465: Case Report on Interscalene Brachial Plexus Neurolysis in a Patient with Thoracic Outlet Syndrome

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Chronic cancer related pain, Pharmacological treatments, Treatment/management

Background and Aims: A case of a 51 year old female, married, diagnosed with lung cancer stage 4 in 2019. She received 6 cycles of chemotherapy and 1 cycle of immunotherapy. Persistent aching pain over the left shoulder, left arm, radiating to the left anterior chest and back despite the pharmacologic therapy prompted referral to an interventional pain specialist. A minimally invasive procedure was contemplated using low volume neurolytic agent.

Methods: Left Brachial Plexus chemical Neurolysis using 95% alcohol via interscalene approach through Computer Tomography guidance was performed. After mild sedation patient was positioned supine on a gantry then scout images of the left shoulder and neck were taken. A gauge 22 Quincke needle was aseptically inserted at the level of 5th cervical vertebra medially traversing the tumor approximately 6 centimeters deep approaching the trunk of the plexus between the anterior and middle scalene muscles. Precise location was confirmed by Iopamidol 1.5ml injection. Alcohol 95% 3ml was slowly injected. Post procedure scan showed C5 to T1 spread of the agents.

Results: Post procedure, there was an immediate and substantial reduction in the pain score from Numeric Pain Scale of 9/10 to 2/10. No complications were observed such as Horner's Syndrome, motor block of the left arm, or difficulty of breathing due to phrenic nerve paralysis. Intravenous Ketamine drip was discontinued. Non Steroidal Anti Inflammatory Drugs, gabapentinoids, transdermal fentanyl as well as intravenous fentanyl rescue doses were subsequently reduced by half. Patient was able to resume activities of daily living.

Conclusions: Interventional pain procedures can be safely performed with precision through image guidance with minimal or no adverse events. Pervious literatures show high volumes of neurolytic agents (11ml to 20ml) which resulted to Horner's Syndrome and motor block of the extremities following interscalene brachial plexus neurolysis. A low volume neurolytic agent may be adequate to provide analgesia without motor block and other complications aside from improving quality of life of the terminally ill.

References: P. Christo. " New Perspectives on Neurogenic Outlet Syndrome" Practical Pain Management Volume 14 Issue #8 (2015): pages 1 to 3
S. Diwan and P. Staats. Altas of Pain Medicine Procedures. Pennsylvania. McGraw-Hill; c2015
P.A Sloan. "The evolving role of interventional pain management in oncology", Journal of Supportive Oncology, Volume 2, pages 491 to 506, 2004
M. Cousins, D Carr, T Horlocker, P Bridenbaughn "treatement of Cancer Pain". Neural Blockade in Clinical Anesthesia and Pain Medicine. Philadelphia : Lippincott2009 pages 118 to 122
T Hsing Loh, S Patel A Mirchandani M Eckmann "Brachial Plexus Chemical Neurolysis with Ethanol for Cancer Pain", Case Reports in Medicine Volume 2018, Issue 1, 8628645

Presenting Author: Jose G. Beltran Jr. MD
Submitting Author: Jose Jr Beltran

Senior Author: Jose G. Beltran, Jr. MD

IASP 2026 Global Year theme of Neuropathic Pain: No