CRPS: Stellate Ganglion Blockade v. Radiofrequency Neurolysis

CT-guided stellate ganglion blockade vs. radiofrequency neurolysis in the management of refractory type I complex regional pain syndrome of the upper limb

Adrian Kastler, Sébastien Aubry, Nicolas Sailley, Demosthene Michalakis, Gaye Siliman, Guillaume Gory, Jean-Louis Lajoie and Bruno Kastler



EUROPEAN RADIOLOGY
2012, DOI: 10.1007/s00330-012-2704-y

Leonardo da Vinci: Vitruvian Man

Abstract

Objective
To describe and evaluate the feasibility and efficacy of CT-guided radiofrequency neurolysis (RFN) vs. local blockade of the stellate ganglion in the management of chronic refractory type I complex regional pain syndrome (CRPS) of the upper limb.

Methods
Sixty-seven patients were included in this retrospective study between 2000 and 2011. All suffered from chronic upper limb type I CRPS refractory to conventional pain therapies. Thirty-three patients underwent stellate ganglion blockade and 34 benefited from radiofrequency neurolysis of the stellate ganglion. CT guidance was used in both groups. The procedure was considered effective when pain relief was ≥50 %, lasting for at least 2 years.

Results
Thirty-nine women (58.2 %) and 28 men (41.8 %) with a mean age of 49.5 years were included in the study. Univariate analysis performed on the blockade and RFN groups showed a significantly (P < 0.0001) higher success rate in the RFN group (67.6 %, 23/34) compared with the blockade group (21.2 %, 7/33) with an odds ratio of 7.76.

Conclusion  
CT-guided radiofrequency neurolysis of the stellate ganglion is a safe and successful treatment of chronic refractory type I CRPS of the upper limb. It appears to be more effective than stellate ganglion blockade.

Key Points  
• Complex regional pain syndrome is painful, disabling and often refractory to treatment.
• Sixty-seven percent of patients had lasting pain relief (2 years) after radiofrequency neurolysis.
• Retrospective study showed a significantly higher success rate for radiofrequency neurolysis.
• CT guidance is mandatory for a successful and safe procedure.


ABOUT THE AUTHORS

Authors

• Adrian Kastler(136)adriankastler@gmail.com
• Sébastien Aubry(23)
• Nicolas Sailley(2)
• Demosthene Michalakis(2)
• Gaye Siliman(4)
• Guillaume Gory(3)
• Jean-Louis Lajoie(5)
• Bruno Kastler(23)

Author Affiliations

1. Radiology Department, University Hospital CHU Gabriel Montpied, 63000 Clermont-Ferrand, France
2. Radiology and Interventional Pain Unit, University Hospital CHU Jean Minjoz, Besancon, France
3. I4S Laboratory-EA 4268-IFR 133, Franche Comté University, Besancon, France
4. Clinical Investigation Center, University Hospital CHU St Jacques, Besancon, France
5. Pain evaluation and Management Unit, University Hospital CHU Jean Minjoz, Besancon, France
6. Hôpital Gabriel Montpied, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000 Clermont-Ferrand, France

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Articles and abstracts that may also be of interest:

Interventional Therapies, Allen W. Burton, MD

CRPS and Sympathectomy

Paresthesiae During Radiofrequency Neurolysis of Lumbar Sympathetic Trunk in CRPS: Human Evidence of a Sympatho-Sensory Connection?


Management of Lower Limb Complex Regional Pain
Syndrome Type 1: An Evaluation of Percutaneous
Radiofrequency Thermal Lumbar Sympathectomy Versus
Phenol Lumbar Sympathetic Neurolysis—A Pilot Study


Haynsworth RF, Noe CE. Percutaneous lumbar sympathectomy: a comparison of Radiofrequency denervation versus phenol neurolysis. 

Evidence-based interventional pain medicine according to clinical diagnoses. 16. Complex regional pain syndrome.

Cervico-thoracic or lumbar sympathectomy for neuropathic pain and complex regional pain syndrome.

Indications and Technique of Thoracic(2) and Thoracic(3 )Neurolysis.

My Leftist Easy Answers... USAmerica Can No Longer Afford to Be Stupid

I can do nothing but write honestly this morning.  Part of that is that my computer demands it.  My S-key and my T-key are sticking, a plot to make me slow down.

Listening to "Up With Chris (Hayes)" as I was trying to convince myself that getting out of the bed that I had just urinated on was worth it, there came a segment on the "current" heightening of conflict between Israel and Gaza.  I was quickly reminded of how dumb-downed I've allowed myself to become, not just on this topic -- but on most topics.

