http://sipc.me/

1. Radiofrequency for Chronic
Visceral Pain
David Pang
Consultant in Pain Management
St Thomas’ Hospital
London

2. 44 year old Female
Long history of chronic
abdominal pain since
mid 2010
Pain is predominantly
upper epigastric; worst
on the right side
Multiple analgesic
treatments

3. ULTRASOUND AND CT REVEALS BILE DUCT DILATATION
HIDA SCAN SHOWS HOLD UP OF TRACER
ERCP WAS NOT DONE DUE TO THE RISK OF ACUTE PANCREATITIS
SECRETIN MRCP SHOWED MILD BILE DUCT DILATATION BUT NO
RESPONSE TO SECRETIN
SHE DESCRIBED SEVERE PAIN AFTER SECRETIN AND THIS REQUIRED
A FURTHER HOSPITAL ATTENDANCE

4. A PROVISIONAL DIAGNOSIS OF SPHINCTER
OF ODDI DYSFUNCTION WAS MADE

5. The pain itself
EPISODIC; AGGRAVATED
BY FATTY FOODS
CRAMP LIKE IN NATURE
CAN LAST WEEKS AND
SEVERITY IS 10/10 ON
THE NRS SCALE

6. PAST MEDICAL HISTORY
IRRITABLE BOWEL SYNDROME
LAP CHOLECYSTECTOMY IN 2008
APPENDICETOMY
SMOKES 15-20 PER DAY

7. EXAMINATION IS
UNREMARKABLE
VERY MILD
TENDERNESS AT
THE EPIGASTRIC
AREA
CARNETT’S SIGN
NEGATIVE

8. SHE WAS GIVEN GTN, NIFEDIPINE AND INCREASING DOSES OF
MORPHINE SULPHATE
GABAPENTIN 600MG TDS
HER BASELINE LONG ACTING MORPHINE WAS 40MG DAILY BUT
SHE REQUIRED UP TO 2 HOURLY
DURING FLARE UPS SHE CAN TAKE UP TO 260MG MORPHINE
DAILY
SHE HAS MULTIPLE ATTENDANCES TO HOSPITAL

9. • IT AFFECTS 7.8 MILLION PEOPLE IN THE UK
• 4.6 MILLION GP APPOINTMENTS PER YEAR
• IT IS RESPONSIBLE FOR A HIGH LEVEL OF DISABILITY AND MEDICAL
INPUT
• 10TH MOST COMMON CAUSE OF HOSPITAL ADMISSION IN MEN, 6TH IN
WOMEN
• UP TO 25% OF THE POPULATION WILL REPORT ABDOMINAL PAIN AT
ANY ONE TIME
• Halder SL, McBeth J, Silman AJ, Thompson DG, Macfarlane GJ. Psychosocial risk factors for the onset of
abdominal pain. Results from a large prospective population-based study. Int J Epidemiol
2002;31:1219–25.
About patients with chronic pain

10. • 1 IN 5 WILL CONSULT THEIR DOCTOR IN THE
COMMUNITY
• UP TO 67% OF CONSECUTIVE SURGICAL
ADMISSIONS ARE DUE TO NONSPECIFIC
ABDOMINAL PAIN
• Sandler RS et al. Abdominal pain, bloating, and diarrhea in the
United States: prevalence and impact. Dig Dis Sci 2000;
45(6):1166.
Chronic abdominal pain

11. • ESTIMATED A COST OF £100 MILLION EVERY YEAR
TO THE NHS
• US: $16.6 BILLION YEARLY
• EUROPE: €28.4 BILLION
• 25% WILL LOSE THEIR JOBS AS A RESULT
• Shih YC, Barghout VE, Sandler RS, Jhingran P, Sasane M, Cook S, Gibbons DC, Halpern M.
Resource utilization associated with irritable bowel syndrome in the United States 1987–
1997. Dig Dis Sci 2002;47:1705–15
•
based study. Scand J Gastroenterol 2010;45:582–91.

