visceral pain
TRANSCRIPT
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