Anaesth Intensive Care 2008; 36: 732-735

Anterior ultrasound-guided superior hypogastric plexus

neurolysis in pelvic cancer pain
S. Mishra*, S. Bhatnagar†, D. Gupta‡, S. Thulkar§
Department of Anaesthesia, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, Ansari Nagar, New Delhi,
India

Summary
The hypogastric plexus block is classically performed by a posterior approach, but there are recent reports of a
computed tomography-guided anterior approach for patients who have difficult access to the hypogastric plexus by
the posterior approach. We present two patients who were successfully given ultrasound-guided superior hypogastric
plexus block by an anterior approach. The anterior ultrasound-guided superior hypogastric plexus neurolysis
technique is simple to perform. We believe this block can be useful in cancer patients who are having difficulty in lying
prone, because it is a bedside procedure performed in the supine position and it is less time-consuming. It also avoids
the radiation exposure involved with a computed tomography-guided anterior approach.
Key Words: superior hypogastric plexus, neurolytic block, imaging, ultrasound-guided, pelvic pain

Chronic pelvic cancer pain is a major disturbing CASE HISTORIES

symptom. There are various modalities of treatment
mentioned in the literature, such as pharmacological,
surgical and neurolytic blocks1-3. The superior
hypogastric plexus mediates nociceptive visceral
stimuli from the various pelvic organs including the
bladder, uterus, ovary, vagina, prostate and rectum.
The hypogastric plexus block is classically performed
by a posterior approach in patients with chronic
pelvic pain originating from malignant and non-
malignant diseases of pelvic organs. This block can
be performed under computed tomography (CT)
guidance and fluoroscopy guidance3-10. The recent
literature included a few reports of a CT-guided
anterior approach for patients who have difficult
access to the hypogastric plexus by the posterior
approach7-10. We have not found any publications
describing superior hypogastric plexus neurolysis
performed using an anterior approach under
ultrasound guidance. Hence, we present a report
of two patients who were successfully treated by an
ultrasound-guided superior hypogastric plexus block
by an anterior approach.
* M.D., Assistant Professor Anaesthesia.
† M.D., Associate Professor Anaesthesia.
‡ M.D., Senior Research Associate Anaesthesia.
§ M.D., Associate Professor Radiology.
Address for reprints: Dr S. Mishra, Assistant Professor Anesthesiology,
F-33, AIIMS Residential Campus (West), Ansari Nagar, New Delhi 110029,
India.
Accepted for publication on June 6, 2008.
A 57-year-old patient suffering from pelvic pain
presented to the pain clinic for pain management.
She was diagnosed with carcinoma of the cervix and
had undergone transabdominal hysterectomy with
postoperative radiotherapy, but had residual local
and pelvic disease. She was having severe pain (visual
analogue scale [VAS] score 80 out of 100) in the lower
abdomen and radiating to the left lower limb. The
second patient was a 60-year-old female suffering
from chronic pain of the pelvic and anal region. She
was diagnosed with malignant melanoma of the anal
canal with rectal, vaginal and levator ani involvement,
and multiple liver and lung metastases. Her VAS pain
score was 90 out of 100. No curative intervention was
possible at this stage of disease in either case. Both
patients were having severe pain despite analgesics
(tramadol, nonsteroidal anti-inflammatory drugs,
gabapentin). Hypogastric plexus block was planned
for both patients, who were admitted to the hospital-
based in-patient palliative care unit of our oncology
institute. Ultrasound-guided superior hypogastric
plexus neurolysis by an anterior approach was
planned.
The patients fasted for eight hours before the
procedure. Four tablets of activated charcoal and
two tablets of bisacodyl were given the night before
the procedure to clean the bowel of air and contents.
The patients were advised prior to the procedure to
micturate to empty the urinary bladder. They received
an intravenous fluid volume of 1000 ml normal
saline before the procedure to reduce the risk of
Anaesthesia and Intensive Care, Vol. 36, No. 5, September 2008
 Case Report
Figure 1: Longitudinal ultrasound image with Doppler showing
the division of the abdominal aorta into the common iliac
arteries.
Figure 3: Transverse ultrasound image showing the body of fifth
lumbar vertebra with bilateral common iliac vessels seen leaving a
space in the midline.
hypotension. A SonoSite® MicroMaxx® ultrasound
system (SonoSite INC, Bothell, WA, USA) with a
C60e/5-2 MHz transducer was used for sonographic
