failed superior hypogastric block advice?

[pharmer]

I have a patient in her 30's with metastatic cervical cancer and fair amount of pelvic and lower abdominal pain. She got great relief with 0.5% marcaine when doing a test block of the superior hypogastric plexus using the traditional bilateral approach walking along the inferior lateral aspcet of L5 to its anterior border. I brought her back several days later and took the same approach applying 10ml of 10% phenol on both sides and she did not get any relief. Contrast pattern seemed to be adequate, although on the left side I had more cephalad spread of the contrast (as opposed to more desired caudal) than I wanted. Its been a week and I am having her return for repeat block tomorrow. Literature does not really seem to indicate ethanol or phenol being superior with regards to outcome when performing neurolysis and seeing how I have never used ethanol I'm going to stick with phenol. Any advice on what to do different (last resort would be IT pump, but she is so skinny I concerned about reservoir placement)? Im considering taking a posterior median trandiscal approach that has been described in the literature which would allow me to use one needle and hopefully get more of a midline spread and also place me closer to the heart of the superior hypogastric plexus as well. Scares me, however, to enter through the dural sac (don't want to impale a nerve too bad or get a PDPH) and also not a fan drilling a hole through the disc that could allow phenol to track through. Thoughts?

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[lobelsteve]

Send to IR for ct guided attempt.

 

[Ducttape]

or do an anterior approach.

Efficacy of the anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in advanced gynecological cancer patients. - PubMed - NCBI

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Pain Med. 2013 Jun;14(6):837-42. doi: 10.1111/pme.12106. Epub 2013 Apr 11.
Efficacy of the anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in advanced gynecological cancer patients.
Mishra S1, Bhatnagar S, Rana SP, Khurana D, Thulkar S.
Author information
1
Unit of Anaesthesiology, Dr. B.R.Ambedkar, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India. [email protected]
Abstract
BACKGROUND AND AIMS:
Pelvic cancer pain is a chronic pain related to the involvement of viscera, neural, and pelvic muscular. The study was carried out to evaluate the efficacy of anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in gynecological cancer patients.

MATERIAL & METHODS:
The study was conducted after approval of our Institutional Ethics Committee. A total of 50 patients diagnosed with the advanced stage of a gynecological malignancy with severe pelvic pain were enrolled and randomly divided in two groups; in Group I, patients were given oral morphine, while in Group II, patients underwent anterior ultrasonography (USG)-guided superior hypogastric neurolysis. Oral morphine was given as rescue analgesia in both the groups. The parameters recorded were pain, functional capacity, global satisfaction score, and adverse effects.

RESULTS:
There was a significant decrease in visual analog scale (VAS) score in the both groups, but the decline in VAS scores from baseline in Group II was significantly (P < 0.05) greater. The daily morphine consumption in Group II decreased throughout the study, and more patients in Group II improved in their functional capacity, although it was statistically insignificant. It was observed that global satisfaction scores were better in Group II during the initial first (P = 0.001) week and 1 month (P = 0.04) compared with Group I.

CONCLUSION:
The anterior USG-guided superior hypogastric plexus neurolysis is a useful technique in relieving pelvic pain in gynecological malignancies. However, it requires expertise to perform the block. It also avoids the radiation exposure involved with computed tomography-guided and fluoroscopy-guided superior hypogastric block.

can just use fluoro. I would probably do a combination of both.

New technique for superior hypogastric plexus block. - PubMed - NCBI

See comment in PubMed Commons below
Reg Anesth Pain Med. 1999 Sep-Oct;24(5):473-6.
New technique for superior hypogastric plexus block.
Kanazi GE1, Perkins FM, Thakur R, Dotson E.
Author information
1
Department of Anesthesiology, University of Rochester Medical Center, New York 14642, USA.
Abstract
BACKGROUND AND OBJECTIVES:
: The classical technique for blocking the superior hypogastric plexus (SHP) described by Plancarte sometimes renders the desired needle placement difficult. This article describes an alternative approach for blocking the SHP.

METHODS:
Three patients with pelvic pain from endometriosis underwent an anterior approach to block the SHP with fluoroscopic guidance. The ages of the patients ranged from 21 to 34 years, pain duration ranged from 2 to 4 years, and pain score on a visual analog scale of 0-10 ranged from 7 to 8.

RESULTS:
All patients had significant pain relief immediately after the block. The pain scores postblock ranged from 0 to 4/10. The duration of pain relief varied from 1 to 14 days. The contrast material localized at the L5 vertebral body in the posteroanterior and lateral views.

CONCLUSION:
We present a new approach to block the SHP with fluoroscopic guidance in patients with chronic benign pelvic pain.

 

[pharmer]

I saw the articles on anterior approach. I do not fancy myself "expert" enough to take an ultrasound probe and learning on the job with this one.


