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Relief of intractable pain by the intraspinal (subarachnoid) injection of alcohol
RELIEF OF INTRACTABLE PAIN BY THE INTRASPINAL
(SUBARACHNOID)
INJECTION
ELIAS LINCOLN STERN,
OF ALCOHOL*
M.D.
NEW YORK CITY
T
HIS paper deaIs with the rehef of excruciating pain of a chronic nature. It does not consider the relief of acute surgica1 pain, nor pain of a temporary nature reheved by medication. Chronic, severe pains are usuaIIy caused by chronic pathoIogica1 processes which often cannot be corrected by surgery or medicine. The reIief of severe pain may enable a sufferer to receive more intensive x-ray, radium or other medica treatment which otherwise couId not be tolerated. The importance of being abIe to reIieve chronic sufferers of their pain is very evident, and any effort to do this is a most humane endeavor. Severe chronic pain arising from deepseated Iesions is diffrcuh to stop by paravertebra1 nerve-bIocking for the foIIowing reasons : I. Usually the somatic nerzIes affected by the disturbance are numerous. These nerves are usuaIIy deepIy situated. They may’ be bIocked near their points of origin aIong the side of the spina coIumn by the paravertebra1 method. To bIock, by this method, a11 the afferent pathways invoIved, one wouId have to bIock motor nerves as weI1. 2. Very often fibers of the sympathetic nervous system are invoIved in addition to the irritation of cerebrospinal nerves. In Iesions of the interna organs, these sympathetic nerves are principaIIy invoIved. It is diffrcuIt to effectuaIIy bIock sympathetic fibers paravertebraIIy because of their Iocation. 3. ParavertebraI bIocking is usuaIIy accompanied by some pain and shock, and is time-consuming.
The method of reIieving intractabIe pain by. injecting smaI1 quantities of aIcoho1 intraspmaIIy into the subarachnoid space is a safe, quick, painIess, non-shocking procedure. WhiIe no serious complications have resuIted in my experiences, if the procedure is not done properly, serious, if not fat& resuIts may occur, as demonstrated experimentally in Iower animals. I beIieve that many pains experienced by the human body are due to impuIses transmitted by both somatic and sympathetic fibers. As a ruIe, the svmpathetic component of a pain is not considered, and rareIy do we fathom out its pathways. In considering any procedure which aims towards the bIocking of painfu1 impuIses, one must have in mind this fact: that the pain may be the resuIt of impuIses traveIing over severa different afferent pathways, as we11 as over different types of nerve fibers. The forerunner of the subarachnoid aIcoho1 bIock, was the epidura1 aIcoho1 bIock, conceived by the writer. In some extremely painful peIvic conditions in the Iate stages of cancer, injections of 93 per cent aIcoho1 were made epiduraIIy into the sacra1 canaI.* In some of these cases, whiIe the pain was reIieved, the * These procedures were as follows: I. 35 CL. of z per cent novocaine were injected into the sacraI canal, foIlowed by 39 C.C. of 95 per cent aIcoho1 (Jan. 25, I93zj. 2. q C.C. of z per cent novocaine foIlowed by 35 C.C. of 95 per cent alcoho1. 3. 5 C.C. of z per cent novocaine folIowed by 30 C.C. of 95 per cent aIcoho1. 4. 25 C.C. of 2 per cent novocaine folIowed by 25 C.C. of 95 per cent aIcoho1. 5. 30 C.C. of 2 per cent novocaine folIowed by 25 C.C. of 95 per cent alcohol.
* From the Department of Anatomy, CoIumbia University, Sydenham Flospital, New York. Presented at the meeting 2x7
and the Clinic for the Relief of IntractabIe Pain, of the American Society of Regional Anesthesia.
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procedure was foIIowed by disagreeabIe bIadder and recta1 symptoms. From DogIiotti’s’ report and from my own experiences, aIcoho1 can safeIy be introduced into the subarachnoid space. Again, may I impress upon you at this time, that this type of intraspina1 injection may endanger &e by causing respiratory DaraIvsis or DaraIvsis of the meduIIarv iente;s. .This’ is IikeIy to occur if thi procedure is attempted without a11 due precaution or by one not perfectIy acquainted with the anatomy and the technique. IMPORTANT THE
ANATOMICAL SPINAL
NERVE
DETAILS
OF
ROOTS
Coursing through the cerebrospina1 fIuid, on either side of the spina cord, to penetrate the IateraI waIIs of the dura1 sac, are thirty-one pairs of spina nerve roots, each pair representing an anterior and a posterior root (Fig. I). Sometimes an additiona pair of coccygea1 nerve roots are found in the f&m terminaIe, which is the fineIy eIongated termination of the tip of the spina cord extending verticaIIy downward to the Iowermost part of the dura1 sac. The fiIum terminaIe then pierces the sac, and is attached in the sacra1 cana in the region of the coccyx. In some instances, the coccygea1 nerve is absent, or onIy a few fibers representing its vestigea remains are in the fiIum. Each spina nerve has a dorsa1 and ventraT root. The dorsa1 root enters the posteroIatera1 aspect of the spina cord, by means of from five to ten fiEaments caIIed the fiIa radicuIaria. These fiIaments form the root fan which is the expanded part of the dorsa1 root. The more compact part of the root is known as the radicuIar fascicuIus, or root strand. The fiIaments forming the root fan of the dorsa1 root, spread out usuaIIy from two bundIes of the root strand which in turn, come from the dorsa1 root gangIion. 1DogIiotti, A. M. Traitment des syndromes douloureaux de la pkriphkrie par I’aIcooIisation sub-arachnoidienne des racines posthrieures i Ieur emergence de Ia moeIIe iipini&e. Presse mtd., No. 67 (Aug. ZZ) 1931.
