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Comparison of Different Spinal Level Approaches in Splanchnic Sympathetic Neurolysis for Intractable Upper Abdominal
Dhanalakshmi Koyyalagunta1, Steven Mach1, Matthew Chung1
1Department of Pain Medicine, University of Texas, MD Anderson Cancer Center, Houston, TX.
Background:
Celiac plexus or splanchnic nerve neurolysis is a treatment modality commonly offered for cancer-related upper abdominal pain. The optimal spinal level for performing celiac/splanchnic sympathetic neurolysis remains unclear.
Objective:
We aimed to assess the outcome, effectiveness, and complications associated with undergoing splanchnic sympathetic neurolysis at various spinal levels for treating intractable upper abdominal cancer pain.
Study Design:
This is an analysis of a retrospective cohort.
Setting:
Pain management clinic at a large quaternary comprehensive cancer center.
Methods:
A retrospective chart review of patients with unremitting cancer-related upper abdominal pain refractory to medical management was performed. Data were collected on pertinent demographic, clinical characteristics, cancer diagnosis and staging, location of abdominal pain, pain Numeric Rating Scale (NRS-11) scores, prior cancer treatments, level/laterality of splanchnic neurolysis, agents and volumes used for neurolysis, adverse events, pre- and postprocedure daily morphine milligram equivalents (MME), and symptom burden/quality-of-life outcomes.
Results:
A total of 254 patients treated with splanchnic sympathetic neurolysis for intractable upper abdominal cancer pain from July 2014 through June 2017 were included. Of the splanchnic sympathetic neurolysis procedures performed, most were done at T12 (44%) and L1 (54%)., The vast majority were bilateral (96%) using absolute alcohol (98%). There was no significant difference in MME requirements at postprocedure 6-months. Additionally, while NRS-11 scores improved at postprocedure one month and 6 months compared to baseline, there was no significant difference in NRS-11 scores based on the level at which the procedure was performed. A subgroup analysis of patients (n = 201 observations) with cancer pain related to intraabdominal viscera innervated by the splanchnic nerves (i.e., pancreatic, hepatobiliary, renal/adrenal, and gastrointestinal tract) also revealed that block level was not significantly associated with pain score. Time was a significant factor associated with NRS-11 score; patients had a significantly decreased pain score at postprocedure one month and 6 months. For patients with abdominal cancers of predominately splanchnic innervation, splanchnic sympathetic neurolysis also improved quality of life measures such as nausea, feeling of wellbeing, and mental clarity.
Limitations:
One-third of the patients in our study were lost to follow-up at 3 months, likely due to the patient population with end-stage cancer, the natural history of cancer disease progression, or death.
Conclusion:
The majority of splanchnic sympathetic neurolysis were performed at L1 and T12. Improved pain scores were comparable between block levels and provided sustained pain relief for at least 6 months. Significant changes in daily MMEs were demonstrated with neurolysis in association with the one month follow-up. While we found that splanchnic sympathetic neurolysis was effective in reducing opioid requirements, larger randomized studies are needed to look for any meaningful difference in long-term efficacy for pain control and side effects for splanchnic nerve sympathetic neurolysis.