guidance. The division of the abdominal aorta into the
common iliac arteries was located using longitudinal
sonography (Figure 1) and oblique sonography
(Figure 2). Then, the transducer was rotated to image
the body of the fifth lumbar vertebra, at which level
bilateral common iliac vessels were seen leaving a
space in the midline (Figure 3). Colour Doppler
imaging was useful in confirming the location of the
common iliac vessels (Figure 4).
After providing local cutaneous and subcutaneous
anaesthesia, a 15 cm long, 22 gauge Chiba needle
(Cook Urological Inc., USA) was introduced
into the hypogastrium, paramedian to the
transversely placed ultrasound transducer. This is
a unilateral technique to access the fifth lumbar
Anaesthesia and Intensive Care, Vol. 36, No. 5, September 2008
733
Figure 2: Oblique ultrasound image with Doppler showing the
division of the abdominal aorta into the common iliac arteries.
Figure 4: Doppler ultrasound image of the common iliac vessels
leaving a space in the midline just anterior to the body of fifth
lumbar vertebra.
vertebral body at its anterior-most point, so that
injected drug spreads equally bilaterally along the
anterior curvature of the fifth lumbar vertebral body.
With the operator standing on the right side of the
patient, the needle held by the operator in his/her right
hand was introduced into the patient’s hypogastrium
in a left paramedian plane to the transversely
placed ultrasound transducer that was held by the
operator in his/her left hand. The tip of the needle
was ultrasonographically guided and advanced into
the retroperitoneal area, flanked posteriorly by the
fifth lumbar vertebra and laterally by the common
iliac vessels. The depth of needle insertion was 10 to
11 cm from the port of skin entry diagonally to the
most anterior point of the anterior curvature of
the fifth lumbar vertebral body. Once the tip of the
needle appeared to be correctly positioned at the
most anterior point of the fifth lumbar vertebral
body in the midline (Figure 5), after hitting the fifth
vertebral body the tip was withdrawn 1 mm, to avoid
a periosteal position of the needle tip. Suction was
applied to the needle to confirm that it was not within
734 S. Mishra, S. Bhatnagar et al
Figure 5: Transverse ultrasound image of the tip of needle
positioned at the most-anterior point of the fifth lumbar vertebral
body in the midline for superior hypogastric plexus neurolysis.
a vessel and a ‘diagnostic block’ was performed by
injecting a local anaesthetic (0.25% bupivacaine 10 ml).
In both patients pain relief was complete. The next
day a hypogastric neurolytic block was planned.
We followed the same procedure as at the time of
diagnostic block and 10 ml of 50% ethanol in 0.25%
bupivacaine was injected for neurolysis in both
patients. The neurolysis was performed one day after
diagnostic block, so that the patients could appreciate
the pain-relieving effects of the intervention with
local anaesthetic and would not have lower
satisfaction scores with their pain management
during the delayed onset of analgesic effects of
ethanol. The spread of local anaesthetic or neurolytic
agent was visualised by real-time sonography to
ensure that injection was in the midline, with the
drug spreading uniformly to both sides of the anterior
curve of the fifth lumbar vertebral body. The
procedure under sonographic guidance took about
five minutes in total. In the first patient needle
manipulation was required twice to reach the exact
site required for the hypogastric block and in the
second patient the desired site was reached at the first
attempt.
The VAS pain scores 24 hours after the neurolytic
block were 0 and 30 respectively. No visceral injury
or other complications were reported in either
patient. The patients were discharged after four
days of admission to the palliative care unit, taking
nonsteroidal anti-inflammatory drugs on an as-
required basis. Pain relief was assessed one week,
one month and two months after the procedure. The
first patient reported VAS pain scores of 0, 0 and
10 at one week, one month and two months
respectively, while the second patient reported a VAS
score of 10, 20 and 20 at one week, one month and
two months respectively. Both the patients rated their
pain relief as more than 80% at all three assessment
time-points.
DISCUSSION
Cancer patients with tumour extension into the
pelvis may experience severe pain that is unresponsive
to oral or parenteral opioids. In addition, excessive
sedation or other side-effects may limit the
acceptability and usefulness of oral opioid therapy.
Therefore, a more invasive approach is needed to
control pain and improve the quality of life of these
patients. Pelvic pain associated with cancer and
