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LETTERS TO EDITOR
Year : 2021  |  Volume : 22  |  Issue : 2  |  Page : 197-198
 

Radiofrequency ablation of stellate ganglion for neuropathic pain due to brachial plexus neurofibroma in a patient with neurofibromatosis type 1


1 Department of Anesthesiology and Pain Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
2 Department of Anesthesiology and Pain Medicine, Sree Balaji Medical College and Hospital, BIHER, Chennai, Tamil Nadu, India

Date of Submission25-Mar-2021
Date of Decision14-Apr-2021
Date of Acceptance29-May-2021
Date of Web Publication29-Sep-2021

Correspondence Address:
Prof. M S Raghuraman
Department of Anesthesiology and Pain Medicine, Sree Balaji Medical College and Hospital, BIHER, #7, Works Road, New Colony, Chromepet. Chennai - 600 044, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_45_21

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How to cite this article:
Murugesan A, Raghuraman M S, Krishnagopal V. Radiofrequency ablation of stellate ganglion for neuropathic pain due to brachial plexus neurofibroma in a patient with neurofibromatosis type 1. Indian Anaesth Forum 2021;22:197-8

How to cite this URL:
Murugesan A, Raghuraman M S, Krishnagopal V. Radiofrequency ablation of stellate ganglion for neuropathic pain due to brachial plexus neurofibroma in a patient with neurofibromatosis type 1. Indian Anaesth Forum [serial online] 2021 [cited 2021 Dec 7];22:197-8. Available from: http://www.theiaforum.org/text.asp?2021/22/2/197/326979




Sir,

Peripheral nerve sheath tumors (PNSTs) in patients with neurofibromatosis (NF) involving various sites of the body including the brachial plexus have been reported in the past.[1] Although gross total resection is the primary treatment performed for symptomatic PNSTs,[1] some cases would require other modalities such as percutaneous radiofrequency ablation (RFA) to remove the tumor.[2] Because of the fear of neurological sequelae such as permanent sensory or motor deficits during excision, some patients prefer pain relief procedures only. RFA or pulsed radiofrequency (PRF) of the stellate ganglion (SG) is one of the commonly performed procedures to provide relief from chronic pain due to various neuropathies of upper extremities.[3] However, to our knowledge, no case has been reported for its application in neuropathy due to a neurofibroma of the brachial plexus. Here, we present case management of painful brachial plexus neurofibroma with NF-1 treated by RFA of the SG and a continuous infusion of ropivacaine and ketamine through an infraclavicular brachial plexus catheter.

A 31-year-old woman presented to the pain clinic with pain in the left axilla radiating down the medial aspect of the arm, forearm to the middle, ring, and little finger of the left hand for the past 20 years. The pain was progressing in the last 6 months despite medications. She was unwilling for surgical excision of the lesion offered by the concerned specialists and hence referred to us for interventional pain management. As the patient was having unbearable pain, we performed a diagnostic ultrasound and found a small mass along the medial cord of the left brachial plexus [Figure 1].
Figure 1: Diagnostic ultrasound showing a small mass along the medial cord of the left brachial plexus

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She was given a diagnostic left-sided SG block using 8 ml of 2% preservative-free lignocaine under ultrasound guidance. The pain score has come down to visual analog scale (VAS) 0/10 from 6/10. After 2 h, the pain score remained 0/10 and RFA of SG was initiated under ultrasound guidance, at the C6 level, using a 20-gauge 10-mm active tip needle by in-plane technique. Following confirmation of the needle position [Figure 2] by sensory stimulation with 50 Hz at 0.3–0.5 V and motor stimulation using 2 Hz at 0.9–1.5 V, RFA of SG was done with the conventional mode at 80° centigrade for 3 cycles of each 60 s. Subsequently, the left infraclavicular brachial plexus catheter was placed using ultrasound guidance and a bolus of 15 ml of 0.2% ropivacaine and 0.5 mcg/kg of clonidine was given followed by 3 ml/h infusion of drug mixture containing 0.2% ropivacaine and 1 mg/kg ketamine (in 50 ml syringe) for 24 h. The patient pain score decreased to VAS 0/10 and discharged after 24 h. She was advised to take tablet paracetamol 1 g twice daily for 5 days and capsule pregabalin 75 mg twice daily for 1 month. The pain score remained VAS 0–1/10 and we started tapering the pain medications gradually after 1 month. The patient developed Horner's syndrome after the procedure and was persistent until the last follow-up at 2 months for which she was reassured.
Figure 2: Needle trajectory and final position of the tip of the needle at stellate ganglion

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RFA or PRF has been applied for various chronic pain conditions.[3] However, to date, no literature is available regarding the application of RFA of SG for a brachial plexus tumor. We have chosen the conventional RFA (also known as continuous radio frequency) instead of PRF because RFA would provide longer pain relief, although it is controversial as different studies have observed varying results on the long-term effects of RFA versus PRF.[3] We have also provided a continuous brachial plexus block for 24 h to provide an immediate pain relief and a mixture of drugs was used as it would provide a better quality of pain relief with lesser side effects. The infusion rate for perineural ropivacaine 0.2% is usually about 4–8 ml/h for postsurgical pain.[4] Therefore, we administered infusion at 3 ml/h for chronic pain condition, a dose which is slightly lesser than advocated for postoperative pain. We also prefer a bolus dose of 15 ml here, in contrast to 20 ml or more (in higher concentration too) used for surgical anesthesia. Also, ketamine was added as it has been proven to be useful in diverse chronic neuropathic pain conditions.[5]

To conclude, RFA of SG may be an alternative approach to manage chronic pain due to a neurofibroma sitting over the brachial plexus. It also avoids potential complications such as sensory and motor deficits.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Guha D, Davidson B, Nadi M, Alotaibi NM, Fehlings MG, Gentili F, et al. Management of peripheral nerve sheath tumors: 17 years of experience at Toronto Western Hospital. J Neurosurg 2018;128:1226-34.  Back to cited text no. 1
    
2.
Mrowczynski O, Mau C, Nguyen DT, Sarwani N, Rizk E, Harbaugh K. Percutaneous radiofrequency ablation for the treatment of peripheral nerve sheath tumors: A case report and review of the literature. Cureus 2018;10:e2534.  Back to cited text no. 2
    
3.
Zacharias NA, Karri J, Garcia C, Lachman LK, Abd-Elsayed A. Interventional radiofrequency treatment for the sympathetic nervous system: A review article. Pain Ther 2021;10:115-41.  Back to cited text no. 3
    
4.
Ilfeld BM, Morey TE, Wright TW, Chidgey LK, Enneking FK. Interscalene perineural ropivacaine infusion: A comparison of two dosing regimens for postoperative analgesia. Reg Anesth Pain Med 2004;29:9-16.  Back to cited text no. 4
    
5.
Culp C, Kim HK, Abdi S. Ketamine use for cancer and chronic pain management. Front Pharmacol 2020;11:599721.  Back to cited text no. 5
    


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