Pain
The anterior, ventra1, or motor root emerges from the anteroIatera1 surface of the cord by means of fine fiIaments, usuaIIy three or four for each root. These fiIaments soon converge into a single compact strand which extends Iateralward to meet the incoming posterior root within or near the intervertebra foramen. The dorsa1 roots carry inpuIses into the spina cord; the ventra1 roots carry impuIses from the spina cord. It is beIieved by some that the dorsa1 root carries some efferent sympathetic fibers. The dorsa1 root is therefore Iarger than the ventra1, and has a greater number of fiIaments entering into the formation of the root fan than does the anterior root. The dorsa1 root, because it is Iarger and less compact than the anterior root, has a greater surface exposed to the cerebrospina1 fluid, and hence to any aIcoho1 which may be introduced into the cerebrospina1 fluid. In the cervica1 region, the nerve roots are reIativeIy short; the Iower cervica1 roots extend the height of one vertebra before entering the cord itseIf; those in the thoracic region extend the height of two to three vertebrae; whiIe the five Iumbar nerves extend the height of four to six vertebra1 bodies, and the five sacra1 nerves, five to eIeven vertebra1 bodies. INTRASPINAL
MEMBRANES
CEREBROSPINAL
AND
FLUID
The pia consists of two main Iayers. The externa1 Iayer consists of paraIIe1 IongitudinaI fibers arranged in thick bundies covered by thin membranes. This Iayer is inconstant. The more essentia1 interna Iayer is generaIIy known as the intima piae. This Iayer is composed of three sheaths: the externa1, consisting of an eIastic, IongitudinaI network; the middIe, composed of circuIar fibers; and the inner Iayer which is a thin membrane cIoseIy investing the spina cord. It consists of connective tissue which accompanies the bIood vesseIs, and forms their adventitia1 tunic. Key and Retzius state that through
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the Iatter a discharge of fluids is effected from the depths of the brain and cord into the subarachnoid spaces. According to Hassin, dense masses of connective tissue strands, or trabecuIae, traverse the space between the pia and the arachnoid. These form a spongy mass containing numerous bIood vesseIs and innumerabIe channeIs which are Iined with mesotheIia1 ceIIs, and which harbor the cerebrospina1 fluid. The mesotheIia1 ceIIs also cover the bIood vesseIs and the a\-ascuIar arachnoid membrane, forming a continuous Iining. It is into this space between the pia and arachnoid membranes that the aIcoho1 is injected in this method of reIieving pain. The arachnoid membrane is composed of two Iayers of connective tissue, the viscera1 Iayer and the parieta1 Iayer. The two Iaminae of arachnoid are separated by a narrow cIeft, the aruchnoid space. The inner Iayer is thin, transparent and extends the entire Iength of cord. It then descends as far as the apex of the dura1 cuI-de-sac and is reflected outward to become continuous with the parieta1 Iayer. The outer Iayer of arachnoid is adherent to the dura by connective tissue trabecuIae. The arachnoid space is traversed by many connective tissue trabecuIae which hoId the two layers together. This membrane is without bIood, but the arachnoid space or cavity is fiIIed with a serous fluid. Extending aIong the dorsa1 midIine of the cord, between arachnoid and pia, and throughout the subarachnoid space, is the so-caIIed dorsal suspense y Zigument qf the cord. This is a reflection of the arachnoid to the pia. Outside of the arachnoid membrane is the duru or pachymeninx. This is a cyIindrica1 tube, extending from the foramen magnum, to which it is cIoseIy adherent by its outer surface, to the second or third sacra1 vertebra. Separate proIongations from the dura1 cul-de-sac form neura1 sheaths about the second, third, fourth, and fifth sacra1 and coccygea1 nerves. The ligumentum denticulutum, or sus-
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219
pensory ligament of the cord forms twentyone denticulations on each side. It extends from the IateraI aspects of the spinal cord
FIG. I. SpinaI cord, lower thoracic region. Dura spk, exposing arachnoid memhranc. Note ninth and tenth thoracic nerves, and vascular suppIy of cord. iPhotograph, courtesy of i\Ir. George E. Higgins.:
through the subarachnoid space to the inner side of the dura, to which it is attached. The ventra1 and dorsa1 root fibers, the bIood vesseIs accompanying the nerve roots, and the denticulations a11 receive an investment of the arachnoid membrane. The potentia1 space between the arachnoid and dura is caIIed the subdural space, in contradistinction to the epidurul, extra-
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or supradural space which Iies dural, between the dura and the bony vertebra1 waI1.
Pain
pockets into which the aIcoho1 tends to rise when the patient is in the correct position for the injection.
n
A FIG. 2. Demonstration
tubes representing
spina cana in various positions to show how alcohot may be Iayered on cerebrospina1 Auid.
The dorsa1 root gangha of the first, second and third sacra1 nerves Iie in the duraI sheaths immediateIy externa1 to the cuI-de-sac, whiIe the gangIia of the fourth and fifth sacra1 and coccygea1 nerves Iie within the bony sacra1 cana at a considerabIe distance from the dura1 cuI-de-sac. Each spina nerve root at its point of entrance into the intervertebra foramen receives a specia1, separate investment of the dura. The ventraI and dorsa1 root strands as they approach each other are encased in separate dura1 sheaths as far out as the IateraI extremity of the spina root ganghon. Where the actua1 junction between the dorsa1 and ventra1 root strands occurs, the two separate sheaths of dura merge, and the mixed nerve is then surrounded by a singIe fibrous sheath. Within the dura the thin arachnoid forms sheaths over the spina nerve roots. These proIongations of arachnoid fuse over the dorsa1 root gangIia. The proIongations of dura and arachnoid around the emergent nerve roots form
The cerebrospina1 ffuid is a coIorIess, transparent and watery Auid, having a specific gravity of 1.007, and a miId aIkaIine reaction. It is secreted to a considerabIe extent by the choroid pIexus. CataboIic products of the metaboIism of the spina cord and brain are beIieved to enter directIy into the formation of cerebrospina fluid. Some beIieve that the fluid has a nutritive roIe in the metaboIism of the nervous tissue which it bathes. In addition to passing through the Pacchionian bodies which are in direct reIationship with the Iarge venous sinuses of the skuI1, it is now beIieved that the cerebrospina1 ffuid circuIates out of the subarachnoid space through the perineura1 spaces of the cerebra1 and spina nerves. PHYSICS
OF
ALCOHOL
SUBARACHNOID
IN THE
SPACE
The specific gravity of the 95 per cent aIcoho1 used by me for intraspina1 injections is 0.806 to 0.810. It is much lighter than cerebrospina1 ffuid whose specific
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gravity is 1.007. One can therefore float the aIcoho1 upon the cerebrospinal fIuid, and by having the patient flex the spine
FIG. 3. Best position
(c), with spine rotated
American Journal
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of Surgrry
221
forward 45 degrees, the upper posterior roots are horizontal. By this method, one attempts to affect these posterior roots by
sIightIy forward, showing floating aIcoho1 affecting posterior roots and dorsal root gangIia.