chronic non-malignant conditions may be alleviated
by blocking the superior hypogastric plexus. In a
study4 conducted at Roswell Park Cancer Institute
in 1993, it was suggested that visceral pain is an
important component of the cancer pain syndrome
experienced by patients with cancer of the pelvis,
even in advanced stages. Therefore, percutaneous
neurolytic blocks of the superior hypogastric plexus
should be considered more often for patients with
advanced stages of pelvic cancer.
The effectiveness of the block was originally
demonstrated by documenting a significant decrease
in pain via VAS pain scores. In their study, Plancarte
et al3 showed that this block was effective in reducing
VAS scores in 70% of the patients with pelvic pain
associated with cancer, the majority of whom had
cervical cancer. In a subsequent study2, 69% of the
patients experienced a decrease in VAS pain scores.
Moreover, a mean daily morphine reduction of 67%
was seen in those with a successful outcome. In a
more recent multicentre study, 72% of patients had
satisfactory pain relief after one or two neurolytic
procedures. Mean opioid use decreased by 40%
by three weeks after treatment in all the patients
studied. A few other small case series, ranging from
three to 28 patients, are reported in the literature.
Pain relief was observed in up to 70% of patients3-6.
The usefulness of this type of block in chronic
benign pain conditions has not been adequately
documented.
This block is classically performed by a posterior
approach under fluoroscopic guidance. Very few case
series in the literature describe an anterior approach
to the superior hypogastric plexus block under
CT guidance7-10. The observed technique is simple
to perform and the analgesic effect is satisfactory.
There are no case series where anterior approach to
superior hypogastric block was performed under
ultrasound guidance. We believe the ease of
Anaesthesia and Intensive Care, Vol. 36, No. 5, September 2008
 Case Report
performing this short procedure in real-time with
radiation-free guidance by an ultrasound machine
helped our palliative care team to safely perform the
procedure with good success. Though the combined
experience of more than 200 cases from the Mexican
Institute of Cancer3, Roswell Park Cancer Institute4
and M.D. Anderson Cancer Center11 indicates
that neurologic complications do not occur as a
result of this block, those blocks were performed
conventionally under fluoroscopic guidance. There
are some concerns regarding visceral injury with the
anterior approach. However, pre-procedure bowel
and bladder preparation and the Trendelenburg
position can avoid visceral injury, because collapsed
viscera tended to fall away from the needle path.
There are no other organs except for small bowel
loops that lie at the site of needle placement for the
block. The risk of vessel injuries is readily reduced
using imaging guidance and after negative aspiration
of blood. One might expect at some stage to see
injury to the laterally located lumbosacral plexus
and ureters, although these are at least 4 to 5 cm
away from the anterior-most point of the fifth lumbar
vertebral body.
We were able to achieve complete pain relief after
a diagnostic block and there was a decrease in pain
scores in both the patients after the neurolytic block.
More extensive studies are being planned to evaluate
the safety and efficacy of this approach. It is too early
to say that ultrasound guidance is the best approach,
however there are certain advantages and some
limitations to this procedure (Table 1).
Table 1
Advantages and limitations of anterior ultrasound-guided superior
hypogastric neurolysis
Advantages
Ease of access at a depth of 10 to 11 cm
Done in supine position avoiding difficult prone positioning
Bedside procedure
Imaging is portable
Real time visualisation of the spread of drug
Real time visualisation of needle advancement with
simultaneous visualisation of viscera and vessels to avoid
Less time consuming
Radiation free
Limitations
Lack of absolute confirmation of intravascular uptake
Potential for bowel or bladder injury, lumbosacral plexus injury
Anaesthesia and Intensive Care, Vol. 36, No. 5, September 2008
735
In summary, the anterior ultrasound-guided
superior hypogastric plexus neurolysis technique
is simple to perform. This block can be useful in
cancer patients who are having difficulty lying prone,
because it is a bedside procedure that can be
performed with the patient in the supine position and
because it is less time-consuming than alternative
approaches. It also avoids radiation exposure
associated with a CT-guided anterior approach.
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