Background: The superior hypogastric plexus (SHGP) carries afferents from the viscera of the lower abdomen and pelvis. Neurolytic block of this plexus is used for reducing pain resulting from malignancy in these organs. The ganglion impar (GI) innervats the perineum, distal rectum, anus, distal urethra, vulva, and distal third of the vagina. Different approaches to the ganglion impar neurolysis have been described in the literature. Objectives: To assess the feasibility, safety, and efficacy of combining the block of the SHGP through the postero-median transdiscal approach with the GI block by the transsacro- coccygeal approach for relief of pelvic and/or perineal pain caused by pelvic and/or perineal malignancies or any cancer related causes. Methods: Fifteen patients who had cancer-related pelvic pain, perineal pain, or both received a combined SHGP neurolytic block through the postero-median transdiscal approach using a 20-gauge Chiba needle and injection of 10 mL of 10% phenol in saline plus a GI neurolytic block by the trans-sacro-coccygeal approach using a 22-gauge 5 cm needle and injection of 4 – 6 mL of 8% phenol in saline. Pain intensity (measured using a visual analogue scale) and oral morphine consumption pre- and post-procedure were measured. Results: All patients presented with cancer-related pelvic, perineal, or pelviperineal pain. Pain scores were reduced from a mean (± SD) of 7.87 ± 1.19 pre-procedurally to 2.40 ± 2.10 one week post-procedurally (P 0.05). In addition, the mean consumption of morphine (delivered via 30 mg sustained-release morphine tablets) was reduced from 98.00 ± 34.89 mg to 32.00 ± 28.48 mg after one week (P 0.05). No complications or serious side effects were encountered during or after the block. Limitations: This study is limited by its small sample size and non-randomized study. Conclusion: A combined neurolytic SHGP block with GI block is an effective and safe technique for reducing pain in cancer patients presented with pelvic and/or perineal pain. Also, a combined SHGP block through a posteromedian transdiscal approach with a GI block through a trans-sacrococcygeal approach may be considered more effective and easier to perform than the recently invented bilateral inferior hypogastric plexus neurolysis through a transsacral approach.

Background: The superior hypogastric plexus (SHGP) carries afferents from the viscera of the lower abdomen and pelvis. Neurolytic block of this plexus is used for reducing pain resulting from malignancy in these organs. The ganglion impar (GI) innervats the perineum, distal rectum, anus, distal urethra, vulva, and distal third of the vagina. Different approaches to the ganglion impar neurolysis have been described in the literature. Objectives: To assess the feasibility, safety, and efficacy of combining the block of the SHGP through the postero-median transdiscal approach with the GI block by the transsacro- coccygeal approach for relief of pelvic and/or perineal pain caused by pelvic and/or perineal malignancies or any cancer related causes. Methods: Fifteen patients who had cancer-related pelvic pain, perineal pain, or both received a combined SHGP neurolytic block through the postero-median transdiscal approach using a 20-gauge Chiba needle and injection of 10 mL of 10% phenol in saline plus a GI neurolytic block by the trans-sacro-coccygeal approach using a 22-gauge 5 cm needle and injection of 4 – 6 mL of 8% phenol in saline. Pain intensity (measured using a visual analogue scale) and oral morphine consumption pre- and post-procedure were measured. Results: All patients presented with cancer-related pelvic, perineal, or pelviperineal pain. Pain scores were reduced from a mean (± SD) of 7.87 ± 1.19 pre-procedurally to 2.40 ± 2.10 one week post-procedurally (P 0.05). In addition, the mean consumption of morphine (delivered via 30 mg sustained-release morphine tablets) was reduced from 98.00 ± 34.89 mg to 32.00 ± 28.48 mg after one week (P 0.05). No complications or serious side effects were encountered during or after the block. Limitations: This study is limited by its small sample size and non-randomized study. Conclusion: A combined neurolytic SHGP block with GI block is an effective and safe technique for reducing pain in cancer patients presented with pelvic and/or perineal pain. Also, a combined SHGP block through a posteromedian transdiscal approach with a GI block through a trans-sacrococcygeal approach may be considered more effective and easier to perform than the recently invented bilateral inferior hypogastric plexus neurolysis through a transsacral approach.

