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Interventional radiology

Interventional techniques for pain relief

Percutaneous lysis of neural structures

Malignant tumors situated in the upper abdomen originating from the pancreas, stomach and duodenum, proximal small intestine, liver and biliary system or from compressing lymph nodes or the dilated urinary system may generate intolerable upper abdominal pain. lf opiate medication or radiation therapy is unsatisfactory percutaneous neurolysis of the celiac plexus and the splanchnic nerves can be of great help. A celiac plexus block has also been advocated for treatment of the abdominal pain in Crohn's disease, visceral neuropathy and diabetic reticulopathy. Using CT guidance the region of the celiac plexus is infiltrated with absolute ethanol. Usually an anterior approach is optimal for needle placement.

For splanchnic neurolysis a posterior percutaneous approach under CT guidance is commonly used. Usually pain related to tumor invasion responds best to neurolysis with a significant reduction of pain in about 73 to 87% of the treated patients.

For treatment of vasospastic disorders percutaneous sympathectomy using phenol has been advocated instead of surgical sympathectomy. For vasospastic disorders of the upper limbs or occlusive arteriopathy phenol may be injected paravertebrally at the level of T3 in the region of the sympathetic chain under CT guidance. Similarly percutaneous blockage of the lumbar sympathetic chain may be achieved in advanced atherosclerotic disease of the lower limbs. Done again under CT guidance a 22 gauge Chiba needle is inserted at the L2 and L4 levels and neurolysis is induced by slow injection of phenol after verification of proper placement of the needle by a careful injection of l cc of contrast material. A positive effect can be expected in about 50 to 75% of patients. Percutaneous neurolysis carries a significantly lower risk compared to surgical procedures.

Christoph Zollikofer