Visceral pain

Radiofrequency for Chronic Visceral Pain

David Pang

Consultant in Pain Management

St Thomas’ Hospital

London

44 YEAR OLD FEMALE

LONG HISTORY OF CHRONIC ABDOMINAL PAIN SINCE MID 2010

PAIN IS PREDOMINANTLY UPPER EPIGASTRIC; WORST ON THE RIGHT SIDE

MULTIPLE ANALGESIC TREATMENTS

ULTRASOUND AND CT REVEALS BILE DUCT DILATATION

HIDA SCAN SHOWS HOLD UP OF TRACER

ERCP WAS NOT DONE DUE TO THE RISK OF ACUTE PANCREATITIS

SECRETIN MRCP SHOWED MILD BILE DUCT DILATATION BUT NO RESPONSE TO SECRETIN

SHE DESCRIBED SEVERE PAIN AFTER SECRETIN AND THIS REQUIRED A FURTHER HOSPITAL ATTENDANCE

A PROVISIONAL DIAGNOSIS OF SPHINCTER OF ODDI DYSFUNCTION WAS MADE

The pain itself

EPISODIC; AGGRAVATED BY FATTY FOODS

CRAMP LIKE IN NATURE

CAN LAST WEEKS AND SEVERITY IS 10/10 ON THE NRS SCALE

PAST MEDICAL HISTORYIRRITABLE BOWEL SYNDROMELAP CHOLECYSTECTOMY IN 2008APPENDICETOMY

SMOKES 15-20 PER DAY

EXAMINATION IS UNREMARKABLE

VERY MILD TENDERNESS AT THE EPIGASTRIC AREA

CARNETT’S SIGN NEGATIVE

SHE WAS GIVEN GTN, NIFEDIPINE AND INCREASING DOSES OF MORPHINE SULPHATE

GABAPENTIN 600MG TDS

HER BASELINE LONG ACTING MORPHINE WAS 40MG DAILY BUT SHE REQUIRED UP TO 2 HOURLY

DURING FLARE UPS SHE CAN TAKE UP TO 260MG MORPHINE DAILY

SHE HAS MULTIPLE ATTENDANCES TO HOSPITAL

• IT AFFECTS 7.8 MILLION PEOPLE IN THE UK

• 4.6 MILLION GP APPOINTMENTS PER YEAR

• IT IS RESPONSIBLE FOR A HIGH LEVEL OF DISABILITY AND MEDICAL INPUT

• 10TH MOST COMMON CAUSE OF HOSPITAL ADMISSION IN MEN, 6TH IN WOMEN

• UP TO 25% OF THE POPULATION WILL REPORT ABDOMINAL PAIN AT ANY ONE TIME

• Halder SL, McBeth J, Silman AJ, Thompson DG, Macfarlane GJ. Psychosocial risk factors for the onset of abdominal pain. Results from a large prospective population-based study. Int J Epidemiol 2002;31:1219–25.

About patients with chronic pain

• 1 IN 5 WILL CONSULT THEIR DOCTOR IN THE COMMUNITY

• UP TO 67% OF CONSECUTIVE SURGICAL ADMISSIONS ARE DUE TO NONSPECIFIC ABDOMINAL PAIN

• Sandler RS et al. Abdominal pain, bloating, and diarrhea in the United States: prevalence and impact. Dig Dis Sci 2000; 45(6):1166.

Chronic abdominal pain

• ESTIMATED A COST OF £100 MILLION EVERY YEAR TO THE NHS

• US: $16.6 BILLION YEARLY

• EUROPE: €28.4 BILLION

• 25% WILL LOSE THEIR JOBS AS A RESULT

• Shih YC, Barghout VE, Sandler RS, Jhingran P, Sasane M, Cook S, Gibbons DC, Halpern M. Resource utilization associated with irritable bowel syndrome in the United States 1987–1997. Dig Dis Sci 2002;47:1705–15

• Hillila MT, Farkkila NJ, Farkkila MA. Societal costs for irritable bowel syndrome: a population based study. Scand J Gastroenterol 2010;45:582–91.