IateraIIy, Iimit the spread of the aIcoho1 to a particuIar segment. This can be demonstrated in gIass tubes representing the spinal cana1. (Fig. 2.) The aIcoho1 used for this purpose can be coIored with a small amount of methyIene blue and its specific gravity wiI1 be onIy very sIightIy increased, so that it wiI1 serve as an aImost identica1 arrangement as when used in the actua1 procedure. By fiIIing the tubes with water, and then introducing the aIcoho1 stained with the methyIene bIue slowly through a capiIIary tube, one can study the distribution of the aIcoho1 within the tubes. By bending the tubes at different angIes one finds that there is naturaIIy a greater concentration of the aIcoho1 with the tubes bent at the sharper angIes. With the straightest tube, which wouId correspond to the spina cana in a horizonta1 position, there is the greatest amount of spread of aIcoho1. The posterior roots may be considered as Iying in two pIanes which are tangent to the posterior surface of the cord at 45 degrees and 13-j degrees respectiveIy (Fig. 3). Therefore, with the patient in a latera position and with the spine rotated
the floating aIcoho1. on the opposite side reIative angIe of go to be affected by the CLINICAL
The posterior roots are vertica1, or at a degrees to the roots floating aIcoho1.
OBSERVATIONS
SUBAKACHNOID
FOLLOWING
INJECTION
OF
THE
RLCOHOL
When the injection was we11 localized to the roots involved, in the manner just outIined, the relief of pain was quite remarkable. The patiets usually noticed this reIief immediately. OccasionaIIy, compIete reIief was not experienced unti1 from one to seven or more days after the DogIiotti reported cases not injection. relieved unti1 after a Iapse of twenty to thirty days fohowing the injection. The degree of reIief of pain varies with the accuracy of determining the nerve roots to be affected, and the care with which the procedure is carried out. Dogliotti reported the relief of pain up to six months. In my series of cases, a good number have had compIete relief Iasting from one to eight months. A few- had no relief, or very IittIe reIief. No percentage figures for the different types of cases treated can be given because of the smaI1
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number of cases in each type. However IO per cent of the injections given afforded no reIief, whiIe of the remainder, 70 per cent gave compIete reIief, and 30 per cent partia1 reIief. One shouId not expect, in every case, a dramatic reIief of pain as from a Iarge dose of morphine. When compIete relief was obtained immediateIy, the resuIt certainIy was most satisfactory. However, in some cases, it is advisable to inject cautiousIy with rather smaIIer doses, repeated if necessary after severa days. This method of “ feeIing ” one’s way to the exact nerve roots implicated shouId be expIained in advance to the patient and his doctor, so that neither becomes discouraged if compIete reIief is not immediateIy obtained. In the cases observed, foIIowing the injection of aIcoho1 into the subarachnoid space, there was a Ioss of epicritic sensation in the area affected. Sensation of superficia1 touch, pain, tactiIe discrimination, and temperature sense were Iost. There was usuaIIy a Ioss of pressure pain, as evidenced by loss of pain sense on pinching the skin. OccasionaIIy, a Ioss of vibratory sense was noted. The skin over the region usuaIIy became “numb” and there was a sensation of warmth over this area immediateIy upon introducing the aIcoho1. A sharpIy demarcated cutaneous erythema, distributed segmentaIIy according to the region injected, was sometimes noticed. This was evidentIy due to a disturbance of the vasomotor nerves. These observations Ied me to use this method in an attempt to improve the circuIation in cases of periphera1 vascular disease. The effects produced, I beIieve, are due to the action of the alcohol on the posterior nerve roots and the posterior root gangIia, and not on the afferent pathways in the spina cord. In no case has there been any Ioss of muscIe, tendon, or joint sense; no IOSS of synergic controI of muscles; no loss of equihbrium; no Ioss of automatic contro1
Pain
of muscIe; and no trophic uIcerations of any kind.2 In no case has there been any motor paraIysis, aIthough transitory motor weakness may be complained of when the Iarger doses of aIcoho1 are used. A transitory sensory paraIysis of the bIadder and rectum may occur with injections between the second and third Iumbar spines. This can now be avoided by Iimiting the dose at this IeveI to 8~. The factor of drug addiction is a most important consideration in determining the percentage of reIief .obtained. It is advisabIe to inject the sufferer before he becomes addicted to drugs, for once the habit is obtained, the craving for the drugs is most diffIcuIt to contro1. FUNDAMENTAL TECHNIQUE
PRINCIPLES FOR
INJECTION
THE OF
OF
THE
INTRASPINAL ALCOHOL
I. Determine the IeveI, or IeveIs to be bIocked, taking into consideration the somatic as we11 as the sympathetic pathways invoIved in the particuIar case. 2. Take extreme care in putting the patient in the correct position, with the center of the area to be affected uppermost, in the horizonta1 IeveI. Keep the patient’s head Iower than the part of the spine which is to be injected. (Fig. 4.) 3. Under strict asepsis, introduce a fine Iumbar puncture needIe in the midIine of the back, into the subarachnoid space. Obtain free, cIear spina ffuid. Attach the tubercuIin syringe containing the exactIy measured amount of aIcoho1 to be used. If the intraspina1 pressure is low, try biIatera1 pressure on the juguIars, or have the patient cough severa times to increase the pressure. SpinaI fluid may be aspirated in cases of Iow pressure. Inject
* One very recent injection of 30 minims between the tenth and eleventh thoracic spines caused complete Ioss of muscle, tendon and joint sense and Ioss of controI of Iower limbs. Knee jerks and ankIe jerks were preserved. No positive Babinski reflex. The maximum safe dose is 16q.
