Background & Aims
We present the case of a 94-year-old female patient with multiple comorbidities, including atrial fibrillation with rapid ventricular response, cirrosis, type 2 diabetes mellitus, a history of stroke, and stage 3 chronic kidney disease.
The patient suffered a fall at home, resulting in a displaced proximal fracture of the left humerus. Given her complex medical history and the high risk of surgery-related complications, a conservative approach was chosen with the application of a shoulder immobilizer.
The patient experienced significant pain in the affected limb, refractory to analgesic treatment including potent opioids, which rendered her unable to mobilize in bed, perform personal hygiene, or carry out other basic functions.
Given the patient’s context and the loss of functionality of the fractured limb, we decided to perform radiofrequency ablation of the brachial plexus using a costoclavicular approach, and radiofrequency ablation of the supraescapular nerve
Methods
The patient was positioned supine, with the head turned to the right side and the head of the bed elevated by 30°.
Using a high-frequency ultrasound probe, the left brachial plexus was identified at the level of the cords. A 22-gauge, 80 mm needle (BRAUN Stimuplex ultra 360 30°) was advanced in-plane towards the brachial plexus and 8 mL of 2% lidocaine was injected. Subsequently, a 22-gauge, 50 mm needle was advanced towards the suprascapular nerve at the level of the scapular notch and 2 mL of 2% lidocaine was injected.
Then under two 10 cm radiofrequency needles with a 10 mm active curved tip (20-gauge 4in1 rf bevel needle) were advanced to the brachial plexus and a third needle to the supraescapular notch. RFA at 80°C for 90 seconds was performed using TOP TLG-10 GENERATOR.
Results
Prior to the procedure, the patient reported pain rated 10 on the EVA scale. Procedure was performed under superficial sedation with opioids, without any inconvenience during the procedure. At 4 hours post-procedure, the patient’s pain decreased to an EVA of 8. By 12 hours post-procedure, the patient reported an EVA of 4, without requiring opioid doses. At 24 hours, the patient was able to mobilize the limb and maintain finger mobility, despite motor and sensory ablation of the infraclavicular brachial plexus, which was an unexpected outcome given the initial discussion with the patient and family, where complete limb immobility was anticipated. At 48 hours, the patient continued with an EVA of 4, without requiring opioid doses, only receiving paracetamol and a single dose of non-steroidal anti-inflammatory drugs.
finally the patient passed away due to her multiple comorbidities 7 days after the procedure.
Conclusions
In patients where comorbidities, age, type of fracture, and nutritional status lead the medical team to opt for non-surgical management, radiofrequency ablation emerges as an option to maintain appropriate pain management with minimal doses of opioids and non-steroidal anti-inflammatory drugs. The patient remained hospitalized and was discharged with only paracetamol and COX-2 inhibitors. One month after discharge, the patient passed away due to cardiac arrhythmia
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Presenting Author
German Acuña
Poster Authors
Topics
- Treatment/Management: Interventional Therapies – Other