|Year : 2019 | Volume
| Issue : 2 | Page : 109-111
Pulsed radiofrequency lesioning at multiple trigger points around the scar for management of chronic persistent postsurgical neuropathic pain following total abdominal hysterectomy and laparotomy
Anand Kumar Chopra, Megha Bajaj, Ashok Kumar Saxena, Hazel Talwar, Nitika Yadav, Geetanjali T Chilkoti
Department of Anesthesiology, Critical Care and Pain Medicine, UCMS and GTB Hospital, Delhi, India
|Date of Submission||08-Mar-2019|
|Date of Decision||14-Apr-2019|
|Date of Acceptance||12-Jun-2019|
|Date of Web Publication||7-Aug-2019|
Dr. Anand Kumar Chopra
Department of Anesthesiology, Critical Care and Pain Medicine, UCMS and GTB Hospital, Dilshad Garden, Delhi - 110 095
Source of Support: None, Conflict of Interest: None
Chronic persistent postsurgical pain (CPPP) is a common complication following surgery. If a pain persists for >3 months following surgery and cannot be explained by any other causes, then it is labeled as CPPP. The mechanism is not fully understood. A 35-year-old female presented with chronic persistent postsurgical neuropathic pain following total abdominal hysterectomy and gynecological laparotomy. Multimodal integrated approach for the management of pain was adopted. After having no relief with oral pregabalin therapy, the patient was then planned for pulsed radiofrequency (PRF) lesioning at multiple trigger points along the scar. The patient was followed up to 6 months after the second PRF procedure. After 2 months following the PRF procedure, the Numerical Rating Scale score improved from 9/10 to 2/10.
Keywords: Chronic persistent postsurgical pain, Numerical Rating Scale, pulsed radiofrequency
|How to cite this article:|
Chopra AK, Bajaj M, Saxena AK, Talwar H, Yadav N, Chilkoti GT. Pulsed radiofrequency lesioning at multiple trigger points around the scar for management of chronic persistent postsurgical neuropathic pain following total abdominal hysterectomy and laparotomy. Indian J Pain 2019;33:109-11
|How to cite this URL:|
Chopra AK, Bajaj M, Saxena AK, Talwar H, Yadav N, Chilkoti GT. Pulsed radiofrequency lesioning at multiple trigger points around the scar for management of chronic persistent postsurgical neuropathic pain following total abdominal hysterectomy and laparotomy. Indian J Pain [serial online] 2019 [cited 2019 Nov 19];33:109-11. Available from: http://www.indianjpain.org/text.asp?2019/33/2/109/264072
| Introduction|| |
Chronic persistent postsurgical pain (CPPP) is a frequent and serious complication following surgery. The International Association for the Study of Pain defines CPPP as a persistent pain that is apparent ≥3 months postoperatively and cannot be explained by other causes such as recurrence of disease and inflammation. With the increase in the number of surgical procedures being performed annually, the incidence of CPPP after surgery has increased dramatically.
Various chronic pain conditions are being managed by pain practitioners, across the world, using pulsed radiofrequency (PRF) which is a minimally invasive treatment. It involves the application of short periods of radiofrequency (RF) energy to neural tissue. Here, we present our experience of achieving significant pain relief using an integrated approach encompassing PRF lesioning at various trigger points located in the scar area and pregabalin therapy following total abdominal hysterectomy and gynecological laparotomy.
| Case Report|| |
A 35-year-old female patient visited the gynecology outpatient department of a tertiary care hospital in the capital of Delhi in the year 2011 for total abdominal hysterectomy for multiple large fibroids in the uterus. The patient did not have any comorbidity. Following this, the patient continued to have moderate pain both in the scar tissue and in the lower abdomen. The patient continued to ignore it till the year 2018 when it exaggerated, and the patient was diagnosed to have bilateral hydrosalpinx and multiple cysts in ovaries for the cause of pain. She was scheduled to undergo exploratory laparotomy in the year 2018. Now, the abdominal pain had resolved, but the pain at the site of scar continued, which now was severe in intensity. She was then referred to the pain clinic.
She presented in pain clinic with severe excruciating pain (Numerical Rating Scale [NRS] score: 9/10), with the duration of 6 months following laparotomy; however, she had been experiencing moderate intensity pain for the past 8 years. A detailed history was taken, and thorough examination was done. The patient was obese with no comorbid conditions. The character of pain was burning (Neuropathic Pain Symptom Inventory (NPSI) score: 8/10) and sharp shooting and stabbing (NPSI score: 8/10) in nature. In addition, she also complained of pins and needle sensations (NPSI score: 7/10) around the scar site. The patient also complained of disturbed sleep for 1½ years. The quality of life of the patient which was assessed using the SF-12 questionnaire was found to be severely affected both in terms of physical and mental components. There were no signs of any inflammation around the scar site, and also, there were no specific findings on X-ray and ultrasound abdomen. All blood investigations were within the normal limits.
