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08. Serdar Erdine.Indd AĞRI 2009;21(4):133-140 REVIEW - DERLEME Neurolytic blocks: When, How, Why Nörolitik bloklar: Ne zaman, Nasıl, Niçin Serdar ERDİNE1 Summary Interventional techniques are divided into two categories: neuroablative and neuromodulatory procedures. Neuroablation is the physical interruption of pain pathways either surgically, chemically or thermally. Neuromodulation is the dynamic and functional inhibition of pain pathways either by administration of opioids and other drugs intraspinally or intraventricularly or by stimulation. Neuroablative techniques for cancer pain treatment have been used for more than a century. With the de- velopment of imaging facilities such as fl uoroscopy, neuroablative techniques can be performed more precisely and effi ciently. Key words: Neuroablative techniques; neurolytic blocks; radiofrequency thermocoagulation. Özet Girişimsel teknikler nöroablatif ve nöromodülatör işlemler olarak iki gruba ayrılırlar. Nöroablasyon, cerrahi, kimyasal veya ısı uy- gulamalarıyla ağrı yolaklarında fi ziksel iletinin kesilmesidir. Nöromodülasyon, stimülasyon uygulamasıyla veya intraventriküler ya da intraspinal uygulanan opioidler ve diğer ajanlarla ağrı yolaklarının dinamik ve fonksiyonel inhibisyonudur. Nöroablatif teknik- ler kanser tedavisinde yüzyıldan fazla zamandır kullanılmaktadır. Fluroskopi gibi görüntüleme araçlarındaki gelişmelerle nöroabla- tif uygulamalar daha doğru ve etkili bir şekilde gerçekleştirilmektedir. Anahtar sözcükler: Nöroablatif teknikler; nörolitik bloklar; radyofrekans termokoagulasyon. 1Department of Algology, İstanbul University, İstanbul Faculty of Medicine, İstanbul, Turkey 1İstanbul Üniversitesi, İstanbul Tıp Fakültesi, Anesteziyoloji Anabilim Dalı, Algoloji Bilim Dalı, İstanbul Submitted - August 20, 2009 (Başvuru tarihi - 20 Ağustos 2009) Accepted - September 15, 2009 (Kabul tarihi - 15 Eylül 2009) Correspondence (İletişim): Serdar Erdine, M.D, FIPP. Istanbul University, Istanbul Faculty of Medicine, Depratment of Algology, Monoblok, Çapa 34390 Istanbul, Turkey. Tel: +90 - 212 - 531 31 47 e-mail (e-posta): [email protected] EKİM - OCTOBER 2009 133 AĞRI Introduction Th e life expectancy of the patient is another impor- Cancer pain is one of the most witnessed pain syn- tant criterion for selecting the interventional tech- dromes throughout the world.[1] Th e World Health nique. Most of the cancer patients referred for in- Organization (WHO) analgesic ladder has been terventional treatment are in the terminal stage with reported to be effi cacious in controlling pain in short life expectancy. Th e interventional technique approximately 90% of the patients.[2-5] Th ere thus to be applied should sustain a better quality of life remain quite a number of patients who require in- with the least complications or side eff ects. terventional treatment of cancer pain. Interventional techniques should be applied when Interventional techniques are divided into two cat- more conservative pain modalities fail. Generally, egories: neuroablative and neuromodulatory pro- the WHO ladder is applied, and when all drugs in- cedures.[6] Neuroablation is the physical interrup- cluded in the ladder are inadequate, interventional tion of pain pathways either surgically, chemically techniques are considered. However, in some cases, or thermally. Neuromodulation is the dynamic and interventional techniques may be applied earlier, functional inhibition of pain pathways either by and this will be addressed in a later section. administration of opioids and other drugs intraspi- nally or intraventricularly or by stimulation. Th ere should be no general contraindications such as sepsis or coagulopathy while performing the in- terventional techniques. Patient selection for neuroablation Th e use of neuroablative techniques for the control Neuroablative techniques for cancer pain of cancer pain necessitates training of the pain phy- sician, development of facilities for applying these treatment techniques and follow-up of the patients. Patients Neuroablative techniques for cancer pain treatment who are candidates for interventional therapies re- have been used for more than a century. With the quire special care and follow-up. development of imaging facilities such as fl uoros- copy, neuroablative techniques can be performed Patient selection is very important prior to the in- more precisely and effi ciently. terventional pain treatment. A thorough history of the patient related with his disease and pain should Neuroablative techniques are used less frequently be evaluated, including the onset, duration, inten- than before with the improvement in new drugs sity, localization, and course of the pain. In addi- and use of new routes, such as transdermal applica- tion to the knowledge regarding the disease