Cardiovascular and Interventional Radiological Society of Europe

September 10-14 | Barcelona, Spain

Science for people

September 10-14 | Barcelona, Spain

Science for people

September 10-14 | Barcelona, Spain

Science for people

September 10-14 | Barcelona, Spain

September 10-14 | Barcelona, Spain

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EventsCIRSE 2022Sneak peeksPercutaneous cryoneurolysis: a primer for non-users

Percutaneous cryoneurolysis: a primer for non-users

We spoke to Dr. Filippiadis to learn more about his upcoming presentation at CIRSE 2022.

Catch his lecture during the session, “New frontiers in pain management” on September 10 at 11:30 CEST!

We live in a vintage era where everything old seems new; percutaneous cryoneurolysis could not be the exception to this rule. The first reports on the application of cold for pain reduction date back to the Napoleonic wars, whilst the first published data was released in the 1970s. Cryoneurolysis is a technique involving the application of extreme cold upon nerves for palliation of benign or malignant pain resistant to conservative medication. The pathophysiology behind cryoneurolysis includes a cascade of events that interrupt nerve conduction without causing irreversible damage to the nerve. Temperatures below 10ºC result in a temporary signaling inactivation, while at -5ºC, a conduction block occurs that lasts for hours to days; both these events are related to disruption of the Na/K pump. At -20ºC, loss of axonal continuity occurs, leaving the myelin sheath and the endoneurium intact (Sunderland 2 injury). As opposed to tumor ablation, cryoneurolysis is not dependent on the induction of osmotic gradients for cell death requiring different protocols than historically used by interventional radiologists for cancer management. Goal temperatures during cryoneurolysis should not be below -40ºC. The intensity and duration of the analgesic effect depend on the degree of damage from the ice ball and usually lasts for several (6-12) months.

 

Imaging guidance with precise anatomic delineation, high spatial resolution and good tissue contrast contribute to the safety and efficacy of the technique by offering safe and effective access even to deep nervous system structures as well as monitoring and documentation of the ice ball (i.e. neurolytic zone). Multiple cryoprobes (range of diameter from 8 to 24 Gauge) can be simultaneously used if necessary; at present, the most commonly utilized gases for ice ball formation include argon, nitrous oxide and carbon dioxide. Depending on the system used and the gas utilized, single or double alternating freeze-thaw cycles are applied. Advantages of cryoneurolysis over radiofrequency or chemical neurolysis include visibility of the ice ball, which offers high targeting and a reduced chance of post-treatment neuroma formation.

 

Indications for cryoneurolysis include acute or chronic pain related to peripheral neuropathies and neuropathic syndromes (including among others pudendal, occipital, genicular, genitofemoral and lateral femoral cutaneous nerves for the respective neuralgias) of benign origin, osteoarthritis and joint replacement symptoms, facet and sacroiliac joint syndrome as well as cancer pain. Post-operative (usually related to mastectomy or thoracotomy) and phantom limb pain, complex regional pain syndrome type I, Morton’s neuromas or Schwannomas, digital neuralgia, postherpetic neuralgia and hip adduction spasticity along with obturator neuralgia are also included [4] in the list of indications. Contraindications include the inability to consent, anatomy-related issues precluding safe access to a region of interest, bleeding disorders and coagulopathy, infection, cold urticaria, cryoglobulinemia and Raynaud’s syndrome. A positive diagnostic block (injection of local anesthetic with or without corticosteroid with subsequent pain relief) should precede. Percutaneous cryoneurolysis can be performed either as first-line therapy post a positive diagnostic block or as an incremental strategy after a recurrence of symptoms post infiltration or chemical neurolysis with ethanol or phenol.

 

Numerous studies in the literature report significant pain reduction post application of cryoneurolysis for acute or chronic benign or malignant pain resistant to medication. Percutaneous cryoneurolysis is a safe procedure with minimal risk of complications, including local bruising, bleeding and infection, frostbite, alopecia, depigmentation and necrosis (if the skin is involved) or local vascular thrombotic events. Under- or overlysis of the target nerve may result in allodynia, neurogenic symptoms, and/or exacerbation of underlying symptoms. Proper patient selection, pathology-tailored approach and imaging guidance with close monitoring of the ice ball are the keys to a safe and efficacious session. Current limitations of cryoneurolysis include the lack of real time knowledge of in vivo temperatures as a function of time and individual patient or nerve characteristics in order to under- or overlysis.

