Background & Aims

Adolescent, female, 12 years old, with no morbid history, no allergies, who in June 2023 was diagnosed with stage 4 perianal rhabdomyosarcoma, which underwent chemotherapy, radiotherapy and surgery the same year. In March 2024, coxalgia began, which was studied with an x-ray showing radiolucent areas in the medial part of the right femoral neck, interpreting it as a secondary injury. Pharmacological treatment with paracetamol and pregabalin was started at home. After a month, the patient was hospitalized due to lack of response, anti-inflammatories were started in a continuous infusion pump and a buprenorphine patch was administered, finally she was escalated to an opioid pump plus rescue, despite multimodal management and high doses of opioids, the patient reported a crisis of breakthrough hip pain. about three times a day, irradiated to the anterior face with VAS over 5, evaluated by the pain team, neurolysis of the right hip with radiofrequency was decided.

Methods

To perform the procedure, it was necessary to sedate the patient before positioning her on the surgical table. For this purpose, 50 mg of ketamine and 2 mg of midazolam were administered. The patient underwent the entire procedure with standard monitoring and with an anesthesiologist in charge of sedation. Thermal RF was applied to the capsular branches of the hip, causing a unipolar lesion of 82 degrees for 90 seconds in each of the 3 10-millimeter curved-tip needles for two pulses, previously performing negative motor stimulation at 1.5map. Two of the three needles were placed in the femoral articular branches above the acetabulum, one needle was placed in the obturator branch below the acetabulum. Then 3 needles were placed in the ischiopubic ramus causing two tripolar injuries at 82 degrees for 90 seconds with two pulses. At the end of the procedure, Depomedrol 40 mg and Levobupivacaine 25 mg were injected upon leaving. At the end of the procedure he went to his stable room.

Results

During follow-up, the patient, from the first moment she recovered her response capacity, reported a categorical reduction in pain. It should be noted that the day before the procedure, the patient was receiving a continuous infusion pump of Morphine at 35 ug/kg/hour, bolus Morphine. 3.5 mg ev every 4 hrs, Paracetamol 550 mg every 6 hrs ev (15 mg/kg/dose), Ketoprofen 35 mg every 12 hrs ev, Fentanyl 50 mcg/hr 1 transdermal patch every 3.5 days, Gabapentin 400 mg every 12 hrs PO , Clotiazepam 5 mg every 12 hours. Lansky scale 50%, that is, it requires considerable assistance for any active game; He is able to participate in restful games and after 24 hours he did not require analgesic rescue and in 72 hours he was able to taper off the use of continuous infusion of opioids, reducing the daily use of morphine to 20 kilo hour ranges, suspending the rescue bolus. , in 24 hours the patient managed to sit on the edge of the bed and in 72 hours she was able to fully support her weight and walk with help. The patient was able to participate in physical therapy. She was able to attend radiotherapy in a wheelchair and not on a stretcher as was her baseline condition. The Lansky scale improved to 80%.

Conclusions

There is a paucity of literature on joint denervation procedures in pediatric patients, however high quality prospective controlled trials in adults suggest an immediate and persistent analgesic effect.
While our case was not associated with any adverse events, there is the possibility of negative consequences of denervation of a joint in a pediatric patient, such implications may include the creation of a Charcot joint where, without nociceptive input, degeneration can occur and bone destruction. Using the hip denervation technique described, the sciatic innervation remains and reduces the possibility of a Charcot joint. Regardless, hip denervation in a pediatric patient should be considered a last resort in the treatment of hip pain.
Hip denervation is a potentially useful pain intervention when conservative or surgical options fail. Although this procedure has been performed mainly in an adult population, our case demonstrates a categorical benefit in pediatric oncology.

References

1.Khan JS, Krane EJ, Higgs M, Pritzlaff S, Hoffinger S, Ottestad E. A Case Report of Combined Ultrasound and Fluoroscopic-Guided Percutaneous Radiofrequency Lesioning of the Obturator and Femoral Articular Branches in the Treatment of Persistent Hip Pain in a Pediatric Patient. Pain Pract. 2019 Jan;19(1):52-56. doi: 10.1111/papr.12724. Epub 2018 Jul 9. PMID: 29896934.

2.Kapural L, Jolly S, Mantoan J, Badhey H, Ptacek T. Cooled Radiofrequency Neurotomy of the Articular Sensory Branches of the Obturator and Femoral Nerves – Combined Approach Using Fluoroscopy and Ultrasound Guidance: Technical Report, and Observational Study on Safety and Efficacy. Pain Physician. 2018 May;21(3):279-284. PMID: 29871372.

3.Wu H, Groner J. Pulsed radiofrequency treatment of articular branches of the obturator and femoral nerves for management of hip joint pain. Pain Pract. 2007 Dec;7(4):341-4. doi: 10.1111/j.1533-2500.2007.00151.x. Epub 2007 Nov 6. PMID: 17986165.

4.Stone J, Matchett G. Combined ultrasound and fluoroscopic guidance for radiofrequency ablation of the obturator nerve for intractable cancer-associated hip pain. Pain Physician. 2014 Jan-Feb;17(1):E83-7. PMID: 24452660.

5.Cheney CW, Ahmadian A, Brennick C, Zheng P, Mattie R, McCormick ZL, Nagpal A. Ablación por radiofrecuencia para el dolor crónico de cadera: una revisión narrativa completa. Analgésico. 22 (Suplemento 1): T14-S19. doi: 10.1093/pm/pnab043. PMID: 34308954.

6.Tomlinson J, Ondruschka B, Prietzel T, Zwirner J, Hammer N. Una revisión sistemática y metanálisis de la inervación de la cápsula de la cadera y sus implicaciones clínicas. Sci Rep. 5 de marzo de 2021; 11 (1): 5299. doi: 10.1038/s41598-021-84345-z. PMID: 33674621; PMCID: PMC7935927.

7.Houghton KM: Review for the generalist: evaluation of pediatric hip pain. Pediatric Rheumatol 2009; 7:1–9.

8.Bhatia A, Hoydonckx Y, Peng P, Cohen SP: Radiofrequency Procedures to Relieve Chronic Hip Pain. Reg Anesth Pain Med 2017; 43:1–12.

9.Birnbaum K, Prescher A, Hepler S, Heller K-D: The sensory innervation of the hip joint – An anatomical study. Surg Radiol Anat 1998; 19:371–5.

10.Alzaharani A, Bali K, Gudena R, Railton P, Ponjevic D, Matyas JR, Powell JN: The innervation of the human acetabular labrum and hip joint: An anatomic study. BMC Musculoskelet Disord 2014; 15:1–8.

11.Stone J, Matchett G: Combined ultrasound and fluoroscopic guidance for radiofrequency ablation of the obturator nerve for intractable cancer-associated hip pain. Pain Physician 2014; 17:E83–7

Presenting Author

German Acuña

Poster Authors

German Acuna Game

MD

Hospital Traumatologico de Concepcion CHILE

Lead Author

Paula Retamal MB

Hospital Traumatologico de Concepcion CHILE

Lead Author

Francisca Marin MD

Hospital Regional de Concepcion CHILE

Lead Author

Francisco Bolbaran MD

Hospital Traumatologico de Concepcion CHILE

Lead Author

Oscar Paredes MD

Hospital Traumatologico de Concepción CHILE

Lead Author

Topics

  • Treatment/Management: Interventional Therapies – Ablation Techniques