12. UNLIKE SOMATIC PAIN VISCERAL PAIN IS DIFFUSE AND PATHWAYS
PROJECT TO MULTIPLE LEVELS
THE PROPORTION OF FIBERS IS LOWER COMPARED TO SOMATIC
THE PAIN RESPONSE IS LIMITED COMPARED TO THE POLYMODAL
SOMATIC RESPONSE
SOMATOSENSORY CORTEX IS POOR AT DIFFERENTIATING THE
SOURCE OF PAIN
Physiology of chronic abdominal pain

15. KEY FEATURES OF CHRONIC VISCERAL PAIN:
DIFFUSE, VAGUE LOCALISATION
ASSOCIATED EMOTIONAL AND AUTONOMIC FEATURES
UNRELIABLE ASSOCIATION WITH PATHOLOGY
REFERRED PAIN
SHARPER
LESS EMOTIONAL AND AUTONOMIC SYMPTOMS
SOMATIC HYPERALGESIA
What does this mean?

22. HEALTHY TISSUE EVOKE MINIMAL SENSATIONS
ACUTE INFLAMMATION IS LIKELY TO PRODUCE PAINFUL
SENSATIONS
CHRONIC INFLAMMATION IS UNPREDICTABLE
MANY AFFERENT NEURONES ARE SILENT AND ONLY RESPOND IN
THE PRESENCE OF PATHOLOGY
Unreliable Visceral sensations

23. LOCALIZATION OF THE SITE OF PAIN GENERATION TO
SOMATIC TISSUES WITH NOCICEPTIVE PROCESSING AT
THE SAME SPINAL SEGMENTS
ARM PAIN IN CARDIAC DISEASE
SENSITISATION OF SOMATIC TISSUES
E.G KIDNEY STONES CAUSING LOIN MUSCLE
TENDERNESS
Referred pain

24. Viscero-Somatic convergence
• CONVERGENCE OF VISCERAL AND
SOMATIC AFFERENT FIBERS
• MISINTERPRETATION BY HIGHER
BRAIN CENTERS
• OCCURS WITHIN MINUTES TO
HOURS
• PAIN IS REFERRED TO BODY WALL
• SHARPER, BETTER LOCALIZED
• VERY SIMILAR TO PAIN OF DEEP
SOMATIC ORIGIN

25. Visceral Hypersensitivity
• UNCONTROLLED VISCERAL PAIN CAN LEAD TO
VISCERAL HYPERALGESIA,
• AN INCREASED SENSITIVITY TO VISCERAL
STIMULATION FOLLOWING AN INJURY OR
INFLAMMATION OF AN INTERNAL ORGAN.
• THE INCREASED SENSITIVITY OF THE VISCERA
AFTER INFLAMMATION HAS TWO CAUSES:
– AN ALTERATION OF THE
SENSORY NEURONS IN THE
VISCERA SO THAT THEY NOW
RESPOND MORE INTENSELY TO
NATURALLY OCCURRING
STIMULI (PERIPHERAL
SENSITIZATION)
– AN ENHANCED SENSITIVITY
OF THE SENSORY PATHWAYS
IN THE BRAIN THAT MEDIATE
SENSATIONS FROM THE
VISCERA (CENTRAL
SENSITIZATION).

26. Central Sensitisation
COMMON
PHENOMENON IN
CHRONIC SOMATIC
PAIN
MEDIATED BY
NMDA AND PGE2

27. Viscerovisceral Hyperalgesia
• AUGMENTATION OF PAIN DUE
TO SENSORY INTERACTION
BETWEEN TWO INTERNAL
ORGANS THAT SHARE
AFFERENT CIRCUITRY
• CORONARY HEART DISEASE AND
BILIARY CALCULOSIS
• OVERLAPPING T5 AFFERENT PATHWAYS
• MORE FREQUENT ANGINA AND BILIARY COLIC
ATTACKS
• DYSMENORRHEA AND IBS
• MORE FREQUENT & INTENSE MENSTRUAL
PAIN, INTESTINAL PAIN & REFERRED
ABDOMINO-PELVIC HYPERALGESIA
• DYSMENORRHEA,
ENDOMETRIOSIS & URINARY
STONES
• URINARY CALCULOSIS PAIN IS WORSE IN
WOMEN WITH A LATENT SILENT PELVIC
CONDITION E.G ENDOMETRIOSIS
• MORE INTENSE MENSTRUAL PAIN, URINARY
COLIC PAIN & REFERRED ABDOMINAL/LUMBAR
HYPERALGESIA

