Interventional techniques in gynaecological malignancy

Dorn Spinal Therapy

Spine Healing Therapy

Get Instant Access

Epidural and spinal opiates

Where standard routes of analgesic administration have failed, the epidural route using a percutaneous epidural catheter can provide optimal analgesia. The benefits of opioid administration by the spinal route have been acknowledged for some time and there is clear evidence that some patients find epidural analgesia of a higher quality with a diminished incidence of unwanted side effects such as nausea, drowsiness and constipation. Epidural catheters can be inserted percutaneously and brought out through the skin or attached to a number of subcutaneous administration devices (Figure 2). Subcutaneous pumps have been used to facilitate epidural and spinal analgesia, as have subcutaneous ports through which opiates can be given on a daily or more frequent basis.

All opiates currently on the market have been used in the epidural space. The most commonly used are morphine and (in the UK) diamorphine. Opiates have been given also in combination with local anaesthetic drugs to improve the quality of analgesia. This may be particularly helpful in terminal cases where there is extreme and intractable pelvic and neuropathic pain. Drugs such as clonidine, midazolam and baclofen have also been given epidurally in such circumstances.

Superior hypogastric plexus block

The superior hypogastric plexus is formed by the union of the lumbar sympathetic chains in branches of the aortic plexus in combination with the parasympathetic fibres originating in the ventral routes of S2-S4, which form the pelvic splanchnic nerve, some fibres of which ascend from the inferior hypogastric plexus to join the superior hypogastric plexus. The superior hypogastric plexus is situated anterior to the lower part of the body of the fifth lumbar vertebra and the upper part of the sacral promontory. It is retroperitoneal and is often called the presacral nerve. The superior hypogastric plexus gives off branches to the ovarian plexuses.

Technique

The patient is placed prone and two 20 or 22 gauge needles are advanced from a point roughly 5-7 cm lateral to the L4/L5 interspace to a point just anterior to the L5/S1 interspace. These needles are inserted under fluoroscopic or CT guidance, and injected contrast material demonstrates that the needles are anterior to the vertebral body and not in any of the vascular structures. Following aspiration, neurolytic solution of aqueous phenol 8-10 ml is injected, or for local anaesthetic blockade, 10-20 ml 0.5% bupivacaine (Figure 3).

Blockade of ganglion impar

Ganglion impar block has been described for the treatment of intractable perineal and pelvic pain where the sympathetic nerve seems to predominate. The ganglion impar is a retroperitoneal structure located at the level

Ganglion Impar Junction

Insertion of tunnelled epidural catheter. (A) Position of patient: insertion marked at L2. (B) Insertion of 16-gauge epidural catheter via a Tuohy needle. (C) Second incision over 11th rib allows the catheter to be moved over the anterior chest wall. (D) Portal attached to catheter after tensioning loop and second tunnel. (E) Injection technique. of the sacrococcygeal junction. The technique involves placement of a needle through the skin under x-ray control to lie anterior to the coccyx close to the sacrococcygeal junction. Retroperitoneal location of the needle is demonstrated by the injection of contrast medium. Local anaesthetic and/or neurolytic solutions can then be injected. Care must be taken to ensure that puncture of the rectum and accidental trans-bone injection into the epidural space are avoided (Figure 4).

Figure 2

Insertion of tunnelled epidural catheter. (A) Position of patient: insertion marked at L2. (B) Insertion of 16-gauge epidural catheter via a Tuohy needle. (C) Second incision over 11th rib allows the catheter to be moved over the anterior chest wall. (D) Portal attached to catheter after tensioning loop and second tunnel. (E) Injection technique. of the sacrococcygeal junction. The technique involves placement of a needle through the skin under x-ray control to lie anterior to the coccyx close to the sacrococcygeal junction. Retroperitoneal location of the needle is demonstrated by the injection of contrast medium. Local anaesthetic and/or neurolytic solutions can then be injected. Care must be taken to ensure that puncture of the rectum and accidental trans-bone injection into the epidural space are avoided (Figure 4).

Presacral neurectomy

Presacral neurectomy has been used for the control of intractable pelvic pain, whether due to malignancy or chronic pelvic pain syndromes. The technique involves the division of the superior hypogastric plexus at the L5/S1 region as described above. The presacral nerves can be divided as an open procedure or via the laparoscope. Laparoscopic presacral neurectomy is probably the technique of choice (Figures 5 and 6). Bowel preparation is indicated preoperatively to decompress the bowel. Under direct vision an incision is made in the peritoneum over the lateral sacral promontory and dissecting forceps are used to dissect out the hypogastric plexus. It may then be ligated, cut or cauterized (Figure 7).

Superior Hypogastric Plexus Block

Figure 3

Superior hypogastric plexus block

(A) Sagittal section at L5; (B) pelvic anatomy

1 Psoas major muscle

2 Superior hypogastric plexus

3 Bifurcation of iliac vessels

4 Superior rectal artery

5 Internal iliac artery and vein

6 External iliac artery and vein

Sacrococcygeal Junction

Figure 4

Blockade of ganglion impar

1 Rectum

2 Anococcygeal ligament

3 Ganglion impar

4 Sacrococcygeal junction

Bibliography

Bonica JJ (1990) The management of pain. Malvern: Lea & Febiger, second edition.

Cousins MJ, Bridenbaugh PO (1996) editors. Neural blockade in clinical anaesthesia and the management of pain.

Philadelphia: Lippincott/Williams & Wilkins, third edition Doyle D, Hanks GW, MacDonald N (1997) editors. The Oxford textbook of palliative medicine. Oxford: OUP, second edition.

Was this article helpful?

0 0
51 Tips for Dealing with Endometriosis

51 Tips for Dealing with Endometriosis

Do you have Endometriosis? Do you think you do, but aren’t sure? Are you having a hard time learning to cope? 51 Tips for Dealing with Endometriosis can help.

Get My Free Ebook


Responses

  • sophia
    Can phenol be given through epidural catheter?
    8 years ago

Post a comment