I\lrn.
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VOL.
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2
between 4 and 16m. of sterile3 95 per cent aIcoho1, whose specific gravity has been measured and found to be below 0.816.
FIG. FIG.
Pain
Frc;.
for lumbar injection.
The dose depends on the Iocation of the injection and the effect desired. Inject the steriIe aIcoho1 very sIowIy, taking between three and four minutes to inject a 16~. dose. Do not barbitage. Inject no air. This causes rapid diffusion of the aIcoho1 in the spina fluid. 4. In cases of fusion of the particuIar part of the spina coIumn, making it dificuIt or impossibIe to enter the cana at the desired Ievel, enter the cana either at a Iower or higher IeveI, and tiIt the patient accordingIy. This will aIIow the aIcoho1 to rise to the desired area. 3. Remove the needIe, after the injection has been compIeted, warning the patient not to move. Maintain this same position of the patient, especiaIIy of the head, for ten minutes by the watch. Be personaIIy responsibIe for the maintenance of this position. 6. Then turn the patient flat on the back, with the foot of the bed eIevated from 4 to 8 inches. Keep the patient in this position for two hours, we11 covered, and protected from draughts. The head may be raised sIightIy after this, but the patient should not sit up unti1 four hours after the injection. 3ParticuIar care must be taken to use sterilized alcohol; 70 to 96 per cent aIcohoI picked at random may contain spore-bearing bnciIIi! The reader is referred to an editoria1 on the subject: Fallacy of considering alcohol an efficient sterilizing medium, New England J. Med. (July 7) 1932.
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;. Keep the patient in bed at least twenty-four hours. Catheterize if necessary. 8. Tide t.he patient over an\’ post-
4A.
4. A. Position
hmrricxn
R. Position
q3.
fox upper thoracic
injection.
injectiona reaction of headache and pain, by the IiberaI use of sedatives. 9. If the patient is unreIieved of pain, and there is no headache, after five or six days inject one or two segments above or beIow the IeveI first injected, depending upon the segments affected as shown by the skin tests. Sometimes the pain Iingers for as Iong as two weeks after an injection, but then the patient may be compIeteIy relieved of pain. IO. Never insert the needIe above the first throacic vertebra. The maximum amount of aIcoho1 which shouId be injected between the first and second thoracic vertebrae shouId not exceed 8nl. When injections are given to affect the brachial pIexus, be extremely carefu1 not to raise the patient’s head. I I. For biIatera1 pain, or pain requiring biIateraI bIock, inject first to affect the side which pains the most. Repeat in six da,ys to affect the other side. 12. It may be necessary to repeat a bIock severa times at the same IeveI unti1 reIief is obtained. This may be due to the fact that the needIe point may enter the subarachnoid space beIow the dorsa1 suspensory Iigament of the spina cord previousIy described. This Iigament may act as a midIine partition through the subarachnoid space. In this event, the aIcoho1 may be Iimited to the lower haIf of the segment under this septum, instead of the
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American Journal of Surgery
upper haIf, aIong the dorsaI nerve roots to be affected. Chart I shows the segments of the spina cord which receive afferent fibers from the various organs and structures which may give rise to pain. This outIine is most important, and is obtained from a carefu1 study of the autonomic innervation of these organs. CHART I AFFERENT
(SENSORY)
INNERVATION
OF
INTERNAL
ORGANS
Diaphragm.
Lungs.. Heart.. Pleura. Aorta SpIeen
..
. . . . . . . _ C 3, 4 (PIeura covering centraI tendon of diaphragm) T I, 2, 3, 4, 5 T I, 2, 3, 4, 5 T I to 12 (inc.)
................
T I to IO (inc.)
Stomach Liver . . , , Pancreas Small intestine) Ascending and transverse colon.. . Descending colon. Rectum, interna sphincter anus.. . Kidney.. . _. Ovaries and testicIes1 Uterus and tubes Ureters SeminaI vesicles J Bladder Urethra . . . . . . . .._...__...
T 5, 6 7, 8, 9
T 2 to T 7 to
12 12
(inc.)
(inc.)
Pain
AUGUST,
I 934
eighth thoracic spines. His pain was reIieved, and he was abIe to eat and take fluids. Morphine was stopped. He gained I o lbs. in eighteen days. Another injection of I I m. was given between the tweIfth thoracic and first lumbar spines eighteen days Iater for some residual pain over the epigastrium and Ieft side of the abdomen. This compIeteIy relieved the patient for about three months. He continued to put on weight, was abIe to get out of bed and heIp himself. The patient, who was actuaIIy a “IifeIess bag of bones” before the first injection, was seen eight months Iater. He had put on weight, was free of pain, had better coIor, and was able to get about. A woman lifty-two years oId, with an inoperable carcinoma of the stomach and marked ascites, had severe pain in the Ieft side of the chest and in the right Iower quadrant. Sixteen minims of 95 per cent aIcoho1 were injected between the right eighth and ninth thoracic spines. Her pain was relieved in both regions after a few days. She died from the carcinoma about two months later. Carcinoma of the Cervix (3 Cases)
The technique as presented in this paper was deveIoped by the author from the cIinicaI experiences of fifty injections.