itself, a tion of opioids, and use of long-acting opioids and complete evaluation of the patient related with pain adjuvant drugs. Although more limited than before, should be done, and should include a general medi- neuroablative techniques still have a certain role cal and neurological evaluation, laboratory tests and in the treatment of intractable cancer pain. Th ese radiographic evaluation. Most of the interventional techniques are indicated when administration of techniques target the nervous system; thus, a recent analgesics according to the “ladder” is inadequate. radiological evaluation is a must in order to identify Life expectancy of the patient should be limited and the cause of the pain as well as to prevent complica- the pain should be localized to a part of the body. tions related with the technique. It is also important Neuroablative techniques can be used for somatic or to verify the objective fi ndings of pain, which will visceral pain. Th ey do not have a real place in neu- help to clarify the type of intervention to be used. ropathic pain syndromes, except for sympathetic blocks. Th e emotional and psychological status of the pa- tients should be assessed prior to the intervention. Although neuroablative techniques should be per- Th e psychological assessment of the patient will formed when the “ladder” is inadequate in certain guide the physician in determining if the patient is cancer pain syndromes, they may be performed at suitable for an intervention, and if so, which type. an earlier stage. Localized pain at the innervation of 134 EKİM - OCTOBER 2009 Neurolytic blocks: When, How, Why the trigeminal nerve may be interrupted either by to cancer of the region. It should be performed at an neurolytic block or radiofrequency thermocoagula- earlier stage, before the anatomy of the region is dis- tion of the gasserian ganglion. Celiac and splanch- torted by the growth of the cancer to obtain a better nic blocks may also be performed at an earlier stage result. It eff ect lasts for months to years. before the anatomy of the region is distorted. It should be performed under fl uoroscopy. Th e fora- Th e advantages of neuroablative techniques are: men ovale is easily seen under the fl uoroscope, and they require less follow-up of the patient when the neurolytic solution, either alcohol or phenol, compared with neuromodulatory techniques, they which should not exceed 1 ml, is given in smaller ali- are more cost-eff ective, and they may have a place quots. Otherwise, it may spread to the brainstem and in patients with short life expectancy. Th eir disad- cause severe complications. Currently, the use of ra- vantages include: greater potential risks such as of diofrequency lesioning is preferred to the neurolytic permanent motor loss, paresthesia and dysesthesia, agents. More precise location of the nerve is possible their requirement of very well-trained physicians, with radiofrequency lesioning, and there is no risk of and their limited use only for localized pain. spread of neurolytic solution to the brainstem. Neurolytic nerve blocks Trigeminal ganglion neurolysis is not free of com- plications.[10] Facial numbness develops as a result Neurolytic agents of the neurolysis in all cases. Th e patients should Neurolytic agents are chemical substances that be informed in advance regarding facial numbness. destruct the nerve, including 50-100% alcohol, In fact, it may be considered a result of neurolysis 5-15% phenol, glycerol, and hypertonic saline. rather than a complication. Loss of corneal refl ex may occur as a result of the destruction of the oph- Alcohol is the oldest agent, generally used for celiac thalmic branch of the trigeminal nerve. Anesthesia plexus, gasserian ganglion, sympathetic chain, or in- dolorosa is the most severe complication. Th e pain trathecally. Several concentrations varying between 50- is relieved but burning pain and dysesthesia develop 100% are used. Damage to the nerve is nonselective. in the region, and this is diffi cult to control. Phenol is more frequently used in glycerine solu- Intercostal nerve block tions as a hyperbaric solution in concentrations be- By 1922, Labat’s textbook contained an elaborate tween 5-15%. Damage to the nerve is again nonse- description of the intercostal nerve block that is lective, but is more reversible than with alcohol. quite similar to our present-day conceptions.[11] Intercostal nerve block is one of the most eff ective Glycerol is only used for peripheric nerves, but the blocks in the treatment of pain. It may be used in duration of the eff ect is much shorter. the treatment of pain due to fractured ribs and can- cer metastasis. Neurolytic blocks Trigeminal ganglion neurolysis It is much better to perform the block under fl uo- Th e percutaneous
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