Table Of ContentBruno Kastler (Editor)
Interventional Radiology in Pain Treatment
Bruno Kastler
(Editor)
Fabrice-Guy Barral,Bernard Fergane,Philippe Pereira
(Co-editors)
Interventional
Radiology
in Pain Treatment
With contributions by
Hatem Boulahdour,Zakia Boulahdour,Philippe Brunner,Christophe Clair,
Alain Czorny,Pierre Delassus,Olivia Delmer,Vincent Dousset,Patrick Eude,
Blandine Kastler,Jean-Michel Lerais,Jean-François Litzler,Pierre-Yves Marcy,
Jean-George Rohmer,Philippe Sarlieve
Foreword by Georges Salamon
With 159 Figures in 369 Separate Illustrations
and 6 Tables
123
Kastler,Bruno
Professor of Radiology and Head of Radiology
Service de Radiologie A et C
Centre Hospitalier et Universitaire Jean-Minjoz
Boulevard Fleming
Director of Laboratoire d’Imagerie et d’Ingénierie pour la Santé
Université de Franche-Comté
Besançon,France
ISBN-10 3-540-24810-2 Springer Berlin Heidelberg New York
ISBN-13 978-3-540-24810-1 Springer Berlin Heidelberg New York
Library of Congress Control Number:2006925166
Title of the Original French Edition:
Radiologie interventionnelle dans le traitement de la douleur
© Masson,Paris,2003,2005
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I dedicate this book to
(cid:1) My children Tiphaine,Adrian and Florian
(cid:1) My beloved wife Blandine (psychiatrist who made a contribution to this book)
(cid:1) My parents Professor Daniel Kastler and Elisabeth Kastler Sander MD
(cid:1) Nora,Poppi,Michel,Martha,Lucien and Mark
(cid:1) My grandparents
(cid:1) The patients from our daily consultations,who we hope to modestly relieve from their suffering
with these techniques
(cid:1) All my collaborators who work with me in every day’s struggle
(cid:1) Professor Auguste Wachenheim who convinced me to complete my training in radiology
and tought me the basics in neuroradiology
(cid:1) Andia Hashemizadeh for her drawings
Foreword
It is a great honor to present this magnificent book that psychological and psychiatric approach to patients with
Prof.Kastler and coworkers have dedicated to different often-intractable pain.A special chapter is devoted to
modalities ofpain treatment with the help ofinterven- the metastasis ofbones.It is an important message for
tional radiology.Professor Kastler is a very well known every specialist in medicine or surgery to understand
French radiologist working at the University of Besan- that in the hands ofinterventional radiologists with the
con, who has exceptional training in both medicine collaboration ofmany other colleagues from pain ther-
(internal medicine/cardiology) and physics (M.Sc.).His apy, psychiatry, anesthesiology and from scientific
first textbook Understanding MRI was a great success imaging laboratories, pain–benign or intractable–can
(currently in its 6th edition) and was used by all be treated with exceptionally good results.I extend my
students and teachers working in the field ofMRI.This best wishes for the great success ofthis textbook dealing
volume,his third book (the second was titled MRI of with important developments in a field that has so many
Cardiovascular Malformations),is devoted to a fascinat- human implications.
ing field that Kastler has explored for 15 years.I remem-
ber the impact of his first presentations in this field,
when he was among the guest speakers at a meeting Los Angeles,4 May 2006
devoted to recent advances in radiology.