28. Neuromodulatory Processes of the Brain–Gut Axis
Neuromodulation: Technology at the Neural Interface
Volume 11, Issue 4, pages 249-259, 9 OCT 2008 DOI: 10.1111/j.1525-1403.2008.00172.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1403.2008.00172.x/full#f1
INFLAMMATION-GUT
UPREGULATION- DORSAL
HORN
STRESS- BRAIN

29. Psychologic
al
intervention
Education
Physical
Therapies
Pain relief
Principles of pain management

30. Interventional Pain Therapy
• ABDOMINAL WALL BLOCKS
• UP TO 10% OF ALL
ABDOMINAL PAIN IS DUE
TO THE ABDOMINAL
WALL ITSELF
• Srinivassan R, Greenbaum DS. Chronic
abdominal wall pain: A frequently
overlooked problem. A practical approach to
diagnosis and management. Am J Gas-
troenterol 2002;97(4):824–30.
hand-splinting the affected area. Patients may identify spe-
cific circumstances that precipitate or aggravate pain, such
as standing, lifting, walking, stretching, laughing, coughing,
or sneezing. Nausea, bloating, overeating, menstruation, and
urinary bladder distension have also been implicated, pos-
sibly by accentuating nerve entrapment because of associ-
ated vascular congestion (3). Oral contraceptives and preg-
nancy have also been reported to accentuate abdominal wall
pain as well as other entrapment syndromes, perhaps from
tissue edema due to estrogen and progesterone (8, 25).
Characteristically a localized site of maximum tenderness
is identified with the patient in the supine position. This may
be at or close to a surgical scar, or in its absence, tenderness
is most often at the lateral edge of the rectus abdominis, the
linea semilunaris. However, the tenderness may be any-
Table 3. Abdominal Wall Pain Diagnostic Criteria
Very localized pain
(most intense component can be covered by fingertip)
or
Fixed location of tenderness
AND
Superficial tenderness
(depth of rectus abdominis)
or
Point tenderness of 2.5 cm in diameter
or
Increased point tenderness with abdominal wall muscle tensing
(positive Carnett test)
827AJG– April, 2002 Chronic Abdominal Wall Pain

31. Diagnosis of chronic abdominal wall pain
SHARP, LOCALISED
PAIN
PAINFUL PALPATION
ON TENSING
ABDOMINAL
MUSCLES

32. 97% SENSITIVITY
85% SPECIFICITY
INTER-RATER RELIABILITY 93%
Carnett’s test

33. THORACIC EPIDURAL
2-3 DERMATOMES
ABOVE LEVEL OF PAIN

34. CONCORDANT WITH
SENSORY BLOCK
RELIEF PROLONGED
AFTER SENSORY
BLOCK
NO PAIN RELIEF
DESPITE SENSORY
BLOCK
SOMATOSENSORY
VISCERAL
CENTRAL

35. THE RECTUS SHEATH

38. ‘‘ . . . FOLLOWING UP A POSITIVE CARNETT’S
SIGN WITH A SUCCESSFUL INJECTION OF
LOCAL ANESTHETIC MUST BE ONE OF THE
MOST COST EFFECTIVE PROCEDURES IN
GASTROENTEROLOGY’’
Sharpston D, Colin-Jones DG. Chronic, non-visceral abdominal pain. Gut 1994;
35:833.

39. COELIAC PLEXUS BLOCK
Visceral Sympathetic Blocks

40. Note the involvement of the dorsal columns in visceral pain

46. Targeting the Splanchnic Nerves

47. PREGANGLIONIC FIBERS FROM T5-T12 TRAVEL WITH THE VENTRAL ROOTS TO JOIN THE
WHITE COMMUNICATING RAMI, PASS THROUGH THE SYMPATHETIC CHAIN, AND
SYNAPSE ON THE CELIAC GANGLIA.
• THE GREATER, LESSER, AND LEAST SPLANCHNIC NERVES ARE THE MAJOR
PREGANGLIONIC OF THE CELIAC PLEXUS.
• THE GREATER SPLANCHNIC ORIGINATES FROM THE NERVE ROOTS OF T5-T10 AND
TRAVELS ALONG THE VERTEBRAL BODY, THROUGH THE CRUS OF THE DIAPHRAGM,
AND INTO THE IPSILATERAL CELIAC GANGLION.
• THE LESSER SPLANCHNIC NERVE ORIGINATES FROM THE T10/T11 NERVE ROOTS,
WHILE THE LEAST SPLANCHNIC NERVE ARISES FROM T10-T12; THESE ALSO TRAVEL
THROUGH THE DIAPHRAGM TO THE IPSILATERAL CELIAC GANGLION