UNLIKE SOMATIC PAIN VISCERAL PAIN IS DIFFUSE AND PATHWAYS PROJECT TO MULTIPLE LEVELS

THE PROPORTION OF FIBERS IS LOWER COMPARED TO SOMATIC

THE PAIN RESPONSE IS LIMITED COMPARED TO THE POLYMODAL SOMATIC RESPONSE

SOMATOSENSORY CORTEX IS POOR AT DIFFERENTIATING THE SOURCE OF PAIN

Physiology of chronic abdominal pain

KEY FEATURES OF CHRONIC VISCERAL PAIN:DIFFUSE, VAGUE LOCALISATIONASSOCIATED EMOTIONAL AND AUTONOMIC FEATURESUNRELIABLE ASSOCIATION WITH PATHOLOGY

REFERRED PAINSHARPERLESS EMOTIONAL AND AUTONOMIC SYMPTOMSSOMATIC HYPERALGESIA

What does this mean?

HEALTHY TISSUE EVOKE MINIMAL SENSATIONS

ACUTE INFLAMMATION IS LIKELY TO PRODUCE PAINFUL SENSATIONS

CHRONIC INFLAMMATION IS UNPREDICTABLE

MANY AFFERENT NEURONES ARE SILENT AND ONLY RESPOND IN THE PRESENCE OF PATHOLOGY

Unreliable Visceral sensations

LOCALIZATION OF THE SITE OF PAIN GENERATION TO SOMATIC TISSUES WITH NOCICEPTIVE PROCESSING AT THE SAME SPINAL SEGMENTS ARM PAIN IN CARDIAC DISEASE

SENSITISATION OF SOMATIC TISSUESE.G KIDNEY STONES CAUSING LOIN MUSCLE

TENDERNESS

Referred pain

Viscero-Somatic convergence

• CONVERGENCE OF VISCERAL AND SOMATIC AFFERENT FIBERS

• MISINTERPRETATION BY HIGHER BRAIN CENTERS

• OCCURS WITHIN MINUTES TO HOURS

• PAIN IS REFERRED TO BODY WALL

• SHARPER, BETTER LOCALIZED

• VERY SIMILAR TO PAIN OF DEEP SOMATIC ORIGIN

Visceral Hypersensitivity

• UNCONTROLLED VISCERAL PAIN CAN LEAD TO VISCERAL HYPERALGESIA,

• AN INCREASED SENSITIVITY TO VISCERAL STIMULATION FOLLOWING AN INJURY OR INFLAMMATION OF AN INTERNAL ORGAN.

• THE INCREASED SENSITIVITY OF THE VISCERA AFTER INFLAMMATION HAS TWO CAUSES:

– AN ALTERATION OF THE SENSORY NEURONS IN THE VISCERA SO THAT THEY NOW RESPOND MORE INTENSELY TO NATURALLY OCCURRING STIMULI (PERIPHERAL SENSITIZATION)

– AN ENHANCED SENSITIVITY OF THE SENSORY PATHWAYS IN THE BRAIN THAT MEDIATE SENSATIONS FROM THE VISCERA (CENTRAL SENSITIZATION).

