phenol blocks effectively control pain in costopleural syndrome, which is caused by invasion of the pleural cavity and thoracic wall. Adverse effects include PDPH, meningitis (rarely), persistent numbness and paresthesia, loss of motor function due to the unintended neurolysis of ventral rootlets, and sphincter and limb weakness.

Trans-sphenoid Pituitary Neuroablation: Chemical Hypophysectomy
Very useful simple intervention with 70-80% success rate in diffuse cancers of the advanced stage with multiple bony & spinal metastasis especially hormone dependent cancers not responding to all other measures.

3) Intraspinal Opioid Therapy
Continued administration of opioids intrathecally or epidurally with or without dilute concentration of local anesthetic& adjuvant drugs is an important option for patients with thoracic, abdominal or pelvic cancer pain that is refractory to conventional pharmacologic management. Advantages include profound analgesia, often at a much lower opioid dose without the motor, sensory, or sympathetic block. However combinations of low-dose opioids given epidurally with a local anesthetic act synergistically to produce effective analgesia while decreasing the side effects. Administration can be carried out using a variety of drug-delivery systems ranging from a temporary percutaneous epidural catheter to a totally implanted system. The effectiveness of preimplantation procedure and reversibility of effect makes this an attractive treatment option.

Conclusion
The management of patients with cancer pain can be a challenging task, even for physicians trained in cancer pain management Effectively relieving pain in cancer patients requires a range of treatment alternatives, including neural blockade when the patient’s pain no longer responds to opioid analgesia. The type of neural block selected is determined by the location and mechanism of the pain, the physical status of the patient, the extent of tumor spread, and the technical skill and experience of the person performing the intervention. Non-neurolytic blocks can provide safe and effective analgesia for the less serious conditions indicated above. Neurolytic blocks, with their potential for complications, are reserved for select patients who are unresponsive to standard analgesic pharmacotherapy and/or are at a more advanced stage of disease. However, few would question that aggressive intervention is often appropriate. Neurolytic nerve blocks offer an excellent option for the physician in the fight to control cancer pain. Such blocks can be easily utilized to help provide cancer pain relief in most of the patients at the utmost needed times.