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[Aether2000]

10 deg angle on a 22ga 5-7" quincke, through the L5S1 interspace through the dura, using the angle on the needle tip guide the needle transdiscal has been my approach for years.

 

[Ligament]

I would suggest transdiscal but not transthecal. Line it up like a discogram and once you enter the disc steer the tip directly ventrally such that you emerge at the ventral most aspect of the L5-S1 disc. Be sure to flush your needle prior to withdrawing back into disc. You are doing a good service for this unfortunate patient. If this fails or instead of, have it done under CT.

Also if I recall the SPHGP has a slight left of midline preference so take that into account.

 

[Ducttape]

I saw the articles on anterior approach. I do not fancy myself "expert" enough to take an ultrasound probe and learning on the job with this one.


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Then consider under fluoro. Tilt patient slight trendelenburg, direct 22 ga 5 inch needle in gunbarrel approach right at lower margin L5. Pull back slightly, shoot a little contrast, all done.


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[clubdeac]

For you guys going transdiscal, are you using a two needle technique (so your transdiscal needle doesn't touch skin) and are you giving IV antibiotics prior? We used both of these precautions when I learned to do discograms back in the day

 

[Aether2000]

Another twist on Ligament's suggestion- it is possible to perform a trans-canal, extra-thecal, transdiscal approach with the patient in the lateral position. Placing the needle interlaminar on the far lateral portion of the window on the up side will miss the dura in most cases, since the CSF layers to the decubitus (lower) side. Since the spinal nerve exits cephalad to the disc, it is usually safe using this approach.

 

[pharmer]

Thanks for everyone's suggestions! I ended up taking a traditional approach starting on the left side but continued to get more cephalad spread of contrast despite repositioning the needle multiple times. I didn't want to take this given her failure to respond last time. I withdrew the needle. Re prepped the back, gave 1 g of Ancef and then entered on the left lining up like a discogram. Entered the disc and advanced until I was just past the anterior aspect of the disc. In AP view needle was just about midline. Contrast had ideal spread in lateral view layering on the anterior aspect of L5 and S1. Put in 10 ml of 10% phenol, flushed needle with a ml of saline and then pulls back into the disc, gave 50mg of Ancef in 1 ml of preservative free saline and then removed the needle. Patient was having some relief upon discharge so hopefully that will continue.


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[clubdeac]

Thanks for everyone's suggestions! I ended up taking a traditional approach starting on the left side but continued to get more cephalad spread of contrast despite repositioning the needle multiple times. I didn't want to take this given her failure to respond last time. I withdrew the needle. Re prepped the back, gave 1 g of Ancef and then entered on the left lining up like a discogram. Entered the disc and advanced until I was just past the anterior aspect of the disc. In AP view needle was just about midline. Contrast had ideal spread in lateral view layering on the anterior aspect of L5 and S1. Put in 10 ml of 10% phenol, flushed needle with a ml of saline and then pulls back into the disc, gave 50mg of Ancef in 1 ml of preservative free saline and then removed the needle. Patient was having some relief upon discharge so hopefully that will continue.


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Be careful with that intradiscal ancef. Can cause seizures

 

[Aether2000]

Intrathecal Ancef can cause seizures vis-a-vis intradiscal Ancef. Using a discogram approach it is possible to traverse the ipsilateral dura, causing intrathecal tracking of Ancef once the disc is pressurized and the needle is removed.

 

[clubdeac]

Intrathecal Ancef can cause seizures vis-a-vis intradiscal Ancef. Using a discogram approach it is possible to traverse the ipsilateral dura, causing intrathecal tracking of Ancef once the disc is pressurized and the needle is removed.

Yes sorry that's what I meant. Intrathecal can cause seizures via intradiscal leak

 

[nvrsumr]

That is interesting about ancef. Very few discos now. Any incidence or dose numbers?

 

[Orin]

I have a patient in her 30's with metastatic cervical cancer and fair amount of pelvic and lower abdominal pain... Any advice on what to do different (last resort would be IT pump, but she is so skinny I concerned about reservoir placement)

I assume she'll be passing in a few months if you're neurolysing there, so I'd recommend doing a buried intrathecal catheter connected to an external pump of choice. You'd incise, anchor, and then instead of tunneling around to the reservoir, you'd tunnel to an external site away from your back incision and connect to the pump.

If her functional status is pretty good otherwise and you'd rather have the internal pump as it's easier/superior, talk to a general surgeon or a neurosurgeon about helping with the reservoir implantation. I've gone down into the 40 kg cancer patient with a real surgeon making a nice pfannenstiel incision/pocket for the reservoir. The pediatric neurosurgeons put the 20 mL pumps into folks in the 15-20 kg range! There are some interesting places to put the reservoir if you have meat in another region, but that's a bit more difficult.

Regarding the block, this is a case where asking for help from the folks with an O-arm or a CT scanner makes sense, but it may be that technically you had success and this was a false positive from the initial block.