There were 5 cases, nearIy a11 with the same type of pains in the Iower abdomen, Iower back, and in the Iower extremities. Al1 were completely relieved. Those with unilateral pain received one injection; those with biIatera1 pain each received two injections. One injection was given between the twelfth thoracic and first lumbar spines, three between the first and second Iumbar, two between the second and third Iumbar, and one between the third and fourth Iumbar spines. The best resuIts were obtained when the injections were given between the spines of the upper Iumbar vertebra. The ages of the patients were thirtythree, forty-two, forty-nine, fifty-two, and fifty-three years respectivejy.
Cczrcinoma of the Stomach (2 Cases)
Carcinoma of the Prostate (4 Cases)
The lirst case injected was an inoperabIe carcinoma of the stomach, near the cardia. This patient, aged fifty-two years, was markedIy emaciated on account of severe pain on attempting to eat food or even swaIlow Iiquids. He aIso had severe pains over the Ieft side of the abdomen, especialIy the left upper quadrant. An intraspina1 subarachnoid injection of 8m. of 95 per cent aIcoho1 was given on November 2, 1932 between the seventh and
There were 4 cases with metastases to the peIvic bones or lower spine. The pains were usuaIly over the crest of the ilium, in the groin, across the lower back, in the hip and knee, or the patients had radiating pains down both Iower extremities. The relief obtained was considerabIe, but not as marked as in the cervix cases. One injection was given between the tenth and eIeventh thoracic spines, two between the
... . .
L I, 2, 3 T IO, II, 12, L I T IO, II,
12,
L I, 2, 3, 4
L 1, 2, 3, S 2, 39 4
For purposes of bIocking pain by aIcoho1 injections, the entire body is divided according to Chart II. CASE
REPORTS
Stern-IntractabIe
OUTLlNE
Pain
CHART II FOR REGIONAL ALCOHOL PAIN BLOCKIW* -I‘rigeminal
, II, (a) (b) ic)
b&k
(a) Paravertebral, between first and second ribs (b) Subarachnoid T 1-2. Especiallv important in connection with trig&nit1 pain or neuraIgia.
Head
ganglion bIock
Neck
3ervicaI pIexus bIock
Upper extremity
3uharachnoid
Chest
III divisions: Terminal nerves SubgangIionic block Gasserian ganglion block
sym,
‘aravertebral T 2-3 ExceptionaI,
block
Larynx Trachea Bronchi Lungs Heart?
T 3-4
Aorta. Esophagus.
Subarachnoid
bIock
PIeura
Jpper part >ower part
T 3-4 T 8-9
Entire Jpper part Lower part
T 6-7 or T 7-8 T 3-4 T 8-9
Aorta* Spleen
Abdomen
T j-6
Stomach. Liver. P ancreas. SmaII intestine.
T 67 Subarachnoid
PeIvis
Ovaries Testicles Uterus* Tubes Ureters S eminal vesicIes Prostate. Urethra. Bladder* _
4scending
T I 1-12 or T 12-1-1 and transverse colon T 4-5 T 11-12
gIand
T rz-LI Subarachnoid
and L 4-5
block
Rectum-anus. Lower extremity
or T 7-8
bIock
co1on*
Kidney-suprarenal
T 1-2
L 4-f Subarachnoid
bIock
r I 1-12 (sympathetic)
* Notes: I. l Lesions affecting these organs usuaIIy invoIve the sympathetic
and L 1-2 (somatic)
nerves of both sides. BiIatrraI (right and left) injections should be given in these cases. 2. I” bIocking the long viscera, aorta, small and Iarge intestines, or in specia1 cases, it may be necessary to repeat the bIock one or severa segments higher or Iower than the IevcIs given above. 3. This outline applies only to the adult body.
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American Journal of Surgery
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twelfth thoracic and first Iumbar, one between the first and second lumbar, and three between the second and third lumbar. Best resuIts were obtained between the tweIfth thoracic and first Iumbar, or first and second Iumbar. Sensory paraIysis of the rectum and bIadder are apt to occur between the second and third Iumbar spines, especiaIIy with doses greater than 8r(l. The ages of these patients were fifty, fifty-six, sixty-eight, and sixty-eight respectiveIy. Carcinoma of the Rectum (4 Cases) There were 4 such cases, each with excruciating pains in the rectum and ana regions. One injection of 16nl. between the second and third lumbar spines reIieved the patient, but caused sensory bIadder paraIysis for one week. One injection was given between the third and fourth Iumbar spines, with considerable reIief. Two of 16’1Q. each were given between the fourth and fifth Iumbar spines, with compIete reIief and no bIadder or recta1 comp1ication.s. One case had severe dysuria from a complicating cystitis, for which an injection of 16l?l.. between the first and second lumbar spines on one side gave some relief. The best resuIts were obtained between the fourth and fifth Iumbar spines. Not onIy was the painreIieved but recta1 tenesmus was stopped aIlowing thorough recta1 examinations and cIeansing, and faciIitating the direct appIication of radium. The ages of these patients were thirtyfive, forty-eight, fifty-seven and sixty-five respectiveIy. Sarcoma
of the Pelvic Bones (2 Cases)
One case was that of an osteogenic sarcoma of the Ieft pubic bone in a woman sixty years oId. She had excruciating pains over the Ieft groin and Ieft Iower quadrant, and aIso over the anterior part of the Ieft thigh, knee and ankIe. An injection of 8m. between the first and second Iumbar spines gave considerabIe relief for four months. The pubic region became absoIuteIy insensitive after the injection. Another case of Ewing’s sarcoma, in a man twenty-six years oId, presented a Iarge painfu1 mass over the Ieft ilium. Injection of 16?ll. between the tweIfth thoracic and first Iumbar spines gave considerabIe reIief, enabIing the patient to Iie on his Ieft side without having any pain.