The reader will find all possibilities offered to pa- Georges Salamon M.D.
tients in different areas involving facial,cranial and ver- University of California at Los Angeles
tebral or paravertebral areas.But this book,written col- Department of Radiological Sciences
laboratively by numerous specialists,is not limited only Professor and Former Head of Neuroradiology
to the technical aspects ofthese different methods con- Centre Hospitalier Universitaire La Timone
cerning nerves or bones.Great attention is paid to the Marseille France
Preface
Pain,a biopsychosocial model,is by definition multifac- provide a response,one which they considered best for
torial. Its treatment requires complementary medical the patient who expresses his or her pain and whom
and paramedical skills.However,this fact was only able they listen to and believe.
to gain acceptance by the disruption of manifold cus- Radiologists were quick to take an active role in this
toms and attitudes within established organ medicine, approach. Cutting-edge technology has transformed
rooted in decades of tradition and whose undeniable them into more than just “image readers”, a role to
successes gave rise to a degree of immobility,thereby which they were often relegated in the past. Thanks to
guaranteeing and maintaining its power and territory. ultrasound scans,scanners and MRI,they began to play
Nonetheless attitudes are slowly changing.The French a role in fields that until then had been reserved to sur-
Ministry of Health for one,advised by pioneers in the geons and anaesthetists and have been able to make a
field,often hospital doctors,became alerted to the fact contribution to the fight against pain.
that pain is first and foremost a human predicament be- This work is the fruit ofthe faultless collaboration of
fore it is a social issue,and became intent on installing a two doctors, in which the radiologist has played the
new order.A pain control plan was established,backed major role, born out of their joint philosophical and
up by a series of university and hospital decisions:in- humanist beliefs and their unfailing friendship. This
troduction ofa specific module in the graduate medical book provides us with non-exhaustive insight into
studies reform,university diplomas and the setting up interventional radiological indications,indications pro-
of regional hospital pain management consultations, posed by therapists gathered together to study the files
units and evaluation centres. Such structures have and interviews ofpatients,who are provided with all the
drawn attention to the wide-ranging scope ofpain and necessary information.It is the proofthat medical deci-
its many components,the complexity ofunderstanding sions in the field ofpain control can no longer be made
pain, the difficulty of pain control from the patient’s by a single therapist,but must be the fruit ofa concert-
point of view and of relieving pain from the medical ed study by all concerned parties. This requires the
point of view. As a result of these consultations, the adoption ofa team spirit,the relinquishment ofmedical
notion of transversal skills and horizontal know-how power in terms of vertical disciplines,an open ear to
became apparent. everyone’s voice beginning with that ofthe patient,trust
Therefore,although some were reticent at the outset from start to finish and the burning desire to relieve suf-
and others enthusiastic,a variety of specialists met to fering from pain.
share their knowledge and confront their respective We are delighted that the success of the first edition
points of view and indications.Anaesthetists,radiolo- has made it possible to update this work only two years