Objectives: this study aims at assessment of acute infammatory response; measured by high sensitivity C-reactive protein (hs-CRP), and myocardial injury; measured by serum cardiac troponin-T (Tn-T) in patients undergoing elective major abdominal cancer surgery with general anaesthesia or combined general and lumbar epidural anesthesia. Methods: The study included 60 ischemic patients undergoing elective major abdominal cancer surgery with risk factor(s) like(history of myocardial infraction, diabetes, hypertension, obesity or heavy smoking)randomly assigned into 2 groups; 30 patients each to receive general anesthesia (G1) or combined general and epidural anesthesia (G2). Pain severity, time to frst request of rescue analgesic, analgesic consumption, hemodynamics and side effects were recorded in frst 72 hrs postoperative. Serum Tn-T and hs-CRP, ECG were assessed peroperatively and 1,2,3 days postoperativly also 12-lead ECGs were recorded before and 1,2,3 days after surgery. Results: The mean VAS scores were signifcantly reduced in G2 allover time in comparison to G1 (p0.05) except at 32hrs postoperatively. Mean time to frst request for rescue analgesic was signifcantly prolonged in G2 compared to G1 (p=0.001). Mean morphine consumption was signifcantly reduced in G2 (p0.001). Mean serum level of CPR increased in both groups. Mean level of serum troponin-T was signifcantly increased only in G1 compared to baseline value (p0.05) with no signifcant difference between G1 and G2. There were 5 patients (16.6%) in G1 and 2 patients (6.6%) in G2 showed serum troponin-T level > 0.03ng/ml. Regarding ECGs changes there were 2 patients (6.6%) in G1 and one patient (3.3%) in G2 showed new ischemic changes postoperatively in the form of depressed ST segment >1mm. Conclusion: The use of LEA with general anesthesia in high risk patients with ischemic heart disease undergoing major non-cardiac surgery is associated with less perioperative acute infammatory response, less post-operative pain and can reduce the perioperative myocardial damage.

Objectives: this study aims at assessment of acute infammatory response; measured by high sensitivity C-reactive protein (hs-CRP), and myocardial injury; measured by serum cardiac troponin-T (Tn-T) in patients undergoing elective major abdominal cancer surgery with general anaesthesia or combined general and lumbar epidural anesthesia. Methods: The study included 60 ischemic patients undergoing elective major abdominal cancer surgery with risk factor(s) like(history of myocardial infraction, diabetes, hypertension, obesity or heavy smoking)randomly assigned into 2 groups; 30 patients each to receive general anesthesia (G1) or combined general and epidural anesthesia (G2). Pain severity, time to frst request of rescue analgesic, analgesic consumption, hemodynamics and side effects were recorded in frst 72 hrs postoperative. Serum Tn-T and hs-CRP, ECG were assessed peroperatively and 1,2,3 days postoperativly also 12-lead ECGs were recorded before and 1,2,3 days after surgery. Results: The mean VAS scores were signifcantly reduced in G2 allover time in comparison to G1 (p0.05) except at 32hrs postoperatively. Mean time to frst request for rescue analgesic was signifcantly prolonged in G2 compared to G1 (p=0.001). Mean morphine consumption was signifcantly reduced in G2 (p0.001). Mean serum level of CPR increased in both groups. Mean level of serum troponin-T was signifcantly increased only in G1 compared to baseline value (p0.05) with no signifcant difference between G1 and G2. There were 5 patients (16.6%) in G1 and 2 patients (6.6%) in G2 showed serum troponin-T level > 0.03ng/ml. Regarding ECGs changes there were 2 patients (6.6%) in G1 and one patient (3.3%) in G2 showed new ischemic changes postoperatively in the form of depressed ST segment >1mm. Conclusion: The use of LEA with general anesthesia in high risk patients with ischemic heart disease undergoing major non-cardiac surgery is associated with less perioperative acute infammatory response, less post-operative pain and can reduce the perioperative myocardial damage.