Pain Carcinoma of the Lung (I Case) A case of bronchiogenic carcinoma with metastases occurred in a man forty-seven years of age, who had severe pains over both sides of the abdomen, and over the Iower back. An injection of 8?ll. between the eighth andninth thoracic spines for the right side, reIieved the pain on the right side of his back and both sides of his abdomen. He stiI1 had pains over the Ieft side of his back. This observation is comparabIe to that of the second case of carcinoma of the stomach recorded, in which pain on the right side of the abdomen was relieved by an injection between the eighth and ninth thoracic spines on the opposite side. This fact may be expIained by a crossing of the afferent spIanchnit innervation of the abdomina1 viscera. Sarcoma of the Tibia (I Case) A man, thirty-one years oId, with a sarcoma of the left ankIe and metastases to his Iungs, had a very painfu1 x-ray uIceration of the Ieft inner maIIeoIus. He was unabIe to bear weight on this foot, no Iess have the uIcer touched. A recent injection of 161fl. between the 2nd and 3rd lumbar spines gave him immediate reIief of pain. Ten d ays Iater he was compIeteIy reIieved, and abIe to put his weight on that foot. The uIcer, which previousIy had shown no signs of heaIing began to hea after the injection. Twenty-sixinjections of aIcoho1 were done in this group of Ig cancer cases. Twenty-four other injections were given for severe pain caused by conditions other than cancer. These cases wiI1 be reported at a Iater date under their respective CIassifications. SUMMARY I. CIinicaI observations foIIowing fifty intraspina1 subarachnoid injections of 95 per cent aIcoho1 * demonstrate that the procedure is a practica1 and safe one when done properIy. As shown experimentaIIy, it is dangerous to Iife when done improperly. * The author has obtained somewhat better resuIts recently with the use of absoIute akohol instead of 0.~ Der cent aIcoho1. This aIcoho1. fiItered and boiIed // is avaiIabIe in convenient steriIe under pressure, ampuIes containing 2 C.C. each. I
Stern-IntractabIe 2. Used properly, aIcoho1 usualIy rehe\-es intractabIe pain, and may cause onIy partiaI anesthesia, but does not paraIyze muscIes. 3. The fundamenta1 principIes of technique for the intraspina1 subarachnoid injection of aIcoho1 are given. _c. Abstracts of 19 cases of cancer are given, as foIIows: Carcinoma of stomach.. . . . . . 2 Carcinoma of cervix. . . . $ Carcinoma of prostate. . .. . 4 Carcinoma of rectum.. . . 4 Sarcoma of peIvic bones. 2 Bronchiogenic carcinoma of Iung. . . I Sarcoma of tibia with x-ray uIceration. . . I 5. The procedure when successfu1 is invaIuabIe in the reIief of chronic, painfur conditions. A singIe, subarachnoid aIcoho1 injection may give reIief for as Iong as It obviates the necessity eight months. for using narcotics in Iarge doses, and diminishes the possibiIity of making drug
REFERENCES
Open pneumo-thorax; its relation to the treatment of empyema. Am. J. M. SC., 156: 839, 1918. BERRY, F. B., and CHILDS, E. P. The fissures of the Iungs. Ann. Surg., 96: 961, 1932. BETTMAN, R. B. The treatment of acute empyema. Surg. Gynec. Ohst., 54: 39, 1932. COHEN, M. Acute suppurative pIeurisy in children. Surg. Gynec. Obst., 54: 696, 1932. DAXA, J. A. Some principles involved in the pathoIogy and treatment of empyema thoracis with particuIar reference to treatment by periodic aspiration or evacuation with air repIacement without drainage. Surg. Gynec. Obst., 54: 296, 1932. GRAHAM, E. A. Principles invoIved in the treatment of acute and chronic empyema. Surg. Gynec. Obst., 38: 466, 1924. * Continued
BELL and GRAHAM.
Pain fiends of chronic invalids. Bv reIieving it aIIows more intensive x-ray, pain, radium, or other medica treatment to be given, and so tends to proIong Iife. 6. There is some cIinica1 e\-idence that sympathetic fibers are affected b\- 94 per cent aIcoho1 when introduced into the subarachnoid space. This method therefore promises to be one of vaIue in the treatment of diseases and disorders of the sympathetic nervous system. Through the courtesy of the New ‘r’ork City Cancer Institute, Dr. Ira I. KapIan, Director, the author was prkileged to apply this method on 9 patients at the Welfare Island Cancer Hospital. These cases are incIuded in this report. Appreciation for this courtesy is herewith acknowIedged. I am aIso indebted to Dr. Q’m. )I. Rogers of the Department of Anatomy at the CoIIege of Physicians and Surgeons, for his TaIuabIe assistance in the experimental in\-estigations and in the preparation of this paper.
OF
DR.
FRANK*
HART, D. Treatment of chronic empycma by tidal irrigation, suction and thoracoplasty. J. 7%oracic Surg., 2: 157, 1932. HEAD, J. R. Empyema with bronchia tistula simuIating Iung abscess and bronchiectasis. Surg. Gynec. Obst.. 53: 691, 1931. HEDBLOM, C. A. Treatment of empyema. J. A. ,M. A., 97: 1943, ‘931. hlLLLER, G. P. Mortality of empyema. J. Tboracic Surg., 1: 15, ‘932. OCHSNER, A., and GAGE, J. hl. Acute empyema thoracis. Trans. South. Surg. Assn., rq.: 451, 1901. PACKARD, G. B., JR. Empyema in chiIdren. Surg. Gynec. Obst., 53: 255, 1931. WILLIS, B. C. Diagnosis and treatment of empyema in chiIdren. Southern M. J., 24: 785. from p. 216.
(SUBARACHNOID)
INJECTION
ELIAS LINCOLN STERN,
OF ALCOHOL*
M.D.