gists, surgeons, physiotherapists, neurologists, house later with a second edition and now an English version.
physicians,psychiatrists and psychologists met together
in the pain evaluation and control centre to attempt to Bernard Fergane and Bruno Kastler
Contents
1 Evaluating and Managing Pain Pains Within the Context of a Factual Crisis 16
in a Pain Management Center . . . . . . 1 Reactional Depressions . . . . . . . . . . . 16
Bernard Fergane Pathologies ofBereavement . . . . . . . . 16
Post-Accident Pains . . . . . . . . . . . . . 17
Psychosomatic Approach to Pain . . . . . . 1
History . . . . . . . . . . . . . . . . . . . . 1 Pains Within the Context
Definition . . . . . . . . . . . . . . . . . . . 3 of a Progressive Worsening . . . . . . . . . 17
Psychological Signs ofPain . . . . . . . . . 3 Pain and Hysterical Neurosis . . . . . . . . 17
Pain and Identity . . . . . . . . . . . . . . 3 Pain and Hypochondria . . . . . . . . . . . 17
Pain and Speech:Moaning . . . . . . . . . 4 Pains and Somatization . . . . . . . . . . . 18
Meaning and Pain . . . . . . . . . . . . . . 5 Pain and Psychoses . . . . . . . . . . . . . 18
Pain Classification . . . . . . . . . . . . . . 5 Conclusion . . . . . . . . . . . . . . . . . . 18
Treatment . . . . . . . . . . . . . . . . . . . 6 Psychiatric Co-morbidity and Chronic Pains 19
Medicinal Treatment . . . . . . . . . . . . 6 Psychotherapeutic Treatment . . . . . . . . 19
A New Concept:Rotating Opioids . . . . . 8
Chemotherapeutic Treatment . . . . . . . . 20
Non-medicinal Therapies . . . . . . . . . . 8
Antidepressants and Pain . . . . . . . . . . 20
Pain Centers . . . . . . . . . . . . . . . . . 10 Neuroleptics and Pain . . . . . . . . . . . . 22
History ofPain Centers . . . . . . . . . . . 10 Tranquilizers and Pain . . . . . . . . . . . 22
Motivation . . . . . . . . . . . . . . . . . . 10 Hypnotics and Pain . . . . . . . . . . . . . 22
Pain Physicians . . . . . . . . . . . . . . . 10 Anticonvulsants and Pain . . . . . . . . . . 22
Possible Perverse Effects ofThese Centers 11
Sociotherapeutic Treatment . . . . . . . . . 22
A Government Plan . . . . . . . . . . . . . 12
References . . . . . . . . . . . . . . . . . . 23
Broadening the Set ofProblems . . . . . . 12
Conclusion . . . . . . . . . . . . . . . . . . 12
3 Computertomography-guided
References . . . . . . . . . . . . . . . . . . 12
Percutaneous Interventions
General Information,Tips and Hints
2 Pain and Psyche for Optimization of Guidance Techniques . . 25
Clinical and Therapeutic Aspects . . . . . . 13 Bruno Kastler,Marc Couvreur,Jan Fritz,
Blandine Kastler,Jean-Georges Rohmer Philippe L.Pereira
Introduction . . . . . . . . . . . . . . . . . 13 Introduction . . . . . . . . . . . . . . . . . 25
Current Nosologic Aspects . . . . . . . . . . 14 Patient Preparation . . . . . . . . . . . . . 25
Chronic PainSyndrome . . . . . . . . . . . 14 Intervention Room Preparation . . . . . . . 25
Chronic Pain Syndrome Preprocedural Imaging and Planning
with a Dominant Organic Component . . . 15 of Percutaneous Approach . . . . . . . . . . 26
Chronic Pain Syndrome with a Dominant Patient Positioning for Optimal Access . . 27
Psychological Component . . . . . . . . . 16 Gantry Tilting . . . . . . . . . . . . . . . . 27
Utilization ofBreathing . . . . . . . . . . . 29
XII Contents
Target Localization and Visualization 6 Spinal Infiltrations:
of the Needle Tip . . . . . . . . . . . . . . . 29 Technical Difficulties
Identification ofVessels . . . . . . . . . . . 29 and Potential Complications . . . . . . 57
Cross Reference Mark Philippe Brunner,Patrick Chevallier,
