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410 Steven H. S. WONG
is often performed after the procedure to exclude any
complication. For nerve entrapment, therapeutic
block with corticosteroids may be considered. For
tumour infiltration, neurolytic block with phenol
is commonly performed. e use of fluoroscopy
and phenol in contrast enhance the safety of the
procedure by facilitating accurate placement of the
needle and allowing visualisation of the extent of
the spread of phenol (Fig. 25.01).
Blockade of the trigeminal nerve and its
branches
e trigeminal nerve branches into three main
divisions, namely the ophthalmic, maxillary and
mandibular divisions, and supplies the sensory
innervation to the upper, middle and lower thirds
of the face.
In the idiopathic type of trigeminal neuralgia,
trigeminal ganglion block may be indicated when
conventional pharmacological treatment fails to
control the pain or if there are intolerable side
effects. In the past, neurolytic blocks using glycerol
or alcohol have been performed. Nowadays,
radiofrequency thermocoagulation has become the
method of choice for this procedure (Fig. 25.02)
[24]. Please also refer to Chapter 11 for more
details.
ere are no randomised controlled trials in
the literature on the use of radiofrequency
thermocoagulation for the treatment of
trigeminal neuralgia. A recent systematic review
has attempted to compare the effectiveness of
radiofrequency thermocoagulation with other
ablative techniques such as glycerol rhyzolysis,
balloon microcompression and stereostatic
Figure 25.01 Neurolytic intercostal nerve block for
a patient with chest pain due to tumour infiltration of
the chest wall. Note the spread of contrast along the
course of the intercostal nerves.
Figure 25.02 Radiofrequency thermocoagulation of the trigeminal ganglion. Note that the target of insertion
of the electrode (A) is the foramen ovale (B).
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411
Interventional Procedures in Pain Management: An Overview
radiosurgery. It was concluded that radiofrequency
thermocoagulation offers the highest rates of
complete pain relief and is associated with the least
complications [24].
Blockade of the terminal branches of the trigeminal
nerve is useful for relieving pain arising from the
face as a result of localised tumour, or to abolish the
trigger zones when present in trigeminal neuralgia
or postherpetic neuralgia. e terminal branches
of the ophthalmic, maxillary and mandibular
divisions of the trigeminal nerve can be blocked
by local infiltration over the supraocular and
supratrochlear nerves, infraorbital nerve and mental
nerve respectively [43].
Greater occipital nerve block
e greater occipital nerve is derived from the
dorsal rami of the C2 nerve. It supplies the
sensation to the scalp over the occiput. Along its
winding course as it ascends from the posterior
neck, the nerve is susceptible to compression by
the intermingled layers of muscles that are often in
spasm in conditions such as cervical spondylosis.
e resulting referred pain to the occipital area is
referred to as cervicogenic headache. Other causes
of occipital pain include occipital neuralgia and
tension headache.
Greater occipital nerve block has also been found
to be effective as a transitional therapy for cluster
headache. e mechanism of action is unclear and
may be related to the interference of the trigeminal
activity as well as interruption of the trigeminal
autonomic reflex pathway [35].
In a double-blind placebo controlled study
comparing subocciptial injection of steroid (n = 13)
with normal saline (n = 10) in patients with cluster
headache, it was found that 85% of the patients in
the treatment group became pain-free in the first
week after the injection compared to none in the
control group and the effect was maintained for up
to 4 weeks [3].
Greater occipital nerve block is most easily
performed at the superior nuchal line one-third of
the distance from the greater occipital protuberance
to the mastoid process. e nerve runs immediately
medial to the occipital artery.
Suprascapular nerve block
e suprascapular nerve is derived from the C5 and
C6 nerve roots of the brachial plexus. It supplies the
sensation to the shoulder joint as well as the motor
function of the supraspinatus and the infraspinatus
muscles. Passing underneath the coracoclavicular
ligament through the suprascapular notch, the nerve
is susceptible to direct trauma or compression by
shoulder straps. e referred pain to the shoulder
can mimic other causes of shoulder pain.
Pain in the shoulder can be relieved by blocking
the suprascapular nerve at the suprascapular
notch by injection of local anaesthetic with depot
steroid [44]. Careful precaution must be taken
to protect the shoulder after the injection as the
local anaesthetic would temporarily block all the
sensation from the shoulder joint. Please also refer
to Chapter 26 for more details of this procedure.