NEW YORK CITY
T
HIS paper deaIs with the rehef of excruciating pain of a chronic nature. It does not consider the relief of acute surgica1 pain, nor pain of a temporary nature reheved by medication. Chronic, severe pains are usuaIIy caused by chronic pathoIogica1 processes which often cannot be corrected by surgery or medicine. The reIief of severe pain may enable a sufferer to receive more intensive x-ray, radium or other medica treatment which otherwise couId not be tolerated. The importance of being abIe to reIieve chronic sufferers of their pain is very evident, and any effort to do this is a most humane endeavor. Severe chronic pain arising from deepseated Iesions is diffrcuh to stop by paravertebra1 nerve-bIocking for the foIIowing reasons : I. Usually the somatic nerzIes affected by the disturbance are numerous. These nerves are usuaIIy deepIy situated. They may’ be bIocked near their points of origin aIong the side of the spina coIumn by the paravertebra1 method. To bIock, by this method, a11 the afferent pathways invoIved, one wouId have to bIock motor nerves as weI1. 2. Very often fibers of the sympathetic nervous system are invoIved in addition to the irritation of cerebrospinal nerves. In Iesions of the interna organs, these sympathetic nerves are principaIIy invoIved. It is diffrcuIt to effectuaIIy bIock sympathetic fibers paravertebraIIy because of their Iocation. 3. ParavertebraI bIocking is usuaIIy accompanied by some pain and shock, and is time-consuming.
The method of reIieving intractabIe pain by. injecting smaI1 quantities of aIcoho1 intraspmaIIy into the subarachnoid space is a safe, quick, painIess, non-shocking procedure. WhiIe no serious complications have resuIted in my experiences, if the procedure is not done properly, serious, if not fat& resuIts may occur, as demonstrated experimentally in Iower animals. I beIieve that many pains experienced by the human body are due to impuIses transmitted by both somatic and sympathetic fibers. As a ruIe, the svmpathetic component of a pain is not considered, and rareIy do we fathom out its pathways. In considering any procedure which aims towards the bIocking of painfu1 impuIses, one must have in mind this fact: that the pain may be the resuIt of impuIses traveIing over severa different afferent pathways, as we11 as over different types of nerve fibers. The forerunner of the subarachnoid aIcoho1 bIock, was the epidura1 aIcoho1 bIock, conceived by the writer. In some extremely painful peIvic conditions in the Iate stages of cancer, injections of 93 per cent aIcoho1 were made epiduraIIy into the sacra1 canaI.* In some of these cases, whiIe the pain was reIieved, the * These procedures were as follows: I. 35 CL. of z per cent novocaine were injected into the sacraI canal, foIlowed by 39 C.C. of 95 per cent aIcoho1 (Jan. 25, I93zj. 2. q C.C. of z per cent novocaine foIlowed by 35 C.C. of 95 per cent alcoho1. 3. 5 C.C. of z per cent novocaine folIowed by 30 C.C. of 95 per cent aIcoho1. 4. 25 C.C. of 2 per cent novocaine folIowed by 25 C.C. of 95 per cent aIcoho1. 5. 30 C.C. of 2 per cent novocaine folIowed by 25 C.C. of 95 per cent alcohol.
* From the Department of Anatomy, CoIumbia University, Sydenham Flospital, New York. Presented at the meeting 2x7
and the Clinic for the Relief of IntractabIe Pain, of the American Society of Regional Anesthesia.
218
American
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Stern-IntractabIe
procedure was foIIowed by disagreeabIe bIadder and recta1 symptoms. From DogIiotti’s’ report and from my own experiences, aIcoho1 can safeIy be introduced into the subarachnoid space. Again, may I impress upon you at this time, that this type of intraspina1 injection may endanger &e by causing respiratory DaraIvsis or DaraIvsis of the meduIIarv iente;s. .This’ is IikeIy to occur if thi procedure is attempted without a11 due precaution or by one not perfectIy acquainted with the anatomy and the technique. IMPORTANT THE
ANATOMICAL SPINAL
NERVE
DETAILS
OF
ROOTS
Coursing through the cerebrospina1 fIuid, on either side of the spina cord, to penetrate the IateraI waIIs of the dura1 sac, are thirty-one pairs of spina nerve roots, each pair representing an anterior and a posterior root (Fig. I). Sometimes an additiona pair of coccygea1 nerve roots are found in the f&m terminaIe, which is the fineIy eIongated termination of the tip of the spina cord extending verticaIIy downward to the Iowermost part of the dura1 sac. The fiIum terminaIe then pierces the sac, and is attached in the sacra1 cana in the region of the coccyx. In some instances, the coccygea1 nerve is absent, or onIy a few fibers representing its vestigea remains are in the fiIum. Each spina nerve has a dorsa1 and ventraT root. The dorsa1 root enters the posteroIatera1 aspect of the spina cord, by means of from five to ten fiEaments caIIed the fiIa radicuIaria. These fiIaments form the root fan which is the expanded part of the dorsa1 root. The more compact part of the root is known as the radicuIar fascicuIus, or root strand. The fiIaments forming the root fan of the dorsa1 root, spread out usuaIIy from two bundIes of the root strand which in turn, come from the dorsa1 root gangIion. 1DogIiotti, A. M. Traitment des syndromes douloureaux de la pkriphkrie par I’aIcooIisation sub-arachnoidienne des racines posthrieures i Ieur emergence de Ia moeIIe iipini&e. Presse mtd., No. 67 (Aug. ZZ) 1931.