Localization Technique . . . . . . . . . . . 30 Nicolas Amoretti,Jack Sedat,Elodie Cazaux,
Needle-Target Pathway Angulation . . . . . 31 Françoise Fuerxer,Jean-Michel Cucchi,
Exact Positioning ofthe Needle Tip . . . . 32 Michel-Yves Mourou
Localization ofthe Needle . . . . . . . . . 34
What Are the Potential Complications
Techniques for Needle Guidance . . . . . . 34 of Periradicular Infiltrations? . . . . . . . . 57
References . . . . . . . . . . . . . . . . . . 41 Inefficacy . . . . . . . . . . . . . . . . . . . 57
Hematoma . . . . . . . . . . . . . . . . . . 58
Infection . . . . . . . . . . . . . . . . . . . 58
4 Complications
Vagal Reaction . . . . . . . . . . . . . . . . 58
and Patient Management
Hypersensitivity . . . . . . . . . . . . . . . 58
Type of Agents Infiltrated . . . . . . . . . . 43
Puncture ofImportant Organs . . . . . . . 58
Pierre Delassus,George Hadjidekov,
How to Avoid These Problems . . . . . . . . 61
Bruno Kastler
Conclusion . . . . . . . . . . . . . . . . . . 61
Type of Agents Infiltrated . . . . . . . . . . 43
Local Anesthetics . . . . . . . . . . . . . . 43 References . . . . . . . . . . . . . . . . . . 62
Neurolytic Substances . . . . . . . . . . . . 44
Corticosteroids for Local Infiltration . . . 45 7 Trigeminal Neuralgia . . . . . . . . . . . 63
Patient Management . . . . . . . . . . . . 46 Alain Czorny,Romain Billon-Grand
Conclusion . . . . . . . . . . . . . . . . . . 47 Anatomical Review,Secondary Neuralgias 63
References . . . . . . . . . . . . . . . . . . 47 Surgical Treatment . . . . . . . . . . . . . . 65
Percutaneous Approach . . . . . . . . . . . 65
5 Foraminal Injections of Corticosteroids Surgical Approach . . . . . . . . . . . . . . 67
Under Tomodensitometric Control . . . 49 Results . . . . . . . . . . . . . . . . . . . . 68
Olivia Delmer,Vincent Dousset Conclusion . . . . . . . . . . . . . . . . . . 69
Introduction . . . . . . . . . . . . . . . . . 49 References . . . . . . . . . . . . . . . . . . 69
Anatomical Review . . . . . . . . . . . . . 49
Etiology of Foraminal 8 Arnold’s Neuralgia . . . . . . . . . . . . . 71
Radicular Constrictions . . . . . . . . . . . 50 Bruno Kastler,Zakia Boulahdour,
Stenosis ofDiscal Origin . . . . . . . . . . 50 Sebastien Aubry,Bernard Fergane,
Stenosis ofOsseous Origin . . . . . . . . . 50 Zoltan Patay
Fibrosis . . . . . . . . . . . . . . . . . . . . 50 Clinically Relevant Anatomy . . . . . . . . 71
Mechanisms Governing Pain Areas ofVulnerability on Nerve Pathway 71
in Radiculalgias . . . . . . . . . . . . . . . 52 Etiopathogenesis . . . . . . . . . . . . . . . 72
Indications . . . . . . . . . . . . . . . . . . 52 Clinical Considerations . . . . . . . . . . . 73
Contraindications . . . . . . . . . . . . . . 52
Contraindications . . . . . . . . . . . . . . 74
Technique . . . . . . . . . . . . . . . . . . 52
Technique . . . . . . . . . . . . . . . . . . 74
Criteria ofSuccess . . . . . . . . . . . . . . 54
Complications . . . . . . . . . . . . . . . . 79
Refining Technique;Variations
for Different Levels . . . . . . . . . . . . . 54 Results . . . . . . . . . . . . . . . . . . . . 79
Complications,Side Effects,Monitoring . . 54 References . . . . . . . . . . . . . . . . . . 79
Results . . . . . . . . . . . . . . . . . . . . 55
Specific Advantages ofInjection Under CT 55
Conclusion . . . . . . . . . . . . . . . . . . 55
References . . . . . . . . . . . . . . . . . . 55
Contents XIII
9 Pterygopalatine Ganglion Neurolysis 12 Other Sympatholysis . . . . . . . . . . . 105
Under CT Guidance . . . . . . . . . . . . . 81 Bruno Kastler,Philippe Manzoni,
Christophe Clair,Bruno Kastler, Laurent Laborie,Hussein Haj Hussein,