Sympathetic block
e sympathetic nervous system is the major nerve
supply to the visceral organs of our body. It carries
vasoconstricting efferents to various organs such as
the gut, the kidneys and the skin. It is important
in diverting blood flow to vital organs such as the
brain and the heart in fright and flight response. It
also carries pain afferents from various organs such
as the heart, the gastrointestinal and the urogenital
tracts.
Pain from visceral organs can be interrupted by
sympathetic blockade. e classic example is the
use of epidural analgesia for labour pain, where a
diluted local anaesthetic may block the sympathetic
fibres while sparing the sensory and motor fibres
and can successfully interrupt the pain afferents
from the contracting uterus during the first stage
of labour.
e sympathetic nervous system forms paired
chains of sympathetic ganglia, which run along
the anterolateral aspects of the cervical, thoracic
and lumbar vertebrae. ese sympathetic ganglia
receive preganglionic fibres from T1 to L2 levels
of the spinal cord and send out postganglion fibres
to various organs. ese ganglia and the network
of pre- and postganglionic fibres form the coeliac
plexus and the hypogastric plexus. Selective
sympathetic block can be performed at these
ganglia and plexuses because they are anatomically
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412 Steven H. S. WONG
separated from the somatic nerves. ese are
discussed in detail in Chapter 27.
Intravenous regional sympathetic block
Intravenous regional sympathetic block with
guanethidine is a non-invasive alternative to block
the sympathetic outflow to the extremities. A
diluted solution of guanethidine (10 mg in about
25 ml normal saline for the upper limb and about
40 ml for the lower limb) is injected intravenously
into the affected limb with a pneumatic tourniquet
on for about 20 minutes. Guanethidine will cause
release of noradrenaline and a subsequent depletion
of noradrenaline from the sympathetic nerve
endings resulting in a prolonged sympathetic block.
In patients with sympathetically maintained pain,
the noradrenaline release may cause exacerbation of
pain, but it is important not to add local anaesthetic
in the guanethidine solution as it will inhibit the
noradrenaline release [5]. Apart from guanethidine,
bretylium is also useful for intravenous regional
sympathetic block.
ere are few randomised controlled studies in
the literature on the effectiveness of intravenous
regional sympathetic block for treatment of
peripheral neuropathic pain. Some of the
studies [17, 40] have been criticised for diluting
guanethidine in lignocaine thus limiting its
usefulness. Nevertheless, a randomised double-
blind crossover study comparing guanethidine in
normal saline with normal saline showed that there
was no significant difference [15].
Injections for chronic back pain
Chronic back pain is the most common health
problem that has significant societal and economic
impact. Studies have shown that a number of
structures in the spine are capable of generating
pain. Common ones include the facet joint, the
sacroiliac joint, nerve roots and the intervertebral
disc. Injection procedures play an important role in
the diagnosis and treatment of chronic back pain.
ey are discussed in detail in Chapter 28.
ere have been only a few randomised controlled
trials on lumbar facet joint injections. In one study
comparing a total of 6 ml of local anaesthetic with
steroid into two adjoining lumbar facet joints (n =
28) with a total of 8 ml of normal saline into two
facet joints (n = 42), it was found that there was no
significant difference between the two groups with
respect to subjective assessment, objective disability
score and work outcome [23]. Notice that the
volume of injectate used was far in excess of what
is recommended in current practice, which should
not exceed 1 ml into each facet joint.
In another study comparing a total of 2 ml of local
anaesthetic with steroid into two adjoining lumbar
facet joints (n = 49) with an equal volume of normal
saline (n = 48), it was found that there was no
significant difference in the improvement (42% vs
33%) between the two groups in the flexion of the
spine, the functional status and self-report of overall
effect within 3 months after injection. Despite the
fact that there was a significantly higher percentage
of patients with marked improvement at 6 months
in the treatment group compared with the control
group (42% vs 15%), it was concluded that the
results were not significant when the percentage of
patients in the treatment group having sustained
improvement from the first to the sixth month was
compared to that in the control group (22% vs
10%) [7].
ere was only one randomised, non-placebo
controlled trial concerning cervical facet joint
injection. Intra-articular injection of corticosteroid
(n = 21) was compared with local anaesthetic (n =
20) in patients with cervical facet joint pain after
whiplash injury. It was found that in both groups
less than half of the patients reported pain relief for
more than 1 week and a conclusion was made that
intra-articular steroid injection was not effective
[4]. However, it was worth noting that in the study
only a single cervical facet joint was injected, which
is an uncommon practice as it is very unlikely that
whiplash injury involves only a single facet joint.