A multimodal approach for pain relief was adopted. She was prescribed with capsule pregabalin 75mg BID, tablet etoricoxib 90mg OD, and tablet tramadol hydrochloride 150 mg OD. Initially, she continued this therapy for a week, but the pain was not relieved. We then tried to titrate pregabalin up to 300 mg/day, but still, there was no improvement, and rather, she started complaining of dizziness, especially on movement.
The patient was then advised for PRF lesioning. The advantages and disadvantages of the procedure were duly explained to the patient in her own language, and the informed consent was taken from the patient. Under all aseptic precautions, the patient was taken on the (Operation theatre) OT table. Monitors were instituted, and an intravenous access was secured. On the OT table, under all aseptic precautions, a diagnostic block was carried out using 1.5% lignocaine and 22G 54-mm RF cannula with 4-mm active tip. The trigger points were observed to be located around the midline scar. There were six such trigger points located at 5–7-mm lateral to the midline scar, both to the right and left of the scar area, all along the whole length of the scar area. Following a diagnostic block and administration of 20 mg of triamcinolone topically, the RF cannula was introduced at the trigger points as located on examination. The RF cannula was directed at each trigger point and then moved both cephalad and caudate along the subcutaneous tissue. Initially, an electric stimulus of 50 Hz at 0.1 volts was applied, and then, another stimulus of 2 Hz at 0.1 volts was given and verified that muscle did not contract when the voltage was increased up to 0.8 volts 1 min after injecting 1.5% bupivacaine. The whole aim of using two frequencies at 50 Hz and 2 Hz was actually meant for both sensory/motor differentiations. PRF lesioning was performed for 240 s at 42°C, and the same procedure was repeated at other trigger points and PRF delivered at similar fashion. The vitals of the patient remained normal throughout the procedure, and no side effects such as bleeding, infection, needle placement-induced nerve injury, burns, and postprocedural discomfort were encountered.
After 7 days following the PRF procedure, the NRS score improved to 5/10 vis-a-vis 9/10, at the time of presentation. Capsule pregabalin 150 mg/day was administered orally and continued for 2 months, following which the patient presented with the same type of pain, however the pain was of lower intensity(overall NRS – 2/10). this time. The PRF lesioning at the trigger points was repeated again. After the second administration of PRF lesioning, capsule pregabalin was again started at 150 mg/day and then gradually tapered to capsule pregabalin 75 mg HS after 2 weeks for a total of 6 weeks. The patient was followed up for the next 6 months and reported remarkable relief in the pain. The patient was also advised to practice relaxation therapy. The patient was followed up to 6 months after the second procedure. There was no exacerbation of pain or any other complaint or side effect after the procedure. The NRS score remained between 2/10-3/10 during follow-up. Furthermore, the quality of life of the patient in terms of physical and mental components of the patient improved with NPSI score for pins and needles to 3/10, for burning to 2/10, and for sharp shooting and stabbing to 2/10. The overall NPSI score reduced to 2/10.
| Discussion|| |
In the present case report, PRF application has been observed to be efficacious for the management of CPPP following hysterectomy and gynecological laparotomy, and this happens to be the first report of PRF application for the management.
With the increase in the number of surgical procedures being performed annually, the incidence of CPPP after surgery has also increased dramatically. In an interesting study, Kehlet et al. observed that as many as 50% of patients who have undergone surgery experience persistent pain long after the expected postoperative recovery period; among them, 2%–10% of these patients experienced severe pain. Total abdominal hysterectomy is a frequently performed gynecological surgery, and in the opinion of Brandsborg et al., the prevalence of CPPP following hysterectomy has been observed to be 5%–32%. Interestingly, it has been observed that the incidence of CPPP following gynecological laparotomy is as high as 32%.
In the present case report, the mechanisms of CPPP may be complex and not fully understood. Kehlet et al., in an interesting study, noted that CPPP is usually a continuation of acute postsurgical pain or may develop after an asymptomatic period. Recently, Avni et al. studied the mechanism which leads to chronic pain. It occurs in the peripheral as well as in the central nervous system and induces changes in any of the four components of the pain pathway, i.e., transduction, transmission, perception, and modulation. Overall, the genesis of chronic neuropathic pain is a complex dynamic phenomenon.
Very recently, Feller et al. concluded that various predisposing factors for the development of CPPP include age, sex (female sex is associated with more incidence of CPPP), cognition, emotions, genetic polymorphism, and previous or other ongoing chronic pain conditions. Again recently, Buvanendran et al. found that acute postoperative pain is an important predictor of chronic postsurgical pain in total knee arthroplasty. In the present case report, one of the important predisposing factors was her catastrophizing personality which was associated with high degree of preoperative anxiety. Recently, Kadampti et al. also emphasized catastrophizing profile for its strong association with chronic pain.
In a recent study done by Saxena et al., the incidence of CPPP following staging laparotomy for carcinoma ovary was observed to be 38.1% at the end of postoperative day 90. All the patients experienced moderate pain (NRS: between 5 and 7/10). Another interesting aspect of this study was a significant positive correlation between the incidence of CPPP following staging laparotomy for carcinoma ovary and the expression of signal transduction genes (PKA, PKC, and ERK) at the end of postoperative day 90.
