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to anterior epidural space on AP and lateral fluoroscopic views respectively. Efficacy Measure (EM) injection depomedrol 80 mg diluted in 8 ml 0.2% ropivacaine was injected slowly SM in increments under continuous fluoroscopy. The patient was instructed to indicate immediately if he had headache, change in field of vision, or worsening of leg pain indicating a non‑permissible rise in epidural pressure and its attendant sequel. SM The patient had 100% pain relief immediately post procedure which persisted till 6 weeks of follow‑up. An early caudal epidural in the absence of absolute contraindications not only provided immediate pain relief but also acceptable functional capacity, adequate sleep, and rest, avoided intolerable medication side‑effects, and hence improved overall quality of life. An immediate and adequate analgesic response also strengthened the patient trust and compliance to subsequent definitive treatment, i. e., radiotherapy. The purpose of this article is to highlight the above in addition to the indispensable role of safetySM and efficacy measuresEM described throughout the text. It is of utmost importance to conform to the following safety measures (SM): • A complete neurological examination to rule out any neurological compromise • MRI spine • To check for anatomical‑dermatomal congruency as well as pre‑planning the needle trajectory and final position so as to avoid any needle trauma to the fragile metastatic tissue and subsequent probability of bleeding • To rule out thecal sac or spinal cord compression • A controlled injection of the dye and therapeutic injectate under continuous fluoroscopy along with repeated enquiry for the absence of the symptoms suggestive of raised epidural pressure and halt the procedure at its first sign • AP fluoroscopic view to restrict the final needle tip position below the site of metastatic soft tissue or S3 whichever is lower whereas confirmation of ventral epidural spread of injectate on lateral fluoroscopy
ensures delivery of medication to the putative etiological site. To conclude, the authors would like to propose epidural metastasis is‑mediated pain in the absence of absolute contraindications as a valid practical indication of an early caudal epidural steroid injection provided: • Spinal cord compression has been ruled out • The above safety and efficacy measures are strictly adhered to • Necessar y definitive (radiotherapy) and prophylactic neuro‑protective (dexamethasone) measures are co‑administered.
Mayank Gupta Department of Anaesthesia, Shri Guru Ram Rai Institute of Medical and Health Sciences and Shri Mahant Indiresh Hospital, Delhradun, Uttarakhand, India
Address for correspondence: Dr. Mayank Gupta; E‑mail:
[email protected]
REFERENCES 1.
Flynn DF, Shipley WU. Management of spinal cord compression secondary to metastatic prostatic carcinoma. Urol Clin North Am 1991;18:145‑52. 2. Osborn JL, Getzenberg RH, Trump DL. Spinal cord compression in prostate cancer. J Neurooncol 1995;23:135‑47. 3. Bennet MI, Smith BH, Torrance N, Potter J. The S‑LANSS score for identifying pain of predominantly neuropathic origin: Validation for use in clinical and postal research. J Pain 2005;6:149‑58. 4. C h e n T C. P r o s t a t e c a n c e r a n d s p i n a l c o r d c o m p r e s s i o n . Oncology (Williston Park) 2001;15:841‑55. Access this article online Quick Response Code: Website: www.jpalliativecare.com
DOI: 10.4103/0973-1075.164899
Transnasal Approach to Sphenopalatine Ganglion Blockade: An Alternate Technique Sir, Palliative pain treatment for head and neck cancers manifesting as intractable atypical facial pains, headaches, and deep‑seated otalgias is one of the indications for sphenopalatine ganglion blockade (SPGB). Similar benign pains could also be indications.[1] 360
The anatomical distortion of tissues by oral cancers, surgery, or post‑radiation fibrosis often makes the approach to the ganglion by the lateral or greater palatine foramen difficult by masking the landmarks. This makes transnasal approach an attractive option. During such an approach performed commonly with cotton‑tipped applicator, it is Indian Journal of Palliative Care / Sep-Dec 2015 / Vol 21 / Issue 3
