|Year : 2016 | Volume
| Issue : 4 | Page : 151-156
Comparison between fluoroscopic posterior versus ultrasound-guided anterior approach for superior hypogastric plexus neurolysis: a prospective, randomized, comparative study
Mahmoud A Kamel1, Ahmed Shaker R Ahmed1, Mohamed H Shaaban2, Rania Hamdy Hashem2
1 Department of Anesthesia and Pain Management, National Cancer Institute, Cairo, Egypt
2 Department of Diagnostic and Interventional Radiology, Cairo University, Cairo, Egypt
|Date of Submission||09-Dec-2015|
|Date of Acceptance||29-May-2016|
|Date of Web Publication||16-Dec-2016|
Mahmoud A Kamel
National Cancer Institute, Cairo, 11617
Source of Support: None, Conflict of Interest: None
Pain due to advanced pelvic cancer is a common and disabling complain. This study compared the safety and efficacy of the ultrasound (US)-guided anterior approach of superior hypogastric plexus (SHP) neurolysis with the fluoroscopy-guided posterior approach in the management of patients with intractable pelvic cancer pain.
Patients and methods
A total of 30 patients with advanced-stage pelvic cancer were enrolled and divided into two equal groups. The first group was named group F, which included 15 patients in whom SHP block was performed with the fluoroscopy-guided posterior oblique technique. The second group was named group U, which included 15 patients in whom the SHP block was performed with the US-guided anterior approach. Visual analogue scale score, patient satisfaction score, and daily morphine consumption were assessed at the following time points: before the procedure and on day 1, 1 month, and 3 months after procedure. Any adverse effects of the procedure were also recorded.
For both groups, visual analogue scale score and daily morphine consumption were significantly decreased at day 1, 1 month, and 3 months after procedure compared with before the procedure. Patient satisfaction score significantly improved at day 1, 1 month, and 3 months after procedure compared with before the procedure.
The present study demonstrated a comparable efficacy of the US anterior approach for SHP neurolysis in patients with advanced pelvic cancer pain with the standard, classic, fluoroscopic posterior technique.
Keywords: fluoroscopic SHPB, pelvic cancer pain, superior hypogastric plexus, ultrasonographic SHPB
|How to cite this article:|
Kamel MA, Ahmed AR, Shaaban MH, Hashem RH. Comparison between fluoroscopic posterior versus ultrasound-guided anterior approach for superior hypogastric plexus neurolysis: a prospective, randomized, comparative study. Res Opin Anesth Intensive Care 2016;3:151-6
|How to cite this URL:|
Kamel MA, Ahmed AR, Shaaban MH, Hashem RH. Comparison between fluoroscopic posterior versus ultrasound-guided anterior approach for superior hypogastric plexus neurolysis: a prospective, randomized, comparative study. Res Opin Anesth Intensive Care [serial online] 2016 [cited 2017 Jun 27];3:151-6. Available from: http://www.roaic.eg.net/text.asp?2016/3/4/151/195882
| Introduction|| |
Pelvic pain is not an uncommon complaint with a prevalence of 16–25% . Chronic pelvic pain (CPP) is a poorly defined state with multiple underlying pathophysiological pain generators such as pelvic viscera, neural structures, or the pelvic musculoskeletal system. There are ∼15 million CPP sufferers who are poorly diagnosed and managed. They represent a further burden on healthcare services .
Pain due to advanced pelvic cancer is a common and disabling feature of this group of patients. It is nearly reported in 75% of cancer patients with advanced stage of the disease ,.
Cancer pain can be effectively managed in about 90% of patients with stepwise use of the WHO analgesic ladder system . Selective interventions are needed in the remaining 10–15% of pelvic cancer patients to treat the intractable pelvic pain, which is refractory to pharmacotherapy or in those who cannot tolerate the side-effects caused by opioids. Neurolytic sympathectomy was tried to interrupt visceral pelvic pain in the form of superior hypogastric plexus (SHP) neurolysis since 1990 by Plancarte et al. .