Besides, about one-fifth of the patients in both
groups had prolonged pain relief of up to 2 months.
Although it was attributed to placebo effect by the
author, there was no placebo group in the study
design.
ere have been a few randomised controlled
trials on the use of radiofrequency medial branch
neurotomy in the treatment of chronic facet
joint pain. In one study, a group of patients with
lumbar facet joint pain was randomised to receive
radiofrequency lesion of medial branches (n = 15)
or a sham procedure (n = 16) in which the electrodes
were introduced but without radiofrequency
lesioning. It was found that a significantly higher
percentage of patients in the treatment group had
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413
Interventional Procedures in Pain Management: An Overview
significant reduction in their pain score, global
perceived effect and the disability scale at 8 weeks,
and the effect was maintained up to 12 months
after treatment [52].
Conflicting results were found in another
study comparing radiofrequency medial branch
neurotomy (n = 36) with a sham procedure (n =
34) for the treatment of lumbar facet joint pain.
Apart from an initial improvement at 4 weeks in
the functional score in the treatment group, there
was no significant difference between the two
groups with respect to the pain level and functional
disability for up to 12 weeks [22].
With regard to the treatment of cervical facet joint
pain after whiplash injury, a study comparing
radiofrequency neurotomy for multiple levels of
the medial branch (n = 12) to a sham procedure
(n = 12) found that by 27 weeks about half of the
patients in the treatment group remained free of
pain and the treatment group had significantly
longer median time for the pain to return to at least
50% of the preoperative level (263 vs 8 days) [26].
In a subsequent systematic view on the use of
radiofrequency denervation for neck and back pain,
it was concluded that there is limited evidence that
radiofrequency denervation had a positive short-
term effect on chronic cervical facet joint pain, but
the evidence for chronic lumbar facet joint pain
remains conflicting [31].
In a systematic review on the efficacy of epidural
steroid injections for low back pain and sciatica,
of the 12 randomised clinical trials, half reported
positive outcomes and the other half reported
negative outcomes. It was concluded that the
efficacy of epidural steroid injection has not yet been
established [21]. It was worth noting, however, that
during the time of the earlier studies, fluoroscopy
was still not widely practised. In studies that
reported negative outcomes, usually only a small
volume of injectate was used. In one of the studies,
only 2 ml of either 80 mg methylprednisolone or
normal saline was injected via the interlaminar
approach [48] and in the other the total volume of
injectate was only 7 ml [8].
Studies which reported positive outcomes tended
to use a larger volume of injectate. In one study
comparing the interlaminar epidural injection
of 80 mg methylprednisolone in 10 ml normal
saline (n = 51) with superficial injection of 1 ml
normal saline into the interspinous ligament
(n = 48), it was shown that there were highly
significant differences in respect of relief of pain
and resumption of normal occupation in favour of
the group treated by epidural injection for up to 3
months [9]. In another study comparing the same
volume of injectate in the treatment group (n = 19)
with superficial injection of 2 ml normal saline in
the control group (n = 16), it was found that there
were significant differences in pain relief compared
to the control group for up to 3 months [39].
Positive outcomes were also reported with injection
via the caudal route. In one study comparing caudal
epidural injection of 80 mg triamcinolone in 25 ml
0.5% procaine (n = 12) with 25 ml of normal saline
(n = 11), it was shown that there was significant
pain relief and mobility in the treatment group for
up to 1 year [6]. Forceful epidural injection has
also been shown to be effective for the treatment of
lumbosciatic pain in postoperative lumbar spinal
fibrosis. In this study, a forceful injection via the
caudal route of 125 mg prednisolone acetate and
40 ml normal saline (n = 29) was compared with
injection via the same route of corticosteroid alone
(n = 31). It was found that significantly higher
proportion of patients in the treatment group had
relief of sciatica for up to 6 months [38].
