Critical Evaluation of Chemical Neurolysis of the Sympathetic Axis for Cancer Pain

Oscar A. de Leon-Casasola, MD, Department of Anesthesiology, Roswell Park Cancer Institute, Buffalo, NY.

Cancer Control. 2000;7(2) 

In This Article

Superior Hypogastric Plexus Block

Cancer patients with tumor extension into the pelvis may experience severe pain that is unresponsive to oral or parenteral opioids. Also, excessive sedation or other side effects may limit the acceptability and usefulness of oral opioid therapy. Therefore, a more invasive approach is needed to control pain and improve the quality of life of these patients.

Pelvic pain associated with cancer and chronic nonmalignant conditions may be alleviated by blocking the superior hypogastric plexus.[30,31,32] Analgesia to the organs in the pelvis is possible because the afferent fibers innervating these structures travel in the sympathetic nerves, trunks, ganglia, and rami. Thus, a sympathectomy for visceral pain is analogous to a peripheral neurectomy or dorsal rhizotomy for somatic pain. A recent study [31] suggests that visceral pain is an important component of the cancer pain syndrome experienced by patients with cancer of the pelvis, even in advanced stages. Thus, percutaneous neurolytic blocks of the superior hypogastric plexus should be considered more often for patients with advanced stages of pelvic cancer.

The superior hypogastric plexus is situated in the retroperitoneum, bilaterally extending from the lower third of the fifth lumbar vertebral body to the upper third of the first sacral vertebral body. The technique for the blockade has been described elsewhere.[30,31,32] Fig 3 shows adequate needle placement and contrast medium spread prior to neurolysis of the superior hypogastric plexus.

Figure 3.

Anteroposterior view showing adequate needle placement (black arrows) and contrast medium spread (open arrow) for neurolysis of the superior hypogastric plexus.

Complications

The combined experience of more than 200 cases from the Mexican Institute of Cancer, Roswell Park Cancer Institute, and M.D. Anderson Cancer Center indicates that neurologic complications do not occur as a result of this block.[32]

Efficacy

The effectiveness of the block was originally demonstrated by documenting a significant decrease in pain via VAPS scores. In this study, Plancarte et al [30] showed that this block was effective in reducing VAPS scores in 70% of the patients with pelvic pain associated with cancer. The majority of the enrolled patients had cervical cancer. In a subsequent study, 69% of the patients experienced a decrease in VAPS scores. Moreover, a mean daily opioid morphine reduction of 67% was seen in the success group (736 ± 633 reduced to 251 ± 191 mg/day), and 45% in the failure group (1,443 ± 703 reduced to 800 ± 345 mg/day).[31] In a more recent multicentric study, 159 patients with pelvic pain associated with cancer were evaluated. Overall, 115 patients (72%) had satisfactory pain relief after one or two neurolytic procedures. Mean opioid use decreased by 40% from 58 ± 43 reduced to 35 ± 18 equianalgesic mg/day of morphine 3 weeks after treatment in all the studied patients. This decrease in opioid consumption was significant for both the success group (56 ± 32 reduced to 32 ± 16 mg/day) and the failure group (65 ± 28 reduced to 48 ± 21 mg/day).[32] Success was defined in these two studies as the ability to reduce opioid consumption by at least 50% in the 3 weeks following the block and a decrease in the pain scores below 4/10 in the VAPS scores.[32,33]

In a recent case report, Rosenberg and colleagues [33] reported on the efficacy of this block in a patient with severe chronic nonmalignant penile pain after transurethral resection of the prostate. Although the patient did not receive a neurolytic agent, a diagnostic block performed with 0.25% bupivacaine and 20 mg of methylprednisolone acetate was effective in relieving the pain for more than 6 months. The usefulness of this block in chronic benign pain conditions has not been adequately documented.

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