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Interventional Techniques in Palliative Care

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Essentials of Palliative Care

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Abstract

Advances in the field of pain management have resulted in greater opportunities in management of complex patients worldwide. This is true in the field of Palliative Care. Interventional pain management, including neuroablative techniques and stabilizing procedures such as vertebroplasty, are efficacious and tolerable. Agents for neurolysis, such as alcohol, glycerol, and phenol, are compared. Radiofrequency thermocoagulation, spinal cord stimulation, intrathecal pumps, and cryoablation are briefly summarized in this review as well. A focus on techniques, equipment, and populations that may benefit from advanced interventional pain management practice within the environment of Palliative Care medicine is emphasized. Close consultation with an interventional pain specialist is advised in Palliative Care medicine.

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References

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Author information

Authors and Affiliations

  1. Department of Anesthesiology, Guthrie Clinic-Big Flats, Horseheads, NY, USA

    Rinoo V. Shah M.D., M.B.A.

  2. Department of Anesthesiology, Louisiana State University School of Medicine, New Orleans, LA, USA

    Alan David Kaye M.D., Ph.D., Christopher K. Merritt M.D. & Lien B. Tran M.D.

Authors
  1. Rinoo V. Shah M.D., M.B.A.
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  2. Alan David Kaye M.D., Ph.D.
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  3. Christopher K. Merritt M.D.
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  4. Lien B. Tran M.D.
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Corresponding author

Correspondence to Rinoo V. Shah M.D., M.B.A. .

Editor information

Editors and Affiliations

  1. Department of Anesthesiology, Yale University, New Haven, 06520, Connecticut, USA

    Nalini Vadivelu

  2. Citrus Road 278, River Ridge, 70123, Louisiana, USA

    Alan David Kaye

  3. Keck School of Medicine, Department of Anesthesiology, Pain Medic, of the University of Southern California, Los Angeles, 90035, California, USA

    Jack M. Berger

Appendices

Review Questions

  1.  1.

    Which of the following agents can be used for neurolysis techniques:

    1. (a)

      Alcohol.

    2. (b)

      Phenol.

    3. (c)

      Glycerol.

    4. (d)

      All of the above.

    5. (e)

      None of the above.

  2.  2.

    Which is false regarding RFTC:

    1. (a)

      A generator produces a high frequency (<1 kHz), alternating electrical current in RFTC.

    2. (b)

      The current passes through an attached electrode and exits out of the tip of an insulated needle.

    3. (c)

      Heat is generated and protein denaturation occurs at the tip. Radiofrequency thermocoagulation affords very discrete neural ablation, while sparing collateral structures.

    4. (d)

      Lesion shape is typically cocoon-like.

    5. (e)

      However, ablation is nonselective and neuromas may form with somatic nerve targeting. Neural destruction occurs at temperatures of 45°C. So, radiofrequency generator temperatures are set at 60–80°C.

  3.  3.

    Which is false:

    1. (a)

      Ethyl alcohol is a clear and hypobaric (relative to water) solution.

    2. (b)

      Direct application leads to tissue dehydration.

    3. (c)

      Neural components are extracted and precipitated. Axonal destruction is followed by Wallerian degeneration.

    4. (d)

      The Schwann cell sheath/conduit is preserved, which allows for nerve regrowth. Sympathetic ganglia, however, are permanently destroyed.

    5. (e)

      Lower concentrations of alcohol produce more complete destruction. Commonly used concentrations vary between 50 and 97%. Alcohol neurolysis is most commonly used for the celiac plexus, sympathetic ganglia, and spinal cord.

  4.  4.

    Which is true regarding metastasis and pain techniques

    1. (a)

      Cement produces an exothermic reaction that results in neurolysis. Cement stabilizes bone metastases and fractures. Vertebroplasty and kyphoplasty are two such procedures.

    2. (b)

      A cement, typically poly methyl methacrylate is prepared. Once a very viscous consistency is reached, the cement is delivered in 0.1–0.5 ml aliquots under live fluoroscopy. Careful monitoring is imperative to ensure that the cement does not extravasate. Cement volumes may range between 3 and 7 ml.

    3. (c)

      Degree of fill on fluoroscopy will determine when to stop. Cement should not extravasate outside the margins of the vertebral body. Sacral metastases may be targeted, as well as flat bones such as the sternum. The latter have demonstrated efficacy and safety.

    4. (d)

      Complications include cement extravasation, cement emboli, neural damage, spinal cord injury, vascular uptake, hematoma, and infection. Other complications may be due to the medical co-morbidities of the patients, anesthesia, and pressure-related injuries (eyes, bony surfaces, and peripheral nerves).

    5. (e)

      All are true.

  5.  5.

