Pain Management

Chronic Pain Management

Interventional management of intractable sympathetically mediated pain by computed tomography-guided catheter implantation for block and neuroablation of the thoracic sympathetic chain: technical approach and review of 322 procedures

Agarwal-Kozlowski K, Lorke DE, Habermann CR, et al (Centre for Palliative Care and Pain Management (T.I.P.S.), Stade, Germany; Florida International Univ, Miami; Univ Med Centre Hamburg-Eppendorf, Germany) Anaesthesia 66:699-708, 2011^§

Abstract

We retrospectively evaluated the safety and efficacy of computed tomography-guided placement of percutaneous catheters in close proximity to the thoracic sympathetic chain by rating pain intensity and systematically reviewing charts and computed tomography scans. Interventions were performed 322 times in 293 patients of mean (SD) age 59.4 (17.0) years, and male to female ratio 105:188, with postherpetic neuralgia (n = 103, 35.1%), various neuralgias (n = 88, 30.0%), complex regional pain syndrome (n = 69, 23.6%), facial pain (n = 17, 5.8%), ischaemic limb pain (n = 7, 2.4%), phantom limb pain (n = 4, 1.4%), pain following cerebrovascular accident (n = 2, 0.7%), syringomyelia (n = 2, 0.7%) and palmar hyperhidrosis (n = 1, 0.3%). The interventions were associated with a total of 23 adverse events (7.1% of all procedures): catheter dislocation (n = 9, 2.8%); increase in pain intensity (n = 8, 2.5%); pneumothorax (n = 3, 0.9%); local infection (n = 2, 0.6%); and puncture of the spinal cord (n = 1, 0.3%). Continuous infusion of 10 ml.h⁻¹ ropivacaine 0.2% through the catheters decreased median (IQR [range]) pain scores from 8 (6–9 [2–10]) to 2 (1–3 [0–10]) (p < 0.0001). Chemical neuroablation was necessary in 137 patients (46.8%). We conclude that this procedure leads to a significant reduction of pain intensity in otherwise obstinate burning or stabbing pain and is associated with few hazards (Fig 2).

Figure 2 (a) Measurements and simulation for needle insertion. The exact distances are measured from the metal marker to the intended point of puncture. The direction of the needle is simulated on the screen. (b) CT images showing the relationship of lung and vertebra. The needle is inserted as far as possible without damaging the lung. (c) CT images following injection of 40 ml saline 0.9%. Note the distance of the lung from the vertebra that allows the needle to pass without causing harm or pneumothorax. (d) CT images showing the catheter in place after subcutaneous placement to avoid infection. (Reprinted from Agarwal-Kozlowski K, Lorke DE, Habermann CR, et al. Interventional management of intractable sympathetically mediated pain by computed tomography-guided catheter implantation for block and neuroablation of the thoracic sympathetic chain: technical approach and review of 322 procedures. Anaesthesia. 2011;66:699-708, with permission from The Authors.)

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