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likely to encounter technical difficulties (due to polyps, deviated septum, spurs, or hypertrophied turbinates; anatomical distortion produced by post‑maxillectomy hollow) or traumatize the nasal mucosa.[2] We herein describe yet another alternate technique of delivering the medications to the SPG apart from those that find mention in the literature.[3‑6] The compliance of the patient for the technique is ensured by lubricating the nostril on the side of the proposed block with Lignocaine hydrochloride jelly (LOX 2% jelly). The position of the middle turbinate is assessed by the point on external nasal wall in the plane of the zygomatic arch and the frontal process of maxillary bone. The distance of this point to the ala nasae is measured approximately. An epidural catheter without the filter (PORTEX SYSTEM 1, Smiths medical) previously stiffened by placing it in ice‑cold water for 15–20 minutes in order to maintain its natural curve during progression in the nasal passage is then introduced to a length 0.5–1 cm more than the calculated distance of the middle turbinate from the ala of the nose. The extra length and the stiff curve ensure the placement of the catheter approximately near the SPG fossa that is normally located a few mm deep to the nasal mucosa. In patients with post‑maxillectomy hollow, the length of the catheter to be inserted can be assessed approximately by finding it on the opposite normal nostril. Besides, though in these conditions, the bone is removed, the middle turbinate behind which the ganglion is situated is normally left intact. We usually assume the end‑point to have been reached after this length has been passed though checking the position with dye spread could be confirmatory. The patient is then turned so as to make the side to be blocked dependant. The patient is instructed to indicate any bitter taste of local anesthetic reaching the throat by raising a finger whereupon the performer can withhold further injection for some time. The medication (local anesthetic [0.5 ml of Lignocaine hydrochloride {Loxicard 2% NEON} + steroid [1 ml of Betamethasone {Betnesol 4 mg/ml, GLAXO}]) is given in very slow titration—0.1 ml per minute per aliquot with a 2 ml syringe because when used in head and neck cancer patients with post‑radiation fibrosis and secretions/infection, the absorption is slow and erratic. The slow administration also avoids trickling of the local anesthesia (LA) to the naso and oropharynx as well as anesthetizing it and blocking the swallowing reflex which is very uncomfortable to the patients. Moreover, 0.5 ml of 2% Lignocaine hydrochloride is injected first at the rate mentioned; after 10 minutes elapses, 1.0 ml of Betamethasone is injected at the same
Indian Journal of Palliative Care / Sep-Dec 2015 / Vol 21 / Issue 3
rate; at the end of the injection of this volume, 0.5 ml of Lignocaine hydrochloride is pushed to remove the steroid remaining in the dead space of the catheter which is about 0.3 ml when the filter is not attached. This method of spaced administration increases the surface area as well as the rate and amount of absorption. The position of the catheter tip can be easily maintained to optimize the drug delivery. Tearing (lacrimation) of the eye on the blocked side is a reliable sign of successful blockade as is the pain relief. The use of the catheter is simple, safe, and inexpensive; use of the 20‑guage catheter that is designed for 18‑gauge needle reduces incidence of mechanical trauma as well as ensures site‑specific controlled delivery of the drug. The three “eyes” situated at 0.5 cm intervals at the proximal end of the catheter serves to spray the drug in different directions, thereby covering wider surface area of the mucosa over the ganglion.
Renuka Pai, Lakshmi Vas Ashirvad Institute for Pain Management and Research, Mumbai, Maharashtra, India
Address for correspondence: Dr. Lakshmi Vas, E‑mail:
[email protected]
REFERENCES 1.
Waldman SD. Atlas of Interventional Pain Management. 3rd ed. Philadelphia: Saunders Elsevier; 2009. p. 12‑14. 2. Raj PP, Lou Leland, Erdine S, Staats PS, Waldman SD, Racz G, et al. Interventional Pain Management. Image‑Guided Procedures. 2nd ed. Philadelphia: Saunders Elsevier; 2008. p. 108‑15. 3. Windsor RE, Jahnke S. Sphenopalatine ganglion blockade: A review and proposed modification of the transnasal technique. Pain Physician 2004;7:283‑6. 4. Candido KD, Massey ST, Sauer R, Darabad RR, Knezevic NN. A novel revision to the classical transnasal topical sphenopalatine ganglion block for the treatment of headache and facial pain. Pain Physician 2013;16:E769‑78. 5. Varghese BT, Koshy RC. Endoscopic transnasal neurolytic sphenopalatine ganglion block for head and neck cancer pain. J Laryngol Otol 2001;115:385‑7. 6. Varghese G, Murthy P. Medical education: Nasal endoscope and you. Indian J Otolaryngol Head Neck Surg 1999;51:84‑9.
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DOI: 10.4103/0973-1075.164885
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