The SHP is situated in front of the lower one-third of S1 at the sacral promontory in the retroperitoneal reflection near the aortic bifurcation and just medial to the ureter. It is a continuation of the celiac plexus and the lumbar sympathetic chain; it receives fibers from the pelvic afferent and efferent sympathetic branches of the aortic plexus, from the splanchnic nerves, and parasympathetic fibers from S2–S4. It innervates the pelvic viscera (hindgut, bladder, prostate, uterus, and vagina) . SHP blockade has been tried for pelvic visceral cancer pain, interstitial cystitis, irritable bowel syndrome, and gynecological diseases such as endometriosis, pelvic adhesions, and pelvic inflammatory disease ,.
SHP blockade can be performed either by fluoroscopy-guided, ultrasound (US)-guided, or CT-guided techniques. It is conducted through anterior (transabdominal) or posterior (lateral, paramedian, oblique, transdiscal, or transvaginal) approaches ,,.
In this prospective, randomized, comparative study, we tried to compare the safety and efficacy of the US-guided anterior approach of SHP neurolysis with the standard, classic, fluoroscopy-guided posterior approach in patients with intractable pelvic cancer pain.
| Patients and methods|| |
The present study was conducted at the National Cancer Institute, Cairo University (Cairo, Egypt) in the period between August 2013 and May 2015 after obtaining approval from the local ethics committee. Written informed consent was obtained from all participants. A total of 30 patients with advanced-stage pelvic cancer were enrolled for this study, with severe pain [visual analogue scale (VAS)≥7], either refractory to medical treatment (including opioids and adjuvant therapy) or not tolerating the side-effects caused by opioids; we included patients more than 18 years of age. Patients with local or systemic sepsis, coagulopathy, unstable cardiovascular and respiratory diseases, previous neurological deficits, history of psychiatric disorders, history of drug abuse, distorted local anatomy, and those who were allergic to the used medications were excluded from the study.
All patients were fasted for 6 h in the operating theater. American Society of Anesthesiologists-standard monitors]None invasive blood pressure (NIBP), pulse-oximetry, and ECG] were used. The intravenous line was inserted, and O2 was supplied through a nasal prong. American Society of Anesthesiologists-recommended conscious sedation was performed using midazolam 0.05 mg/kg, intravenous, with or without fentanyl 1 μg/kg. The selected 30 patients were divided into the following two groups:
- Group F: this group included 15 patients in whom SHP block was performed by the fluoroscopy-guided posterior oblique technique.
- Group U: this group included 15 patients in whom SHP block was performed by the US-guided anterior approach.
Technique of the fluoroscopy-guided oblique posterior approach 
The patient was placed prone on the radiolucent table with a pillow under the pelvis to relax the back muscles. First, we obtained alignment (straightening of the lower border of L5) by steep cephalic orientation of the C-arm. Next, 20–25° obliquity was targeted on each side, and the point of entry was marked at the lower lateral border of L5. Local infiltration of anesthesia was obtained using 1% lidocaine, and a 15-cm, 20-G Chiba needle was inserted in the direction of the irradiation beam (end-on) ([Figure 1]a). The Chiba needle was manipulated under oblique view targeting the paravertebral plane until reasonable depth was obtained (7–8 cm). Subsequently, under the dead lateral view, the needle was further inserted until it reached the anterolateral margin of the vertebral body; 1–2 ml of contrast medium (iohexol, Omnipaque; GE Healthcare Inc., Ireland, Cork, Ireland, 300 mg I2/ml) was injected after negative aspiration to outline smoothly the L5–S1 junction (smooth contour of the contrast medium is due to anterior psoas fascia), both up and down without posterior spread toward the nerve root ([Figure 1]b). The posteroanterior view was obtained to ensure favorable dye position − ‘paramedian globular at L5–S1 position’ ([Figure 1]a). Next, 4 ml of 8% phenol in saline was injected into each needle, and 0.5 ml of lidocaine was injected during needle removal.