48. Origin Nerve Plexus Viscera
T5-9 Greater Splanchnic
Nerve
Coeliac Gastric;Sphincters;
Gallbladder,
Pancreas
T9-11 Lesser Splanchnic
Nerve
Coeliac Small intestine
T12-L1 Least Splanchnic
Nerve
Lumbar
Sympathetic
Coeliac Renal
T12-L1 Least Splanchnic
Nerve
Lumbar
Sympathetic
Superior
Mesenteric
Proximal colon
T10-L3 Lesser and Least
Splanchnic nerve
Paravertebral
Ganglia L1-4
Vasomotor lower
limb, erector pili
L1-2 Lumbar Splanchnic Inferior mesenteric,
Superior
hypogastric
Distal colon

51. FLOUROSCOPIC IMAGING
PLACE THE PATIENT IN A PRONE POSITION
WITH A PILLOW UNDER THE ABDOMEN
TO REDUCE SPINAL LORDOSIS
AP VIEW AND SLIGHT CAUDAL
ANGULATION TO SQUARE THE INFERIOR
ENDPLATE AT T11/12
ANGLE THE C-ARM 5-10 DEGREES
IPSILATERAL
IDENTIFY THE ANGLE BETWEEN THE
BORDER OF THE VERTEBRAL BODY AND
TRANSVERSE PROCESS

52. THE SKIN ENTRY POINT IS AT THE
LATERAL BORDER OF THE
VERTEBRAL BODY AND THE
LOWER BORDER OF THE
TRANSVERSE PROCESS. THE
AIM IS TO PLACE THE NEEDLE
AT THE SPLANCHNIC NERVES
AT T11 AND T12 TO COVER THE
THREE BRANCHES.

53. FREQUENT INTERMITTENT
FLUOROSCOPY IS
MANDATORY TO AVOID
EXCESSIVE LATERAL
ANGULATION WHICH
MAY LEAD TO
PNEUMOTHORAX. AIM
FOR BONY CONTACT
WITH THE VERTEBRAL
BODY.

58. IF A DIAGNOSTIC BLOCK IS TO BE PERFORMED THEN 5 ML OF 0.5%
BUPIVACAINE IS INJECTED AFTER SATISFACTORY CONTRAST
PATTERN.
FOR RADIOFREQUENCY, SENSORY TESTING AT 50Hz WITH STIMULATION
IN THE EPIGASTRIC AREA CONFIRMS CORRECT NEEDLE PLACEMENT.
INJECT LOCAL ANAESTHETIC AND RF FOR 90 SECONDS AT 80°. TURN THE
NEEDLE 180° FOR A SECOND LESION.
LESIONS MUST BE DONE AT BOTH T11 AND T12. ONCE ONE SIDE IS DONE
THE SECOND SIDE IS DONE AT ANOTHER SESSION.

59. PNEUMOTHORAX
NERVE ROOT INJURY
CHYLOTHORAX
SPINAL CORD ISCHAEMIA
Complications

60. Radiofrequency Lesioning of Splanchnic Nerves
Good to excellent results in 50-70%

65. Percutaneous Radiofrequency Ablation of the Splanchnic Nerves in Patients with Chronic
Pancreatitis: Results of Single and Repeated Procedures in 11 Patients
Pain Practice
10 JAN 2013 DOI: 10.1111/papr.12030
http://onlinelibrary.wiley.com/doi/10.1111/papr.12030/full#papr12030-fig-0003

66. VISCERAL PAIN A SIGNIFICANT CAUSE OF
CHRONIC PAIN
NOT ALL ABDOMINAL PAIN IS VISCERAL IN ORIGIN
DIAGNOSTIC BLOCKS USEFUL TO DIFFERENTIATE
VISCERAL AND SOMATIC PAIN
RADIOFREQUENCY CAN GIVE LONG TERM RELIEF
IN SELECTED PATIENTS
Summary