Central Sensitisation

COMMON PHENOMENON IN CHRONIC SOMATIC PAIN

MEDIATED BY NMDA AND PGE2

Viscerovisceral Hyperalgesia

• AUGMENTATION OF PAIN DUE TO SENSORY INTERACTION BETWEEN TWO INTERNAL ORGANS THAT SHARE AFFERENT CIRCUITRY

• CORONARY HEART DISEASE AND BILIARY CALCULOSIS

• OVERLAPPING T5 AFFERENT PATHWAYS

• MORE FREQUENT ANGINA AND BILIARY COLIC ATTACKS

• DYSMENORRHEA AND IBS• MORE FREQUENT & INTENSE MENSTRUAL

PAIN, INTESTINAL PAIN & REFERRED ABDOMINO-PELVIC HYPERALGESIA

• DYSMENORRHEA, ENDOMETRIOSIS & URINARY STONES

• URINARY CALCULOSIS PAIN IS WORSE IN WOMEN WITH A LATENT SILENT PELVIC CONDITION E.G ENDOMETRIOSIS

• MORE INTENSE MENSTRUAL PAIN, URINARY COLIC PAIN & REFERRED ABDOMINAL/LUMBAR HYPERALGESIA

Neuromodulatory Processes of the Brain–Gut Axis

Neuromodulation: Technology at the Neural InterfaceVolume 11, Issue 4, pages 249-259, 9 OCT 2008 DOI: 10.1111/j.1525-1403.2008.00172.xhttp://onlinelibrary.wiley.com/doi/10.1111/j.1525-1403.2008.00172.x/full#f1

INFLAMMATION-GUTUPREGULATION- DORSAL HORNSTRESS- BRAIN

Psychological

intervention

Education

Physical Therapies

Pain relief

Principles of pain management

Interventional Pain Therapy

• ABDOMINAL WALL BLOCKS

• UP TO 10% OF ALL ABDOMINAL PAIN IS DUE TO THE ABDOMINAL WALL ITSELF

• Srinivassan R, Greenbaum DS. Chronic abdominal wall pain: A frequently overlooked problem. A practical approach to diagnosis and management. Am J Gas- troenterol 2002;97(4):824–30.

Diagnosis of chronic abdominal wall pain

SHARP, LOCALISED PAIN

PAINFUL PALPATION ON TENSING ABDOMINAL MUSCLES

97% SENSITIVITY

85% SPECIFICITY

INTER-RATER RELIABILITY 93%

Carnett’s test

THORACIC EPIDURAL 2-3 DERMATOMES ABOVE LEVEL OF PAIN

CONCORDANT WITH SENSORY BLOCK

RELIEF PROLONGED AFTER SENSORY BLOCK

NO PAIN RELIEF DESPITE SENSORY BLOCK

SOMATOSENSORY

VISCERAL

CENTRAL

THE RECTUS SHEATH

‘‘ . . . FOLLOWING UP A POSITIVE CARNETT’S SIGN WITH A SUCCESSFUL INJECTION OF LOCAL ANESTHETIC MUST BE ONE OF THE MOST COST EFFECTIVE PROCEDURES IN GASTROENTEROLOGY’’

Sharpston D, Colin-Jones DG. Chronic, non-visceral abdominal pain. Gut 1994; 35:833.

COELIAC PLEXUS BLOCK

Visceral Sympathetic Blocks

Note the involvement of the dorsal columns in visceral pain

Targeting the Splanchnic Nerves

PREGANGLIONIC FIBERS FROM T5-T12 TRAVEL WITH THE VENTRAL ROOTS TO JOIN THE WHITE COMMUNICATING RAMI, PASS THROUGH THE SYMPATHETIC CHAIN, AND SYNAPSE ON THE CELIAC GANGLIA.

•   THE GREATER, LESSER, AND LEAST SPLANCHNIC NERVES ARE THE MAJOR PREGANGLIONIC OF THE CELIAC PLEXUS.

•   THE GREATER SPLANCHNIC ORIGINATES FROM THE NERVE ROOTS OF T5-T10 AND TRAVELS ALONG THE VERTEBRAL BODY, THROUGH THE CRUS OF THE DIAPHRAGM, AND INTO THE IPSILATERAL CELIAC GANGLION.

