Malik, S; Kumar, N; Joshi, S1
Department of Pain and Palliative Care, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India
1Department of Pain and Palliative Care, Hospice, New Delhi, India
Address for correspondence: Dr. Sunny Malik, Department of Pain and Paliiative Care, Rajiv Gandhi Cancer Institute and Research Centre, Niti Bagh, New Delhi - 110 049, India. E-mail: [email protected]
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Superior hypogastric plexus block is the intervention of choice for the management of pain arising from pelvic organs. This minimally invasive pain and spine intervention (MIPSI) targets the superior hypogastric plexus, which lies retroperitoneally along with common and internal iliac vessels surrounding it. On lateral fluoroscopic view, the needle is seen lying just in front of the L5 vertebral body and contrast spreads just anterior to the vertebral body junction. Accidental embolization due to intra-arterial injection of particulate corticosteroid can lead to devastating complications like paraplegia/quadriplegia due to spinal cord infarction.[1] When nerve blocks are given for the management of cancer pain, a high degree of caution is warranted to prevent this complication as the process of neoangiogenesis is heightened,[2] and chances of encountering new blood vessels in the form of collaterals increase significantly in cancer.[3]
We wish to discuss our experience where a similar situation was encountered. A 65-year-old female, diagnosed with a case of carcinoma ovary with metastasis, was admitted with complaints of severe abdominal pain below the umbilicus. Radiological imaging showed omental deposits in the infraumbilical region close to the midline scar. On injection of contrast dye during SHGB, an upward and backward linear spread was seen along the anterolateral aspect of the vertebral bodies [Figure 1a]. Continuous fluoroscopy showed the vanishing of dye which confirmed the intravascular spread of contrast media. The needle was removed and reinserted to gain the correct access. As per the pattern of the contrast spread, the vessels encountered could be the middle sacral artery or the iliolumbar artery [Figure 1b], but since this is not the expected anatomical location of these vessels, we suspect neoangiogenesis as the cause for encountering a new vessel at the site of injection.
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Figure 1: (a) Fluoroscopic image of spread of contrast dye in an upward, backward linear spread fashion along the anterolateral aspect of the vertebral bodies. (b) Internal iliac artery and its branches
Neoangiogenesis is an important mechanism for the metastasis of tumors, and whenever a MIPSI is planned for pain control in such metastatic tumors, the chances of the formation of new vessels from the preexisting vasculature should always be taken into consideration for prevention and safety.
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