 

Percutaneous cryoneurolysis leads a continuously expanding role in pain management with minimally invasive, imaging-guided techniques. In the era of the opioid overdose crisis, it is the right moment for interventional radiologists to build relations with referring doctors, hospital administrators and local media, proposing a non-opioid procedure that can provide significant pain.

 

Dimitrios Filippiadis

 

National and Kapodistrian University, Athens/GR

 

Dr. Dimitrios Filippiadis serves as associate professor of diagnostic and interventional radiology at the second department of radiology of the Medical School of National and Kapodistrian University in Athens, Greece. He also serves as chairperson of CIRSE’s Online Education Committee and general secretary of the Greek Society of Interventional Radiology. His work has resulted in over 110 scientific publications, hundreds of scientific and business presentations, 32 book chapters, and substantial industrial and scientific grant support. He is a CIRSE Fellow and the recipient of more than 15 major honors/awards.

 

References

  1. Filippiadis D, Bolotis D, Mazioti A, Tsitskari M, Charalampopoulos G, Vrachliotis T, et al. Percutaneous imaging-guided techniques for the treatment of benign neuropathic pain. Diagn Interv Imaging. 2020. On line ahead of print.
  2. Filippiadis DK, Tselikas L, Tsitskari M, Kelekis A, de Baere T, Ryan AG. Percutaneous neurolysis for pain management in oncological patients. Cardiovasc Intervent Radiol. . 2019;42:791-9.
  3. Bittman RW, Behbahani K, Gonzalez F, Prologo JD. Interventional cryoneurolysis: what is the same, what is different, what is new? Semin Intervent Radiol. 2019;36:374-80.
  4. Cornman-Homonoff J, Formenti SC, Chachoua A, Madoff DC. Percutaneous cryoablation for the management of chronic pain secondary to locally recurrent rectal cancer with bowel and nerve root involvement. J Vasc Interv Radiol. 2018;29:1296-8.
  5. Prologo JD, Lin RC, Williams R, Corn D. Percutaneous CT-guided cryoablation for the treatment of refractory pudendal neuralgia. Skeletal Radiol. 2015;44:709-14.
  6. Cazzato RL, Garnon J, Ramamurthy N, Tsoumakidou G, Caudrelier J, Thenint MA, et al. Percutaneous MR-guided cryoablation of Morton’s neuroma: rationale and technical details after the first 20 patients. Cardiovasc Intervent Radiol.. 2016;39:1491-8.
  7. Behbahani K, Chary A, Patel S, Mitchell JW, Fleishon H, Prologo JD. Percutaneous CT-Guided Cryoablation of the Celiac Plexus: A retrospective cohort Ccmparison with ethanol. J Vasc Interv Radiol. 2020;31:1216-20.
  8. Prologo JD, Johnson C, Hawkins CM, Singer A, Manyapu SR, Chang-Yeon K, et al. Natural history of mixed and motor nerve cryoablation in humans- a cohort analysis. J Vasc Interv Radiol. 2020;31:912-6 e1.
  9. Prologo JD. Percutaneous CT-guided cryovagotomy. Tech Vasc Interv Radiol.  2020;23:100660.
  10. Filippiadis D, Ptohis N, Efthymiou E, Kelekis A. A technical report on the performance of percutaneous cryoneurolysis of splanchnic nerves for the treatment of refractory abdominal pain in patients with pancreatic cancer: initial experience. Cardiovasc Intervent Radiol. 2021 May;44(5):789-794.
  11. Filippiadis D, Efth0ymiou E, Tsochatzis A, Kelekis A, Prologo JD. Percutaneous cryoanalgesia for pain palliation: Current status and future trends. Diagn Interv Imaging. 2021 May;102(5):273-278.