Objectives: this study aims at assessment of acute infammatory response; measured by high sensitivity C-reactive protein (hs-CRP), and myocardial injury; measured by serum cardiac troponin-T (Tn-T) in patients undergoing elective major abdominal cancer surgery with general anaesthesia or combined general and lumbar epidural anesthesia. Methods: The study included 60 ischemic patients undergoing elective major abdominal cancer surgery with risk factor(s) like(history of myocardial infraction, diabetes, hypertension, obesity or heavy smoking)randomly assigned into 2 groups; 30 patients each to receive general anesthesia (G1) or combined general and epidural anesthesia (G2). Pain severity, time to frst request of rescue analgesic, analgesic consumption, hemodynamics and side effects were recorded in frst 72 hrs postoperative. Serum Tn-T and hs-CRP, ECG were assessed peroperatively and 1,2,3 days postoperativly also 12-lead ECGs were recorded before and 1,2,3 days after surgery. Results: The mean VAS scores were signifcantly reduced in G2 allover time in comparison to G1 (p0.05) except at 32hrs postoperatively. Mean time to frst request for rescue analgesic was signifcantly prolonged in G2 compared to G1 (p=0.001). Mean morphine consumption was signifcantly reduced in G2 (p0.001). Mean serum level of CPR increased in both groups. Mean level of serum troponin-T was signifcantly increased only in G1 compared to baseline value (p0.05) with no signifcant difference between G1 and G2. There were 5 patients (16.6%) in G1 and 2 patients (6.6%) in G2 showed serum troponin-T level > 0.03ng/ml. Regarding ECGs changes there were 2 patients (6.6%) in G1 and one patient (3.3%) in G2 showed new ischemic changes postoperatively in the form of depressed ST segment >1mm. Conclusion: The use of LEA with general anesthesia in high risk patients with ischemic heart disease undergoing major non-cardiac surgery is associated with less perioperative acute infammatory response, less post-operative pain and can reduce the perioperative myocardial damage.

Objectives: this study aims at assessment of acute infammatory response; measured by high sensitivity C-reactive protein (hs-CRP), and myocardial injury; measured by serum cardiac troponin-T (Tn-T) in patients undergoing elective major abdominal cancer surgery with general anaesthesia or combined general and lumbar epidural anesthesia. Methods: The study included 60 ischemic patients undergoing elective major abdominal cancer surgery with risk factor(s) like(history of myocardial infraction, diabetes, hypertension, obesity or heavy smoking)randomly assigned into 2 groups; 30 patients each to receive general anesthesia (G1) or combined general and epidural anesthesia (G2). Pain severity, time to frst request of rescue analgesic, analgesic consumption, hemodynamics and side effects were recorded in frst 72 hrs postoperative. Serum Tn-T and hs-CRP, ECG were assessed peroperatively and 1,2,3 days postoperativly also 12-lead ECGs were recorded before and 1,2,3 days after surgery. Results: The mean VAS scores were signifcantly reduced in G2 allover time in comparison to G1 (p0.05) except at 32hrs postoperatively. Mean time to frst request for rescue analgesic was signifcantly prolonged in G2 compared to G1 (p=0.001). Mean morphine consumption was signifcantly reduced in G2 (p0.001). Mean serum level of CPR increased in both groups. Mean level of serum troponin-T was signifcantly increased only in G1 compared to baseline value (p0.05) with no signifcant difference between G1 and G2. There were 5 patients (16.6%) in G1 and 2 patients (6.6%) in G2 showed serum troponin-T level > 0.03ng/ml. Regarding ECGs changes there were 2 patients (6.6%) in G1 and one patient (3.3%) in G2 showed new ischemic changes postoperatively in the form of depressed ST segment >1mm. Conclusion: The use of LEA with general anesthesia in high risk patients with ischemic heart disease undergoing major non-cardiac surgery is associated with less perioperative acute infammatory response, less post-operative pain and can reduce the perioperative myocardial damage.

Objectives: To assess the long-term analgesic effect of repetitive transcranial stimulation (rTMS) on chronic phantom pain using high frequency stimulation and to measure the serum beta-endorphin level pre- and post-rTMS. Material and methods: The study included 27 patients with unilateral amputation; all patients had chronic phantom pain. The patients were classified into two groups. Seventeen patients received 10 minutes real rTMS over the hand area of motor cortex (20 Hz, 10 second trains, intensity 80% of motor threshold) every day for five consecutive days and 10 patients received sham stimulation. Pain was assessed using a visual analogue scale (VAS) and the Leeds assessment of neuropathic symptoms and signs (LANSS) scale, before and after the first, fifth sessions, one and two months after the last session. Quantitative determination of serum beta-endorphin before and after five sessions was measured. Results: There was no significant difference between true and sham groups in the duration of illness, VAS, LANSS scores and resting motor threshold in upper and lower limb amputation at the base line. VAS and LANS scores of the patients who received real rTMS decreased more over the course of the treatment through the different points of follow-up (after five sessions, one and two months) than those who received sham stimulation. Serum beta-endorphin was increased significantly after real stimulation with no changes in patients received shame. Serum beta-endorphin showed no significant correlation to Hamilton depression, anxiety, VAS and LANS scores in true or sham groups before or after five sessions for rTMS. Conclusion: These results confirm that five daily sessions of rTMS over motor cortex can produce long lasting pain relief in patients with phantom pain and it might be related to an elevation of serum beta-endorphin concentration.