Gilles Cadel,Bernard Fergane Jean-Yves Cornu,Florence Tiberghien-Chatelain,
Bernard Fergane
Introduction . . . . . . . . . . . . . . . . . 81
Thoracic Sympatholysis . . . . . . . . . . . 105
Anatomy of the Pterygopalatine Fossa . . . 81
Indications . . . . . . . . . . . . . . . . . . 105
Neurolysis Technique . . . . . . . . . . . . 83
Clinically Relevant Anatomy . . . . . . . . 105
Ethanol Neurolysis . . . . . . . . . . . . . . 84
Technique) . . . . . . . . . . . . . . . . . . 106
RF Neurolysis . . . . . . . . . . . . . . . . 85
Lumbar Sympatholysis . . . . . . . . . . . . 107
Advantagesand Disadvantages
Indications . . . . . . . . . . . . . . . . . . 107
of the Two Approaches . . . . . . . . . . . . 85
Clinically Relevant Anatomy . . . . . . . . 107
Ethanol Neurolysis . . . . . . . . . . . . . . 85
Technique . . . . . . . . . . . . . . . . . . 109
RF Neurolysis . . . . . . . . . . . . . . . . 85
Neurolysis of the Interiliac Sympathetic
References . . . . . . . . . . . . . . . . . . 85 Plexus and the Ganglion Impar (Unpaired) 109
Indications . . . . . . . . . . . . . . . . . . 109
10 Stellate Ganglion Neurolysis Under Clinically Relevant Anatomy . . . . . . . . 110
CT-Guidance . . . . . . . . . . . . . . . . . 87 Technique . . . . . . . . . . . . . . . . . . 110
Bruno Kastler,Démonsthène Michalakis, References . . . . . . . . . . . . . . . . . . 111
Nicolas Sailley,Philippe Pereira,Bernard Fergane
Introduction . . . . . . . . . . . . . . . . . 87 13 Pudendal Nerve Infiltration Under
Clinically Relevant Anatomy . . . . . . . . . 87 CT Guidance . . . . . . . . . . . . . . . . . 113
Needle Tip Targeting at the Stellate Ganglion Bruno Kastler,Christophe Clair,
Under CT Guidance . . . . . . . . . . . . . . 88 Zakia Boulahdour,Julien Puget,
Marjolaine De Billy,Bernard Fergane
Stellate Ganglion Blockade . . . . . . . . . 90
RF Neurolysis . . . . . . . . . . . . . . . . 90 Introduction . . . . . . . . . . . . . . . . . 113
Ethanol Neurolysis . . . . . . . . . . . . . 91 Anatomical Background and Etiology . . . . 113
Advantagesand Disadvantages
Symptoms and Signs . . . . . . . . . . . . . 114
of the Two Approaches . . . . . . . . . . . . 92
Diagnosis . . . . . . . . . . . . . . . . . . . 114
References . . . . . . . . . . . . . . . . . . 92
Infiltration Technique . . . . . . . . . . . . 114
Results . . . . . . . . . . . . . . . . . . . . 117
11 Percutaneous Neurolysis of the Celiac
Plexus and Splanchnic Nerves References . . . . . . . . . . . . . . . . . . 117
Under CT and color Doppler US Guidance . . 93
Bruno Kastler,Jean-François Litzler, 14 Injection of Inguinofemoral Nerves . . 119
Pierre-Yves Marcy,Gérard Schmutz Bruno Kastler,Guy Monnier,
Bernard Fergane
Clinically Relevant Anatomy . . . . . . . . . 93
Indications . . . . . . . . . . . . . . . . . . 94 Introduction . . . . . . . . . . . . . . . . . 119
Contraindications . . . . . . . . . . . . . . 94 Lateral Femoral Cutaneous Nerve . . . . . . 119
Technique and Material . . . . . . . . . . . 94 Relevant Anatomy . . . . . . . . . . . . . . 119
Type and Dosageof Chemical Lytic Agent . . 101 Clinical Characteristics . . . . . . . . . . . 119
Technique . . . . . . . . . . . . . . . . . . 120
Complications,Side Effects . . . . . . . . . 101
Complications . . . . . . . . . . . . . . . . 101 Genitofemoral Nerve . . . . . . . . . . . . 121
Side Effects . . . . . . . . . . . . . . . . . . 103 Relevant Anatomy . . . . . . . . . . . . . . 121
Clinical Characteristics . . . . . . . . . . . 122
Results and Efficacy . . . . . . . . . . . . . 103
Technique . . . . . . . . . . . . . . . . . . 122
Conclusion . . . . . . . . . . . . . . . . . . 103
References . . . . . . . . . . . . . . . . . . 104