|Figure 1: (a) Fluoroscopy-guided needle introduction. (b) Fluoroscopy-guided injection.|
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Technique of the ultrasound-guided anterior superior hypogastric plexus block 
Bowl preparation was ensured using activated charcoal and bisacodyl. Patients were placed in the supine position, and after sterilization, the low-frequency, curved probe was used in the longitudinal axis to visualize the aortic bifurcation and was identified using a longitudinal US ([Figure 2]a) (Phillips Healthcare, Andover, Massachusetts, US). Next, the probe was placed deeply transverse to illustrate the body of the L5 vertebra. Local infiltration with 1% lidocaine was obtained at port of entry 1–1.5 inches below the umbilicus. A 15-cm, 22-G Chiba needle was inserted (out-of-plane) ([Figure 2]b) and advanced by ‘avoiding vascular structures’ until contact with the L5-body. It will be withdraw the needle 1–2 mm and inject 8 ml 8% phenol in saline. Finally, 0.5 ml of lidocaine was injected during Chiba needle removal.
All patients were transferred to the recovery unit where their pain intensity and hemodynamic variables were assessed for 2 h and then they were discharged.
Data were collected by a junior doctor who was blinded to the study design. Demographic data including age, sex, pathology of pelvic cancer, preprocedure VAS (the VAS is a 10-cm scale with the left-end 0 cm indicating no pain and the right-end 10 cm indicating the worst imaginable pain), and the duration of the procedure were collected.
Following completion of the VAS procedure, Patient Satisfaction Score (PSS) (for postprocedure pain relief), which was assessed using a linear scale where 0=very satisfied and 10=very dissatisfied , and daily morphine consumption (mg/day) were assessed at the following time points: before the procedure and 1 day, 1 month, and 3 months after the procedure. Patients’ Global Impression of Change scale ([Table 1])  was assessed 1 month after the procedure. Any side-effects of the procedure were also detected (back pain, bleeding, infection, L5 root injury with paresthesia or motor weakness, and visceral or vascular injuries).
Data were statistically described as mean±SD or as frequencies (number of cases) and percentages when appropriate. Comparison of numerical variables between the study groups was carried out using Student’s t-test for independent samples. Within-group comparison of numerical variables was carried out using paired t-test for matched samples. For comparing sex, Fisher’s exact test was used. P values of less than 0.05 were considered to be statistically significant. All statistical calculations were performed using statistical package for the social sciences (SPSS, version 15 for Microsoft Windows; SPSS Inc., Chicago, Illinois, USA).
| Results|| |
Demographic data and clinical characteristics are shown in [Table 2].
|Table 2: Demographic data and clinical characteristics were comparable between the two groups|
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There was a significant decrease in VAS scores in both the study groups at day 1, 1 month, and 3 months after the procedure compared with before the procedure ([Table 3]).
|Table 3: The mean visual analogue scale (0–10) was comparable between the two groups at different time points of the study|
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There was a significant decrease in mean daily morphine consumption in both the study groups at day 1, 1 month, and 3 months after the procedure compared with before the procedure ([Table 4]).
|Table 4: Mean daily morphine consumption was comparable between the two groups at different time points of the study|
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The mean PSS (0–10) decreases in both the study groups at day 1, 1 month, and 3 months after the procedure compared with before the procedure ([Table 5] and [Table 6]).
|Table 5: The mean Patient Satisfaction Score was comparable between the two groups at different time points of the study|
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|Table 6: Patients’ Global Impression of Changes in the studied groups one month after intervention was comparable|
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The following complications were detected in both groups: back pain in six patients in the F group (6/15) and two patients in the U group (2/15), diarrhea in three patients in the F group and two patients in the U group, and hypotension in two patients in the F group and only one patient in the U group.