All the patients who suffer from chronic pain are highly challenging to manage. The results are not satisfying whenever we are optimizing with pregabalin therapy alone to manage neuropathic component of CPPP. Hence, we decided to use multimodal analgesia consisting of pregabalin and PRF application at the multiple trigger points all along the abdominal scar.
On thorough literature search, a number of studies have validated the use of PRF in CPPP conditions. In an interesting study, it was shown that PRF application is superior for chronic postsurgical thoracic pain over pharmacotherapy. In a case reported by Kim et al., it has been shown that PRF lesioning is effective in treating chronic neuropathic pain after breast reduction surgery in a 52-year-old female. In another case series involving patients with chronic inguinal postherniorraphy pain, the long-term pain relief was 6–9 months after PRF (which involved lesioning of lumbar nerve roots) was depicted. Tamini et al. in their study depicted the role of PRF of trigger points in long-term pain relief in patients with myofascial pain with identifiable trigger points. It seems that PRF is a better modality of pain relief over other methods of pain relief such as neurolysis and thermal RF, possibly because of lack of side effects.
In this case, PRF current (which is a low-energy, high-frequency (100,000–500,000 Hz) alternating current) was applied to the tissues. This induced the charged molecules (proteins) to oscillate with rapid changes to oscillating current. Further, the resultant heat produced due to friction causes thermal lesions. It has also been noted that the size of lesion depends on the heat generated, heat lost to surrounding tissues, and on the electrode size. The exact mechanism of action of PRF is still not clear; however, various studies demonstrated that PRF produces very high electric fields that may be capable of disrupting the neuronal membranes and function.
Cooled RF ablation is a recent newer technique that is much more precise and effective than RF. However, the resultant lesion is six times larger with cooled RF ablation. However, the cost of cooled RF is exorbitant, and our institution so far does not have this provision.
| Conclusion|| |
The PRF lesioning has been found to be beneficial in various types of chronic pain syndromes following post thoracotomy and post breast surgery. With the present case report, we emphasize the role of PRF lesioning as a part of multimodal pain approach for the management of CPPP following hysterectomy and gynecological laparotomy. Further, multicenteric randomized controlled trials with a larger sample size are warranted to confirm the role of PRF lesioning in the management of CPPP.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kehet H, Edward RR, Buvanendran A. Persistent postoperative pain; pathogenic mechanism and preventive strategies. In: Pain 2012. Tracey I, editor. Seattle, US: International Association for the Study of Pain Press (IASP Press); 2012. p. 133-46.
Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: Risk factors and prevention. Lancet 2006;367:1618-25.
Brandsborg B, Nikolajsen L, Kehlet H, Jensen TS. Chronic pain after hysterectomy. Acta Anaesthesiol Scand 2008;52:327-31.
Avni G, Kishore G, Eugene R. Persistent post surgical pain after abdominal surgery. Reg Anesth Pain Manag 2011;15:140-6.
Feller L, Khammissa RA, Bouckaert M, Ballyram R, Jadwat Y, Lemmer J. Pain: Persistent postsurgery and bone cancer-related pain. J Int Med Res 2019;47:528-43.
Buvanendran A, Della Valle CJ, Kroin JS, Shah M, Moric M, Tuman KJ, et al.
Acute postoperative pain is an independent predictor of chronic postsurgical pain following total knee arthroplasty at 6 months: A prospective cohort study. Reg Anesth Pain Med 2019. pii: rapm-2018-100036.
Kadimpati S, Zale EL, Hooten MW, Ditre JW, Warner DO. Associations between neuroticism and depression in relation to catastrophizing and pain-related anxiety in chronic pain patients. PLoS One 2015;10:e0126351.
Saxena AK, Chilkoti GT, Chopra AK, Banerjee BD, Sharma T. Chronic persistent post-surgical pain following staging laparotomy for carcinoma of ovary and its relationship to signal transduction genes. Korean J Pain 2016;29:239-48.
Kim HT, Kim KY, Kim YD, Moon HS. Pulsed radiofrequency lesioning for treatment of chronic breast neuropathic pain after breast reduction – A case report. Korean J Anesthesiol 2010;59 Suppl: S238-41.
Tamimi MA, McCeney MH, Krutsch J. A case series of pulsed radiofrequency treatment of myofascial trigger points and scar neuromas. Pain Med 2009;10:1140-3.
Cosman ER Jr., Cosman ER Sr. Electric and thermal field effects in tissue around radiofrequency electrodes. Pain Med 2005;6:405-24.
McCormick ZL, Choi H, Reddy R, Syed RH, Bhave M, Kendall MC, et al.
Randomized prospective trial of cooled versus traditional radiofrequency ablation of the medial branch nerves for the treatment of lumbar facet joint pain. Reg Anesth Pain Med 2019;44:389-97.