I've gotten by as an academic by choosing sides, which makes any even mildly querulous arguments easy.  The stalking away from the fine wooden table, covered with coffee cups or long-necked beer bottles, the sardonic smile, the "I would expect no more, no less of an argument from you,"  the cutting last word.  That stuff.

Never trust an academic -- even one purportedly limited to the teaching of a foreign language and its culture, history, literature -- who has not spent much time in the targeted countries where that language lives.  And trust most those who make it a point to return yearly, or as often as conditions will allow.  "Conditions" meaning states of war, states of peace, visa availability, and a salary that encourages travel, meaning, of course, a university unafraid of the results.  I am thinking of several of my friends, world-class [insert a Ross Perot twang] academics driven by... what was that thing I used to have?  Started with a P. Ah.  Passion.  And underneath the passion?  Love of common humankind.

They're delusional, of course, but they are also the only thing we've got going on, beyond short TV segments aimed at their already established partisanship.  Maybe 2 out of a class of 30 will "get it," and one prays that both of those students are gregarious, insightful, maybe future teachers, themselves.

Who can "explain" -- in language that does not cause hair to bristle and the heart harden, the head freeze -- the conflict between the Palestinian people (in Gaza and their other vast land holdings) and the country of Israel?  People who don't dumb it down, people who can present the history with most of its nuance intact.

How do USAmericans, who have trouble remembering their own history in its varied and various contexts, approach this tragic neighborhood without choosing to be dumbed down?  Look at what the extreme wings of our two pitiful political parties choose to claim to believe -- ridiculous, stupid, obviously untrue things.  With straight faces, Jindal -- an expert in medical management -- can approach the truth and still offer creationism an honored spot in the curriculum of Louisiana's children.  The left can defend Petraeus, defend the White House handling of the Benghazi terrorist assassinations, and deny a blatant threat to national security on the part of the CIA.

I am an extremist, except when I am not.  I believe that my socialist beliefs are very comfortable here, because they have no chance at messy realization.  I have also become intellectually lazy, which make extremism the easiest route to take when wanting to look and sound... well, you know.

Part of the terror is how urban this continual war is.  How the Gazans have no where to go, how Israel controls even the water, much less whether a person can walk freely from here to there.  Yet politician Netanyahu is right -- were 1/5 of any country being bombarded by rockets, no matter how weak, no matter the Iron Dome, that country necessarily defend itself.

But don't you wish to cry out:  But no matter the history?  No matter that Israel's most recent extrajudicial execution of a Hamas leader was the killing of Netanyahu's only real partner in de-escalating the rocket attacks?

Does none of it matter when Israel gets ready to mow the grass?

Israeli hardliners joke about the periodic need to decimate each new generation of Palestinian militants as “mowing the grass,” a process underway again in new bombardments of Gaza. This ugly metaphor has also penetrated the think-tank world of Official Washington, as ex-CIA analyst Elizabeth Murray learned. 

In early 2010, one of Washington DC’s most prestigious think tanks was holding a seminar on the Middle East which included a discussion of Israel’s December 2008-January 2009 assault on Gaza which killed about 1,300 Palestinians. When the death toll was mentioned, one expert on the panel smiled enigmatically and intoned: “It’s unfortunate, but every once in a while you have to mow the lawn.” 

The remark, which likened killing hundreds of men, women and children – many of them noncombatants – with trimming the grass, was greeted with a light tittering around the room, which was filled with some of Washington’s most elite, highly educated and well-paid Middle East experts. Not a single one objected to the panelist’s black humor. 

On the contrary, several analysts and experts were grinning at the reference to Israel’s strategy of mounting periodic attacks on the Palestinians to cull each new generation of militants. Such is the nonchalance of Washington’s policy-advising cognoscenti toward the ongoing and systematic genocide of Gaza’s oppressed population. 

The cavalier language is symptomatic of the policymaking community’s increasingly pervasive tendency to disregard and disparage the humanity of Palestinian victims of Israeli attacks, which are often waged by Israel’s high-tech drones and U.S.-supplied F-16’s. There is also a tendency to ignore or downplay Israeli war crimes. 

This dangerously sociopathic attitude is prevalent whether cloaked in a cheap joke or reflected in the failure by the State Department spokesman to condemn or even acknowledge the criminality of Israel’s latest aerial and sea-based bombardment of Palestinian civilians, at least 18 of whom have been killed in the past 48 hours. Three Israelis also have died in retaliatory rocket fire. 