    Which is false:

    1. (a)

      Spinal cord stimulation is a neuromodulatory device that has demonstrable efficacy in chronic angina and peripheral vascular disease. A special type of electrode is placed in the cervical or thoracic epidural space.

    2. (b)

      Spinal cord stimulation does not block the pain to such an extent, wherein a life-threatening ischemic episode is not noticed.

    3. (c)

      Thoracic and lumbar epidural catheters may be used as a short-term strategy for acute or subacute pain syndromes.

    4. (d)

      A catheter that is silastic and is cuffed may be useful for longer periods, e.g., weeks. This may play an important role in patients that are immunocompromised and have a short life expectancy.

    5. (e)

      All are true.

  6.  6.

    Which is a false statement

    1. (a)

      There is no role for neurolytic procedures in Palliative Care.

    2. (b)

      Strict sterile technique is required for all interventional pain procedures.

    3. (c)

      Significant side effects can occur in interventional pain medicine procedures.

    4. (d)

      Cryoablative procedures are indicated in certain pain states.

    5. (e)

      Monitoring patients for interventional pain procedures is important, as patients may require procedural sedation, and complications such as local anesthetic toxicity, pneumothorax, nerve injury, vascular puncture, and bleeding can occur.

  7.  7.

    Examples of interventional pain blocks include:

    1. (a)

      Intercostal block.

    2. (b)

      Celiac block.

    3. (c)

      Transforaminal nerve root block.

    4. (d)

      Lumbar facet block.

    5. (e)

      All of the above.

  8.  8.

    Regarding spinal cord modulation:

    1. (a)

      Options include neuromodulation with implantable devices.

    2. (b)

      Intrathecal opioid pumps are more common in this population, as compared to spinal cord stimulation.

    3. (c)

      An intrathecal pump involves placing a catheter into the spinal canal. This catheter is tunneled subcutaneously toward the anterior abdomen.

    4. (d)

      A programmable reservoir is placed subcutaneously in the anterior abdominal lower quadrant and connected to the catheter. The pump reservoir holds the drug and the pump delivers small aliquots of drug into the spinal canal. Typically, a preimplantation trial via a subarachnoid injection of morphine, 0.25–1 mg is used. The pump then delivers the drug continuously for pain relief. In some countries, patients can self-administer the drug as a periodic bolus.

    5. (e)

      All are true.

  9.  9.

    Regarding peripheral neurolysis:

    1. (a)

      Peripheral nerve neurolysis is more commonly indicated for spasticity and not for cancer-related pain.

    2. (b)

      Some practitioners may perform intra-operative neurolysis as an adjunct to surgery, e.g., rib resection, thoracic surgery, and limb amputation.

    3. (c)

      The methods employed are similar in strategy to those for peripheral nerve block, with use of electrical stimulation and ultrasound guidance. Phenol may then be injected; this agent is preferable to alcohol, secondary to the local anesthetic effect.

    4. (d)

      All are true.

    5. (e)

      All are false.

  10. 10.

    Regarding trigeminal ganglion procedures:

    1. (a)

      The trigeminal ganglion is an important neural relay for pain originating in face, brain (meninges), head, and upper neck. This structure is accessible through the foramen ovale, which transmits the mandibular branch (V3).

    2. (b)

      The patient is placed in a supine position, with the neck slightly extended and the jaw recessed. Fluoroscopy is used to identify the foramen ovale, which is located medial to the upper portion of the mandible.

    3. (c)

      The yield of sensory stimulation is limited since many of these patients are sedated. Motor stimulation will lead to unilateral jaw contractions. Care must be taken to protect the lips, tongue, mucosa, and other oral structures. With radiofrequency thermocoagulation, temperatures of 60°C for about 60 s are ideal.

    4. (d)

      All are false.

    5. (e)

      All are true.

Answers

  1.  1.

    (d)

  2.  2.

    (a). It is >250 kHz

  3.  3.

    (e). Higher concentrations of alcohol produce more complete destruction

  4.  4.

    (e)

  5.  5.

    (e)

  6.  6.

    (a)

  7.  7.

    (e)

  8.  8.

    (e)

  9.  9.

    (d)

  10. 10.

    (e)

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Shah, R.V., Kaye, A.D., Merritt, C.K., Tran, L.B. (2013). Interventional Techniques in Palliative Care. In: Vadivelu, N., Kaye, A., Berger, J. (eds) Essentials of Palliative Care. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-5164-8_17

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  • DOI: https://doi.org/10.1007/978-1-4614-5164-8_17

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  • Publisher Name: Springer, New York, NY

  • Print ISBN: 978-1-4614-5163-1

  • Online ISBN: 978-1-4614-5164-8

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