Urine retention occurred in one patient in the F group and three patients in the U group.
| Discussion|| |
Pelvic pain may arise from gynecological, gastrointestinal, urological, nervous, or musculoskeletal complications. Mapping of CPP includes both somatic (T12–S5) and visceral (T10–S5) systems. Therefore, pelvic pain is often vague, poorly localized, its differential diagnosis challenging, and is usually difficult to treat ,. Available data are limited regarding painful syndromes of pelvic cancer . Neurolytic SHP blockade has been recommended for pelvic visceral cancer pain, especially in patients refractory to the WHO analgesics ladder or not tolerating the side-effects caused by opioids .
Plancarte et al.  were the first to describe SHP block using neurolytics and bilateral needles without fluoroscopy. They reported 70–90% of significant pain reduction. The classic approach aided by fluoroscopy had been reported and resulted in 69% pain relief with 56% decrease in opioids consumption .
Modified techniques of SHP blockade have been tried, such as transdiscal, transvaginal, and CT-guided posterior approach and anterior approach ,.
The efficacy of the anterior SHP neurolysis has been reported in many studies. Cariat et al.  reported that eight of 10 patients with pelvic cancer pain improved after CT-guided anterior SHP blocks. CT-guided anterior SHP neurolysis showed significant VAS reduction and decrease in opioids consumption .
The results of the present study showed significant pain relief in both groups − that is, the fluoroscopy-guided posterior and US-guided anterior SHP neurolysis groups − with nonsignificant difference between the two groups. Similarly, PSS and opioids consumption were comparable and showed postprocedure improvement at 1 day, 1 month, and 3 months compared with the preprocedure values. Patients’ Global Impression of Change showed postprocedure improvement 1 month after the procedure in the studied groups.
Back pain was reported in six patients of the F group (6/15) and two patients of the U group (may be due to the needle or neurolytic irritation of psoas fascia) (2/15), diarrhea in three patients of the F group and two patients of the U group, and hypotension was reported in two patients of the F group and only one patient of the U group.
Urine retention occurred in one patient in the F group and three patients in the U group (may be explained by bladder irritation by the needle track in the US-guided anterior approach).
The pain relief obtained in the present study was comparable between both the groups. It was similar to the range of 69–79% under fluoroscopy as in previous studies ,,,. The pain relief obtained after anterior US-guided SHP blockade in the present study was approximately similar to the case series of Mishra et al.  and to the study comparing US-guided anterior technique with oral morphine, and concluded comparable results with US with regard to VAS reduction, PSS, and decreased daily morphine consumption .
The classic fluoroscopy-guided posterior approach for the SHP blockade is a well-defined, solid, standard technique with a documented efficacy of about 70–80% of pain relief ,. It has undergone many technical modifications to augment safety and ensure efficacy  and is recommended as interventional therapy for visceral pain due to pelvic tumors .
On the other hand, the anterior US-guided technique for SHP neurolysis is described by many trials as being simple, fast, usable at the bedside, and comfortable to the patient, as the supine posture is favorable particularly in urgent conditions. It minimizes the discomfort due to needles passing through the back musculature and spares the somatic nerve roots ,. It carries the risk of endangering the common iliac vessels, the urinary bladder, and the bowel besides risk of infection on injuring the bowel. US cannot absolutely exclude intravascular uptake of drugs. All these risks have been recorded in early reports of Mishra et al. .
However, these hazards can be minimized now by using meticulous techniques, proper bowel and bladder preparation, smaller Chiba needle size (≤22 G), Trendelenburg’s position, and the use of US probes with Doppler characteristics . The anterior approach is of special interest when the classic approach technique cannot be used. In situations where broad ileac crest or transverse processes of the fifth lumbar vertebra , persistent, coexisting L5 root irritation, laterally prominent L5 osteophytes of a completely degenerated L5–S1 disc with loss of height are found, transdiscal technique cannot be performed .
| Conclusion|| |
The present study demonstrated a comparable efficacy of the US anterior approach for SHP neurolysis in patients with advanced pelvic cancer pain with the standard, classic fluoroscopic posterior technique.
It is a simple bedside and relatively safe technique without hazards of radiation. It should be considered as an option for SHP blockade, especially with regard to the anatomical considerations previously enumerated.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]