After the latest attacks, the State Department’s statement justified Israel’s bombardment of Gaza as Israel’s “right to defend itself” against the launching of relatively primitive rockets, mostly by radical groups, from inside Gaza. Yet, while the State Department urged both sides to avoid civilian casualties, nowhere was there mention of the Palestinians’ right to defend themselves from various attacks by Israel. Apparently only one side is granted that privilege, according to the U.S. statement. 

The relegation of Palestinians to a less-than-human status by Israel and the United States – especially the inhabitants of Gaza who are perpetually locked into an open-air prison and subject to an Israeli blockade – was noted by MIT professor Noam Chomsky after a visit to Gaza to attend an academic conference. In comments broadcast by “Democracy Now” on Nov. 14, Chomsky remarked: 

“It’s kind of amazing … and inspiring to see people managing somehow to survive … as essentially caged animals subject to constant, random, sadistic punishment – only to humiliate them – no pretext. They [the Palestinians] would like to have dignified lives, but the standard Israeli position is that they shouldn’t raise their heads.” 

Instead of a serious effort to reach a peace acceptable to both sides, Israel seems to prefer a state of endless conflict with the Palestinians. After all, the prospect of peace might require the Israeli government to treat their neighbors as equals and withdraw from territory occupied since 1967. 

So, rather than making meaningful concessions, some Israeli hardliners simply promote the idea of periodically “mowing the grass,” i.e. killing the latest generation of Palestinian militants who sprout up from the injustice all around them. Perhaps that is why Israel broke an informal ceasefire on Wednesday by assassinating Hamas military commander Ahmed Jabari in an air strike. -- from "Likening Palestinians to Blades of Grass," Saturday, 17 November 2012 10:59
By Elizabeth Murray, Consortium News | News Analysis from Truth-Out.org

Anyway, I do have opinions on this matter but am blessed not to be living smack-dab in the middle of the facts.  Half of the population of Gaza in under 18.  The Israelis are surrounded by governments and tribes that wish for its annihilation.  Gaza is a concentration camp.  Israel is trapped by long history, as well as the short view.

A rocket is a rocket is a rocket.  An air strike is an air strike is an air strike.  But what is a drone?

I'm sorry, but I am tired now.  And I think of those who have never had that luxury.  Later, I'll come back and, hopefully, add the segments from the Chris Hayes show that woke a small part of my atrophied brain and challenged my nose-in-the-air leftist easy answers.

Visit NBCNews.com for breaking news, world news, and news about the economy

Visit NBCNews.com for breaking news, world news, and news about the economy

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joey ran his race:::joey flew away!

from joey keller's dad, news that i find relieving, news that is bitter to no end for dad nick and mom elizabeth:

Joey finally met in person (face to face) the person he's loved, trusted, admired, talked to, talked about, and worshiped for years, Jesus, tonight, at 9:35p. Buddy, you loved that song, I'll fly away....you beat me there. Which is not the way it's supposed to be. I will be there soon. I never knew I could love someone like I loved you, son. My heart will be broken until I see you again. You are awesome. I told you often how much I loved you and thought of you. I can only hope to run a race as strong, and focused, and effective as you. In spiritual terms, I look up to you. I love you and am a fractured, torn up person without you. I'll never be right. But I will see you soon. One more time, "Dad thinks you are awesome! You make me happy! I am so proud of you." I'm coming buddy. Pray for me.

Some glad morning when this life is o'er, 

I'll fly away; 

To a home on God's celestial shore, 

I'll fly away (I'll fly away). 

I'll fly away, fly away, Oh Glory 

I'll fly away; (in the morning) 

When I die, Hallelujah, by and by, 

I'll fly away (I'll fly away). 

When the shadows of this life have gone, 

I'll fly away; 

Like a bird from prison bars has flown, 

I'll fly away (I'll fly away) 

I'll fly away, Oh Glory 

I'll fly away; (in the morning) 

When I die, Hallelujah, by and by, 

I'll fly away (I'll fly away). 

Oh. How glad and happy when we meet 

I'll fly away 

No more cold iron shackles on my feet 

I'll fly away 

I'll fly away, fly away Oh Glory 

I'll fly away; (in the morning) 

When I die Hallelujah, by and by 

I'll fly away. 

Just a few more weary days and then, 

I'll fly away; 

To a land where joy shall never end, 

I'll fly away (I'll fly away) 

I'll fly away, fly away Oh Glory 

I'll fly away; (in the morning) 

When I die, Hallelujah, by and by, 

I'll fly away (I'll fly away).