Objectives: To assess the long-term analgesic effect of repetitive transcranial stimulation (rTMS) on chronic phantom pain using high frequency stimulation and to measure the serum beta-endorphin level pre- and post-rTMS. Material and methods: The study included 27 patients with unilateral amputation; all patients had chronic phantom pain. The patients were classified into two groups. Seventeen patients received 10 minutes real rTMS over the hand area of motor cortex (20 Hz, 10 second trains, intensity 80% of motor threshold) every day for five consecutive days and 10 patients received sham stimulation. Pain was assessed using a visual analogue scale (VAS) and the Leeds assessment of neuropathic symptoms and signs (LANSS) scale, before and after the first, fifth sessions, one and two months after the last session. Quantitative determination of serum beta-endorphin before and after five sessions was measured. Results: There was no significant difference between true and sham groups in the duration of illness, VAS, LANSS scores and resting motor threshold in upper and lower limb amputation at the base line. VAS and LANS scores of the patients who received real rTMS decreased more over the course of the treatment through the different points of follow-up (after five sessions, one and two months) than those who received sham stimulation. Serum beta-endorphin was increased significantly after real stimulation with no changes in patients received shame. Serum beta-endorphin showed no significant correlation to Hamilton depression, anxiety, VAS and LANS scores in true or sham groups before or after five sessions for rTMS. Conclusion: These results confirm that five daily sessions of rTMS over motor cortex can produce long lasting pain relief in patients with phantom pain and it might be related to an elevation of serum beta-endorphin concentration.

Objectives: To assess the long-term analgesic effect of repetitive transcranial stimulation (rTMS) on chronic phantom pain using high frequency stimulation and to measure the serum beta-endorphin level pre- and post-rTMS. Material and methods: The study included 27 patients with unilateral amputation; all patients had chronic phantom pain. The patients were classified into two groups. Seventeen patients received 10 minutes real rTMS over the hand area of motor cortex (20 Hz, 10 second trains, intensity 80% of motor threshold) every day for five consecutive days and 10 patients received sham stimulation. Pain was assessed using a visual analogue scale (VAS) and the Leeds assessment of neuropathic symptoms and signs (LANSS) scale, before and after the first, fifth sessions, one and two months after the last session. Quantitative determination of serum beta-endorphin before and after five sessions was measured. Results: There was no significant difference between true and sham groups in the duration of illness, VAS, LANSS scores and resting motor threshold in upper and lower limb amputation at the base line. VAS and LANS scores of the patients who received real rTMS decreased more over the course of the treatment through the different points of follow-up (after five sessions, one and two months) than those who received sham stimulation. Serum beta-endorphin was increased significantly after real stimulation with no changes in patients received shame. Serum beta-endorphin showed no significant correlation to Hamilton depression, anxiety, VAS and LANS scores in true or sham groups before or after five sessions for rTMS. Conclusion: These results confirm that five daily sessions of rTMS over motor cortex can produce long lasting pain relief in patients with phantom pain and it might be related to an elevation of serum beta-endorphin concentration.

Background: Various interventions including the superior hypogastric plexus block and ganglion impar block are commonly used for treatment of pelvic or perineal pain caused by cancer. The inferior hypogastric plexus block through the transsacral approach under fluoroscopy, using a local anesthetics/ steroid combination for the diagnosis and treatment of chronic pain conditions involving the lower pelvic viscera was first described by Schultz in 2007. Neurolysis of the inferior hypogastric plexus could be useful for pelvic and perineal pain caused by cancer. Objectives: Assessment of the feasibility, safety, and efficacy of using the newly introduced inferior hypogastric block by the transsacral approach for relief of cancer related pelvic and perineal pain Methods: Injection of 6-8 ml of phenol 10% bilaterally, by passing a spinal needle through the sacral foramen to do the inferior hypogastric block in 20 patients with cancer pain in the pelvis and /or perineum. We measured VAS, sleep score, activity score, psychological score, and oral morphine (MST) consumption pre and post-procedure. Results: Two patients of the twenty died during the follow-up period, so, they were excluded from the study. All patients presented with cancer related pelvic, perineal, or pelviperineal pain. The mean pain score was reduced from 7.22 (1.31) pre-procedural to 4.06 (1.73) post procedural (P0.05). as well the mean morphine sustained release tablets (MST 30mg) consumption was reduced from 106.67 (32.90) mg to 63.33 (43.52) mg after one week (P0.05). No complications or serious side effects were encountered during or after the block. Discussion and Conclusion: the approach provides a good alternative technique for the treatment of low pelvic and perineal cancer related pain. It requires more studies for evaluation and refinement of the technique using other radiological techniques.