Implantable devices
Implantable spinal drug delivery system
Spinal opioid has been widely used by anaesthetists
in the management of acute postoperative pain.
e advantages include higher efficacy of analgesia
with lower incidence of adverse effects compared
with systemic opioid. Spinal opioid can be given
via intrathecal or epidural routes. Intrathecal opioid
is usually given as a single injection while epidural
opioid can be given through an indwelling catheter
inserted percutaneously. e catheter is usually
left in situ for only a few days in the postoperative
period as there is a potential risk of infection. e
use of spinal opioid for chronic pain conditions is
made possible by the availability of an implantable
spinal drug delivery system. Please refer to Chapter
29 for more details on this technique.
ere have been few randomised controlled trials
and no systematic review of the effectiveness of
the implantable spinal drug delivery system in the
treatment of refractory cancer pain. In a recent
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414 Steven H. S. WONG
randomised clinical trial comparing the use of an
implantable intrathecal drug delivery system (n =
71) with comprehensive medical management (n
= 72) for refractory cancer pain, it was found that
patients using implantable intrathecal drug delivery
systems had significant reduction in pain and relief
of common drug toxicities, and improvement in
survival [47].
Spinal cord stimulation
Spinal cord stimulation is based on the gate
control theory postulated by Melzack and Wall in
1965 [28], which stated that stimulation of large
myelinated A-beta fibres will “close” the gate at
the spinal cord to the transmission of nociceptive
signals by small unmyelinated C fibres and lightly
myelinated A-delta fibres.
e first report of electrical stimulation of the spinal
cord was published in 1967 by Shealy et al. [45].
Since then, spinal cord stimulation has undergone
various developments and generations of technical
modifications. It is used in a variety of chronic pain
conditions including neuropathic pain associated
with failed back surgery syndrome and complex
regional pain syndrome, as well as ischaemic pain
associated with peripheral vascular disease and
angina pectoris.
e exact mechanism of action of spinal cord
stimulation is still unclear. Studies have shown
that the analgesia produced is not mediated by
endorphins, as it is not reversible by naloxone.
Other mediators have been proposed and they
include gamma amino butyric acid, serotonin,
substance P, glycine and adenosine [34].
Older generations of spinal cord stimulator used
plate electrodes and required implantation via
laminectomy by neurosurgeons. Newer generations
of electrode leads can be inserted percutaneously
and are usually done by the anaesthetists. Trial
stimulation is recommended before permanent
implantation. Using fluoroscopic guidance, one to
two electrode leads are inserted into the epidural
space under local anaesthesia. e position of
the leads is adjusted so that on stimulation the
paraesthesia produced will cover the target region.
By varying the combinations of electrodes and the
modes of stimulation, the optimal position of the
leads can be found. e leads are then implanted
subcutaneously and then connected via externalised
wires to an external screener during a trial screening
period of about a week, after which implantation of
a permanent stimulator will be decided [32]. Please
refer to Chapter 30 for more details on spinal cord
stimulation.
ere is a lack of high quality evidence regarding
the effectiveness of spinal cord stimulation, the
most obvious reason being that it is impossible
to achieve blinding. In a systematic review of 39
studies, all case reports, it was found that 50–60%
of patients with failed back surgery syndrome
achieved greater than 50% pain relief. However,
the lack of randomised controlled trials limited the
robustness of the conclusions regarding the efficacy
of the technique [50].
In a randomised controlled trial comparing spinal
cord stimulation plus physical therapy (n = 36) with
physical therapy alone (n = 18) for the treatment
of complex regional pain syndrome (previously
known as reflex sympathetic dystrophy), there
was a significant reduction in pain intensity and
improvement of health-related quality of life, but
not functional status in the group receiving spinal
cord stimulation for up to 2 years [18, 19]. However,
on long-term follow-up, it was found that the pain-
alleviating effect diminished with time, and was no
longer effective after 3 years [20].
In a recent randomised controlled trial, patients
who had persistent or recurrent radicular pain
after lumbosacral spine surgery were randomised
to receive spinal cord stimulation (n = 19) or re-
operation (n = 26). It was found that patients initially
randomised to receive spinal cord stimulation had
significantly lower self-reported pain and higher
satisfaction, and were significantly less likely to cross
over to alternative treatment. Patients randomised
to re-operation required significantly more opioid
analgesics [33].
An Algorithmic Approach
Despite the lack of strong evidence supporting the
long-term efficacy of interventional procedures,
their unique diagnostic, prognostic as well as
therapeutic roles have enabled them to remain as
powerful armamentarium in the management of
chronic pain. In order to enhance their efficacy,
interventional procedures should be used in an
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Interventional Procedures in Pain Management: An Overview
algorithmic approach within the context of a
multidisciplinary management plan.
