title: Continuous brachial plexus block at the cervical level using a posterior approach in the management of neuropathic cancer pain.
abstract: OBJECTIVE
  Neuropathic cancer pain due to tumor growth near the brachial plexus is often treated with a combination of nonsteroidal anti-inflammatory drugs, tricyclic antidepressants, anticonvulsants, and oral or transdermal opioids. We propose placement of a catheter along the brachial plexus using a posterior approach for patients not responding to the above-mentioned treatment.
  
  
  METHODS
  We describe 2 patients with neuropathic cancer pain in the arm and shoulder despite treatment with dexamethasone, amitriptyline, gabapentin, opioids, and, in 1 patient, oral ketamine. An increase in daily opioid dosage did not relieve the pain but caused unacceptable side effects of nausea, vomiting, and sedation. Continuous administration of local anesthetics via a brachial plexus catheter inserted at the cervical level using a posterior approach resulted in a markedly improved analgesia and decreased opioid requirement.
  
  
  CONCLUSIONS
  Continuous brachial plexus block should be considered in patients with severe neuropathic cancer pain in the arm and shoulder. To achieve sufficient pain relief for prolonged periods of time, a catheter was inserted to block the brachial plexus using a posterior approach. This technique may be a valuable alternative to the interscalene approach because of the improved fixation of the catheter in the muscle sheet of the trapezius, splenius cervicus, and levator scapulae muscles, and the decreased likelihood of catheter dislodgment during neck movements.
authors.affiliation: Pain Relief Unit, Academic Medical Center, University of Amsterdam, The Netherlands. j.h.vranken@amc.uva.nl
authors.forename: J H
authors.initials: JH
authors.lastname: Vranken
authors.forename: M H
authors.initials: MH
authors.lastname: van der Vegt
authors.forename: W W
authors.initials: WW
authors.lastname: Zuurmond
authors.forename: A J
authors.initials: AJ
authors.lastname: Pijl
authors.forename: M
authors.initials: M
authors.lastname: Dzoljic
mesh_terms: D000328:Adult; D000779:Anesthetics, Local; D001917:Brachial Plexus; D002045:Bupivacaine; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications*; D009407:Nerve Block / Q000009:adverse effects; D010146:Pain / Q000188:drug therapy* / Q000209:etiology*; D011859:Radiography; D013131:Spine / Q000000981:diagnostic imaging
chemical_list: D000779:Anesthetics, Local; D002045:Bupivacaine