•   THE LESSER SPLANCHNIC NERVE ORIGINATES FROM THE T10/T11 NERVE ROOTS, WHILE THE LEAST SPLANCHNIC NERVE ARISES FROM T10-T12; THESE ALSO TRAVEL THROUGH THE DIAPHRAGM TO THE IPSILATERAL CELIAC GANGLION

Origin Nerve Plexus VisceraT5-9 Greater Splanchnic

NerveCoeliac Gastric;Sphincters;

Gallbladder, Pancreas

T9-11 Lesser Splanchnic Nerve

Coeliac Small intestine

T12-L1 Least Splanchnic NerveLumbar Sympathetic

Coeliac Renal

T12-L1 Least Splanchnic NerveLumbar Sympathetic

Superior Mesenteric

Proximal colon

T10-L3 Lesser and Least Splanchnic nerve

Paravertebral Ganglia L1-4

Vasomotor lower limb, erector pili

L1-2 Lumbar Splanchnic Inferior mesenteric, Superior hypogastric

Distal colon

FLOUROSCOPIC IMAGING

PLACE THE PATIENT IN A PRONE POSITION WITH A PILLOW UNDER THE ABDOMEN TO REDUCE SPINAL LORDOSIS

AP VIEW AND SLIGHT CAUDAL ANGULATION TO SQUARE THE

INFERIOR ENDPLATE AT T11/12

ANGLE THE C-ARM 5-10 DEGREES IPSILATERAL

IDENTIFY THE ANGLE BETWEEN THE BORDER OF THE VERTEBRAL BODY AND TRANSVERSE PROCESS

THE SKIN ENTRY POINT IS AT THE LATERAL BORDER OF THE VERTEBRAL BODY AND THE LOWER BORDER OF THE TRANSVERSE PROCESS. THE AIM IS TO PLACE THE NEEDLE AT THE SPLANCHNIC NERVES AT T11 AND T12 TO COVER THE THREE BRANCHES.

FREQUENT INTERMITTENT FLUOROSCOPY IS MANDATORY TO AVOID EXCESSIVE LATERAL ANGULATION WHICH MAY LEAD TO PNEUMOTHORAX. AIM FOR BONY CONTACT WITH THE VERTEBRAL BODY.

IF A DIAGNOSTIC BLOCK IS TO BE PERFORMED THEN 5 ML OF 0.5% BUPIVACAINE IS INJECTED AFTER SATISFACTORY CONTRAST PATTERN.

FOR RADIOFREQUENCY, SENSORY TESTING AT 50Hz WITH STIMULATION IN THE EPIGASTRIC AREA CONFIRMS CORRECT NEEDLE PLACEMENT.

INJECT LOCAL ANAESTHETIC AND RF FOR 90 SECONDS AT 80°. TURN THE NEEDLE 180° FOR A SECOND LESION.

LESIONS MUST BE DONE AT BOTH T11 AND T12. ONCE ONE SIDE IS DONE THE SECOND SIDE IS DONE AT ANOTHER SESSION.

PNEUMOTHORAX

NERVE ROOT INJURY

CHYLOTHORAX

SPINAL CORD ISCHAEMIA

Complications

Radiofrequency Lesioning of Splanchnic Nerves

Good to excellent results in 50-70%

Percutaneous Radiofrequency Ablation of the Splanchnic Nerves in Patients with Chronic Pancreatitis: Results of Single and Repeated Procedures in 11 Patients

Pain Practice10 JAN 2013 DOI: 10.1111/papr.12030http://onlinelibrary.wiley.com/doi/10.1111/papr.12030/full#papr12030-fig-0003

VISCERAL PAIN A SIGNIFICANT CAUSE OF CHRONIC PAIN

NOT ALL ABDOMINAL PAIN IS VISCERAL IN ORIGIN

DIAGNOSTIC BLOCKS USEFUL TO DIFFERENTIATE VISCERAL AND SOMATIC PAIN

RADIOFREQUENCY CAN GIVE LONG TERM RELIEF IN SELECTED PATIENTS

Summary