Brachial Plexopathy secondary to tumor invasion and radiation

[med7343]

what intervention for above have you had most success with?
Thanks

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[Ducttape]

DREZ lesioning by neurosurgery.

 

[deleted993114]

DREZ lesioning by neurosurgery.

Not many folks do that any more. We used to have to send to Univ of VA for that.

 

[BobBarker]

I have two patients that were shot through the brachial plexus have pretty good success with SCS. One has a MDT and one a ABT.

 

[painfree23]

I have two patients that were shot through the brachial plexus have pretty good success with SCS. One has a MDT and one a ABT.

Cervical scs?

 

[BobBarker]

Yes

 

[med7343]

sounds great, thanks team

 

[callmeanesthesia]

I have two patients that were shot through the brachial plexus have pretty good success with SCS. One has a MDT and one a ABT.

I‘ve done one. Brachial plexus avulsion injury from a crash. Did well. Not total relief of pain but it got rid of the severe spikes of pain and he reports better sleep. Nevro fwiw.

 

[BobBarker]

I‘ve done one. Brachial plexus avulsion injury from a crash. Did well. Not total relief of pain but it got rid of the severe spikes of pain and he reports better sleep. Nevro fwiw.

Yes, eliminated peak severe pain. Still have pain and take medication but meq down 50%.

 

[gaschicago]

pulsed RFA

 

[Orin]

If they're dying in days, put in a infraclavicular/supraclavicular nerve catheter in and pray it doesn't get infected before they die.

I haven't done this yet, but if they're dying in a few weeks, this is where I would try the SPR Sprint PNS system. It's a percutaneous peripheral nerve stimulator that you should be able to park in brachial plexus where folks normally do the infraclavicular/supraclavicular approach for a nerve block catheter, with the tip being 1 - 3 cm away from all the roots.

If they've got two or more months, I would go with an intrathecal pump with a catheter tip at C4 dorsally if you can get it up there.
If they've got a year or more, anatomy suitable for it, and don't need an MRI again under a GA, think about the SCS.

I might reach out to the local cancer pain docs or one of the big dogs at the cancer hospitals like Amit Gulati at Sloan Kettering.

 

[med7343]

pulsed RFA

Pulsed RFA of the brachial plexus sounds painful and motor weakness causing- could you explain more

 

[Baron Samedi]

Pulsed RFA of the brachial plexus sounds painful and motor weakness causing- could you explain more

Pulsed RF(sans the ablation) is nondestructive and instead is theorized to work through neuromodulation. It should not cause motor weakness nor be especially painful. It's a useful technique for treating painful large named nerves that you don't want to ablate and cause motor weakness and/or large sensory deficits. I've never done it for the brachial plexus and I'm not sure I would, simply because I think you'd have to treat the entire plexus and I'm not sure I want to sit there doing 20 treatment cycles.

 

[Ligament]

just one patent like this in my practice, young fellow.

Turns out C5-7 mb RADIOFREQUENCY ABLATION and suprascapular nerve blocks with pulsed RF and intercostobrachial nerve blocks helped him a lot. I did not do a SCS trial, thought that woudl have been reasonable.

 

[painfree23]

just one patent like this in my practice, young fellow.

Turns out C5-7 mb RADIOFREQUENCY ABLATION and suprascapular nerve blocks with pulsed RF and intercostobrachial nerve blocks helped him a lot. I did not do a SCS trial, thought that woudl have been reasonable.

oh nice! Can u explain how c5-c7 mb mechanism would work fora brachial plexopathy? That’s awesome it worked!

 

[Ligament]

oh nice! Can u explain how c5-c7 mb mechanism would work fora brachial plexopathy? That’s awesome it worked!

Great question and I should have clarified. I'm not sure it had anything to do with plexopathy per se, but everybody thought that particular pain was from plexopathy, until I investigated if it was facetogenic...and it was, fortunately. Radiation fibrosis causing myofascial strains on the facets? Possibly. Makes some sense.

 

[clubdeac]

just one patent like this in my practice, young fellow.

Turns out C5-7 mb RADIOFREQUENCY ABLATION and suprascapular nerve blocks with pulsed RF and intercostobrachial nerve blocks helped him a lot. I did not do a SCS trial, thought that woudl have been reasonable.

where do you block the intercostobrachial nerve ligament? And do you use US or fluoro

 

[Ligament]

where do you block the intercostobrachial nerve ligament? And do you use US or fluoro

I just block 1-3 intercostal nerves. This works wonders for post mastectomy pain! A very high percentage of mastectomy patients have this nerve injured.

I use fluoro but U/s is completely fine if you are not using particulates and not concerned about cord uptake of anesthetics at that level. I'd say initial placement with u/s then DSA during contrast injection would be ideal, but that is very challenging in the real world.

 

[painfree23]

I just block 1-3 intercostal nerves. This works wonders for post mastectomy pain! A very high percentage of mastectomy patients have this nerve injured.

I use fluoro but U/s is completely fine if you are not using particulates and not concerned about cord uptake of anesthetics at that level. I'd say initial placement with u/s then DSA during contrast injection would be ideal, but that is very challenging in the real world.

Do u ever burn these?

 

[Ferrismonk]

I've got a guy with traumatic brachial plexus avulsion. Had an elective disarticulation of his arm due to recurrent pressure ulcers/infections. Continued left "shoulder", scapular, and supraspinatus aarea pain. Trigger points did minimal. Botox for dystonia helped tightness/retraction, but not pain. Suprascapular NB did nothing. TPI to anterior scalene + pec minor (another provider) did nothing. Have him slated for a stim trial early next year.

 

[Ligament]

Do u ever burn these?

I've only pulsed this high up.