If you wish to respond to a paper or other item already published in the BJA, please go to the abstract/full text version of that item and click on the link "E-Letters: Submit a response to the article".
Electronic Letters to:
|
|
E-letters: Electronic letters published:
-
![[Read E-letter]](/icons/misc/sectionDOWN.gif)
Intrathecal Neurolysis
- James H. Antrobus, Daniel Munday (10 July 2008)
|
|
|||
|
James H. Antrobus, Consultant Anaesthetist Warwick Hospital, Daniel Munday
Send letter to journal:
|
We welcome the publication of Professor Chambers’ article ‘Nerve blocks in palliative care', in particular his discussion of central neuraxial infusions, but were surprised at the lack of any mention of intrathecal neurolysis. We have found this technique, when utilized for selected patients, is a useful addition to many of the techniques discussed by Prof Chambers. We have used intrathecal neurolysis in 25 patients between December 2002 and April 2008, which represents approximately 1 in 200 hospice admissions. In one patient we used alcohol; the remainder were treated with 6% phenol in glycerol. We recognise two main indications: unilateral chest pain and pelvic pain, particularly perineal disease that prevents comfortable sitting. In 15 patients receiving unilateral block at thoracic level at least ten achieved good or complete pain relief within the treated area (no data recorded in five) with a median reduction in opioid dose of 46% (range 23 – 69%). Function was improved in seven and unchanged in three (no data in four) and 11 were discharged home. Transient adverse effects included headache and nausea. Three patients experienced proprioceptive impairment in the upper limb that recovered within 48 hours. One patient, whose disease had required spinal stabilisation surgery, experienced motor weakness that recovered but proprioceptive loss persisted with loss of fine control of movement in the dominant arm. Ten patients with pelvic or perineal pain were treated with saddle blocks. Seven achieved good or complete relief of local pain, two acknowledged partial pain reduction and one reported no change. Median opioid dose reduction was 49% (range 20 – 93%). Function was improved in seven and unchanged in two. One patient, whose pain extended into the leg, was warned that proprioceptive loss would occur, but chose to proceed. All but two were catheterised or had urinary diversion prior to treatment. Of the two uncatheterised patients, one required a catheter post treatment. No patient who was continent of faeces before treatment became incontinent after. Intrathecal neurolysis has proved a reliable technique which is conveniently performed within the hospice. Useful gains have included a reduction in opioid side effects, improved mobility and the ability to be comfortable at rest when sitting or lying. One patient experienced unpredicted, persistent adverse effect. Professor Chambers rightly stresses the issues of selection and counselling and the benefits of joint working with the Palliative Medicine team. It has been our experience that developing such an integrated multidisciplinary approach, with weekly face to face contact, has facilitated appropriate and timely referral for nerve blocks. In addition it has provided the context for a holistic approach to pain management which we believe enhances the effectiveness of these procedures. Such is the success of this service that it is now attracting referrals from a wider area. Conflict of Interest:None declared |
|||