Before embarking on interventional procedures,
the patient should be assessed to identify risk
factors that would contribute to the development
of chronicity and disability. Psychological factors,
notably psychological distress, depressive mood and
somatisation, have been shown to be implicated
in the maintenance of chronicity [36]. Patients’
illness beliefs and coping such as catastrophising
cognitions and fear-avoidance behaviour strongly
impede their recovery process [53]. Occupational
factors such as low level of job satisfaction, poor
workplace conditions, injury at work with ongoing
compensation or litigation issues also have
important roles in the maintenance of disability
and are thus poor prognostic factors for return to
work [51]. Social factors such as relationship with
spouses or significant others have also been found
to influence the pain behaviour [41].
Based on the clinical evaluation, diagnostic blocks
should be performed following a strict algorithm.
It is important to critically interpret the clinical
response to diagnostic blocks as placebo response
is often enhanced in patients with chronic pain.
Ideally, all diagnostic blocks should include placebo
injection with normal saline. However, in clinical
practice, the use of comparative blocks using two
local anaesthetics of different durations of action is
a reasonable alternative [25].
erapeutic blocks should be considered according
to the results of the diagnostic blocks. Prognostic
blocks should be performed before contemplation
of neuroablative procedures. Before implantation
of any permanent devices, an adequate period of
trial should be given to the patient to assess the
satisfaction and acceptance.
It is also advisable to incorporate interventional
procedures into the multidisciplinary treatment
programme to facilitate other modes of therapy. For
instance, the effect of physiotherapy and exercise
therapy would be greatly enhanced by the interruption
of nociceptive response after a nerve block. e results
of diagnostic blocks can help to alleviate the anxiety
of the patients about the causes of the pain.
Conclusion
e practice of interventional procedures is an
essential component in the multidisciplinary
management of pain. Despite the lack of evidence
regarding their long-term efficacy, their unique
diagnostic, prognostic and therapeutic roles are
valuable adjuncts to other modes of therapies. It
is important to perform them in an algorithmic
approach and in accordance with a multidisciplinary
treatment plan.
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418 Steven H. S. WONG
History
Risk factors for chronicity
and disability:
psychological, occupational,
social factors
Organic causes:
infection, malignancies
Psychological intervention Further investigations
Physical examination
Non-localisable pain Localisable pain
Diagnostic block
positive
Therapeutic block
Physical therapy and
rehabilitation
Analgesics Diagnostic block
negative
Figure 25.03 An algorithmic approach in the use of interventional procedures in multidisciplinary pain
management.
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Introduction
Peripheral nerve blocks are cost-effective anaesthetic techniques
used to provide anaesthesia and analgesia. When applied to
multidisciplinary pain management, peripheral nerve blocks
serve a dual function of both diagnostic and therapeutic tools.
ere are two approaches to the production of differential
neural blockade, an anatomical approach and a pharmacological
approach. e anatomical approach is based on sufficient
anatomical separation of somatic and/or sympathethic fibres.
e pharmacological approach is based on the presumed
difference in the sensitivity of the various types of nerve fibres
to local anaesthetic agents. While differential neural blockade is
not intended to replace a detailed history, a complete physical
examination, and appropriate laboratory, radiographic and
psychological studies, it is pertinent in delineating neural
mechanisms in patients with chronic pain.
If the pain distribution is limited to one or two peripheral
nerves, neurolysis — by placing a needle close to the nerves
and either injecting neurodestructive chemicals (phenol or
ethanol) or producing neural damage with cold (cryotherapy)
or heat (radiofrequency coagulation) — may result in long-
term pain relief in selected patients. In this chapter, neural
blockades used in pain management will be discussed with an
overview of their techniques, indications, relevant anatomy
and complications.
Organisation of the Nerve Block
Facility
Adequate space, equipment and a comfortable environment
are imperative to ensure proper preparation and care of the
Peripheral Nerve Blocks
26
Theresa Tak Lai LI
INTRODUCTION
ORGANISATION OF THE NERVE
BLOCK FACILITY
BRACHIAL PLEXUS BLOCK
INTERCOSTAL NERVE BLOCK
SUPRASCAPULAR NERVE BLOCK
OBTURATOR NERVE BLOCK
MAXILLARY NERVE BLOCK
MANDIBULAR NERVE BLOCK
SCIATIC NERVE BLOCK
REFERENCES
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