|Year : 2016 | Volume
| Issue : 1 | Page : 58-60
Radiofrequency ablation of superior hypogastric plexus for the management of pelvic cancer pain
Neerja Bharti1, Navneet Singla2, Yatindra K Batra1
1 Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India
2 Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India
|Date of Web Publication||7-Jan-2016|
Dr. Neerja Bharti
Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012, Punjab and Haryana
Source of Support: None, Conflict of Interest: None
Radiofrequency ablation is a safe and minimally invasive procedure that has been found effective for the treatment of various chronic pain conditions. Hereby, we report a case of severe pelvic pain due to advanced carcinoma cervix refractory to oral medications that was managed successfully by radiofrequency ablation of the superior hypogastric plexus under fluoroscopy. Her pain relieved markedly immediately after the procedure with significant reduction in opioid consumption. The effect was sustained during her follow-up period with improved quality of life.
Keywords: Cancer cervix, pelvic pain, radiofrequency ablation, superior hypogastric plexus
|How to cite this article:|
Bharti N, Singla N, Batra YK. Radiofrequency ablation of superior hypogastric plexus for the management of pelvic cancer pain. Indian J Pain 2016;30:58-60
|How to cite this URL:|
Bharti N, Singla N, Batra YK. Radiofrequency ablation of superior hypogastric plexus for the management of pelvic cancer pain. Indian J Pain [serial online] 2016 [cited 2020 May 30];30:58-60. Available from: http://www.indianjpain.org/text.asp?2016/30/1/58/173481
| Introduction|| |
Pelvic pain is a common feature in advanced stages of cervical malignancy due to the involvement of viscera, pelvic muscular structures, or neural structures by the tumor.  Though, the superior hypogastric plexus neurolysis has been found effective in relieving chronic pelvic cancer pain resistant to conventional analgesics in few studies, ,, the neurolytic blocks have their own limitations and adverse effects. ,
Radiofrequency ablation is a minimally invasive and safe procedure that has been used effectively for the management of various chronic pain conditions.  However, there is meager literature available on the radiofrequency ablation of superior hypogastric plexus for pelvic cancer pain. Here, we report a case of successful management of refractory pelvic pain due to carcinoma cervix by radiofrequency ablation of superior hypogastric plexus.
| Case Report|| |
A 27-year-old female patient known case of cancer cervix for 8 months, having severe pelvic pain due to metastasis was referred to our pain clinic. The patient was in the advanced stage of cervical malignancy with no curative intervention planned. She had chronic pelvic pain of greater than 8/10 score on the numeric rating scale (NRS) with radiation to thighs. Despite receiving 150 mg of oral morphine daily her pain was not adequately relieved. She had very poor quality of life with sleep disturbances due to intractable pain. Her past medical history was insignificant. The diagnostic block of superior hypogastric plexus with 10 mL of 0.25% bupivacaine was found very effective and her pain reduced to NRS of 3/10 but reappeared after 2 days. Therefore, the radiofrequency ablation of superior hypogastric plexus was planned for long-term pain relief.
The procedure was explained to the patient and written informed consent was obtained. It was performed in operation theatre under all aseptic precautions with standard monitoring of electrocardiogram, blood pressure, and pulse oximetry. Ceftriaxone (1 gm) was given through the intravenous route as a prophylactic antibiotic to prevent discitis. Mild sedation with midazolam (1 mg) and fentanyl (50 μg) was given to improve the patient's comfort. The patient was placed in prone position with a pillow under the iliac crest. Fluoroscopic (O-ARM) guided localization of L4, L5, and S1 vertebra was performed under direct anteroposterior view with proper alignment of L5-S1 end plates. The entry point was marked at 6 cm lateral from the midline and the skin was anesthetized with 2% lidocaine. A 15-cm 22-G straight radiofrequency needle was inserted through the entry point [Figure 1] and advanced slowly through L5/S1 intervertebral disc under fluoroscopic guidance until the loss of resistance was felt. Lateral view was then obtained to confirm proper placement of the tip of the needle at the anterior junction of L5-S1 vertebra [Figure 2]. The radiofrequency lesioning was performed at 90°C for 90 s twice. After completion of the procedure, 2 mL of 2% lidocaine with 8 mg dexamethasone was injected to reduce the postoperative tissue edema and the patient was turned to the supine position.
|Figure 1: Anteroposterior fluoroscopic view of lumbosacral spine showing tip of the radiofrequency needle advancing toward L5/S1 intervertebral disc|
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|Figure 2: Lateral fluoroscopic view of lumbosacral spine showing final position of radiofrequency needle|
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The patient was observed in the recovery room for pain relief, sensory and motor deficits, and vital signs. Ten minutes after the completion of the procedure, she reported pain relief as 4/10 on the NRS scale. The patient was discharged after the confirmation of no complications. During the 6-week follow-up, she reported that her reduction in pain was sustained and the quality of life was significantly improved. She had stopped taking morphine and was receiving only pregabalin and diclofenac with tramadol off and on.
| Discussion|| |
Cervical cancer is the second most common cause of cancer deaths in women worldwide. Unfortunately, cure is less likely when the disease is diagnosed at an advanced stage, and the life expectancy is less than 10 months. Unresectable recurrent disease may be associated with moderate-to-severe pelvic pain resistant to medical therapy and interventional pain management is needed to improve the quality of life. Since the superior hypogastric plexus contains afferent pain fibers from the bladder, urethra, uterus, vagina, vulva, perineum, prostate, penis, testes, rectum, and descending colon, its block can potentially alleviate pain originating from the above mentioned regions. Plancarte et al.  showed that the neurolytic block of superior hypogastric plexus was effective in reducing pain scores in 70% of patients with chronic pelvic cancer pain. In another multicentric study,  out of 159 patients with pelvic pain associated with cancer, 115 patients (72%) had satisfactory pain relief after one or two neurolytic procedures. Neurolytic blocks, however, sometime do not provide total pain relief and the effect may be short-lived.  Repeated blocks are required to obtain adequate pain relief that may lead to various complications. 
Radiofrequency thermoablation is reported to be a predictable and safe technique that is based on the thermocoagulation of selected nerves. The recovery is rapid without any untoward effects and the effect is usually long-lasting. However, the use of radiofrequency thermoablation is not well evaluated for cancer pain management. In a small case series, paravertebral nerve radiofrequency neurotomy has been found effective in relieving postmastectomy neuropathic pain in breast cancer patients.  In pancreatic malignancies, radiofrequency thermocoagulation of bilateral thoracic splanchnic nerve significantly reduced the abdominal cancer pain with improved quality of life during the end-stage disease. 
Our patient was suffering from an advanced stage of cervical malignancy with severe pelvic pain not relieved by conventional analgesics. We succeeded in achieving a significant reduction in pain intensity immediately after radiofrequency thermoablation of superior hypogastric plexus as well as during the entire follow-up period with improved quality of life as reported by the patient. The procedure was performed under fluoroscopy using a paramedian transdiscal approach. Though, several techniques have been described in literature for superior hypogastric plexus block such as anterior, posterior, and transdiscal approach, the paramedian transdiscal approach has been found to be easier, safer, and more effective, with lesser side effects than the classic posterior approach.  We did not report any complication during the procedure or follow-up period.
| Conclusion|| |
We found that radiofrequency ablation of superior hypogastric plexus significantly reduced pelvic cancer pain, decreased consumption of systemic opioids, and improved the patients' quality of life during the terminal phase of the disease. Therefore, radiofrequency thermoablation of the superior hypogastric plexus may be considered as a useful technique in the management of intractable pain secondary to the pelvic malignancies.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]