Pain
The anterior, ventra1, or motor root emerges from the anteroIatera1 surface of the cord by means of fine fiIaments, usuaIIy three or four for each root. These fiIaments soon converge into a single compact strand which extends Iateralward to meet the incoming posterior root within or near the intervertebra foramen. The dorsa1 roots carry inpuIses into the spina cord; the ventra1 roots carry impuIses from the spina cord. It is beIieved by some that the dorsa1 root carries some efferent sympathetic fibers. The dorsa1 root is therefore Iarger than the ventra1, and has a greater number of fiIaments entering into the formation of the root fan than does the anterior root. The dorsa1 root, because it is Iarger and less compact than the anterior root, has a greater surface exposed to the cerebrospina1 fluid, and hence to any aIcoho1 which may be introduced into the cerebrospina1 fluid. In the cervica1 region, the nerve roots are reIativeIy short; the Iower cervica1 roots extend the height of one vertebra before entering the cord itseIf; those in the thoracic region extend the height of two to three vertebrae; whiIe the five Iumbar nerves extend the height of four to six vertebra1 bodies, and the five sacra1 nerves, five to eIeven vertebra1 bodies. INTRASPINAL
MEMBRANES
CEREBROSPINAL
AND
FLUID
The pia consists of two main Iayers. The externa1 Iayer consists of paraIIe1 IongitudinaI fibers arranged in thick bundies covered by thin membranes. This Iayer is inconstant. The more essentia1 interna Iayer is generaIIy known as the intima piae. This Iayer is composed of three sheaths: the externa1, consisting of an eIastic, IongitudinaI network; the middIe, composed of circuIar fibers; and the inner Iayer which is a thin membrane cIoseIy investing the spina cord. It consists of connective tissue which accompanies the bIood vesseIs, and forms their adventitia1 tunic. Key and Retzius state that through
NEW
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Stern-IntractabIe
the Iatter a discharge of fluids is effected from the depths of the brain and cord into the subarachnoid spaces. According to Hassin, dense masses of connective tissue strands, or trabecuIae, traverse the space between the pia and the arachnoid. These form a spongy mass containing numerous bIood vesseIs and innumerabIe channeIs which are Iined with mesotheIia1 ceIIs, and which harbor the cerebrospina1 fluid. The mesotheIia1 ceIIs also cover the bIood vesseIs and the a\-ascuIar arachnoid membrane, forming a continuous Iining. It is into this space between the pia and arachnoid membranes that the aIcoho1 is injected in this method of reIieving pain. The arachnoid membrane is composed of two Iayers of connective tissue, the viscera1 Iayer and the parieta1 Iayer. The two Iaminae of arachnoid are separated by a narrow cIeft, the aruchnoid space. The inner Iayer is thin, transparent and extends the entire Iength of cord. It then descends as far as the apex of the dura1 cuI-de-sac and is reflected outward to become continuous with the parieta1 Iayer. The outer Iayer of arachnoid is adherent to the dura by connective tissue trabecuIae. The arachnoid space is traversed by many connective tissue trabecuIae which hoId the two layers together. This membrane is without bIood, but the arachnoid space or cavity is fiIIed with a serous fluid. Extending aIong the dorsa1 midIine of the cord, between arachnoid and pia, and throughout the subarachnoid space, is the so-caIIed dorsal suspense y Zigument qf the cord. This is a reflection of the arachnoid to the pia. Outside of the arachnoid membrane is the duru or pachymeninx. This is a cyIindrica1 tube, extending from the foramen magnum, to which it is cIoseIy adherent by its outer surface, to the second or third sacra1 vertebra. Separate proIongations from the dura1 cul-de-sac form neura1 sheaths about the second, third, fourth, and fifth sacra1 and coccygea1 nerves. The ligumentum denticulutum, or sus-
Pain
An~hxn
Journal 01 S,,rnvrv
219
pensory ligament of the cord forms twentyone denticulations on each side. It extends from the IateraI aspects of the spinal cord
FIG. I. SpinaI cord, lower thoracic region. Dura spk, exposing arachnoid memhranc. Note ninth and tenth thoracic nerves, and vascular suppIy of cord. iPhotograph, courtesy of i\Ir. George E. Higgins.:
through the subarachnoid space to the inner side of the dura, to which it is attached. The ventra1 and dorsa1 root fibers, the bIood vesseIs accompanying the nerve roots, and the denticulations a11 receive an investment of the arachnoid membrane. The potentia1 space between the arachnoid and dura is caIIed the subdural space, in contradistinction to the epidurul, extra-
220
American
Journal
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Stern-IntractabIe
or supradural space which Iies dural, between the dura and the bony vertebra1 waI1.
Pain
pockets into which the aIcoho1 tends to rise when the patient is in the correct position for the injection.
n
A FIG. 2. Demonstration
tubes representing
spina cana in various positions to show how alcohot may be Iayered on cerebrospina1 Auid.
The dorsa1 root gangha of the first, second and third sacra1 nerves Iie in the duraI sheaths immediateIy externa1 to the cuI-de-sac, whiIe the gangIia of the fourth and fifth sacra1 and coccygea1 nerves Iie within the bony sacra1 cana at a considerabIe distance from the dura1 cuI-de-sac. Each spina nerve root at its point of entrance into the intervertebra foramen receives a specia1, separate investment of the dura. The ventraI and dorsa1 root strands as they approach each other are encased in separate dura1 sheaths as far out as the IateraI extremity of the spina root ganghon. Where the actua1 junction between the dorsa1 and ventra1 root strands occurs, the two separate sheaths of dura merge, and the mixed nerve is then surrounded by a singIe fibrous sheath. Within the dura the thin arachnoid forms sheaths over the spina nerve roots. These proIongations of arachnoid fuse over the dorsa1 root gangIia. The proIongations of dura and arachnoid around the emergent nerve roots form
The cerebrospina1 ffuid is a coIorIess, transparent and watery Auid, having a specific gravity of 1.007, and a miId aIkaIine reaction. It is secreted to a considerabIe extent by the choroid pIexus. CataboIic products of the metaboIism of the spina cord and brain are beIieved to enter directIy into the formation of cerebrospina fluid. Some beIieve that the fluid has a nutritive roIe in the metaboIism of the nervous tissue which it bathes. In addition to passing through the Pacchionian bodies which are in direct reIationship with the Iarge venous sinuses of the skuI1, it is now beIieved that the cerebrospina1 ffuid circuIates out of the subarachnoid space through the perineura1 spaces of the cerebra1 and spina nerves. PHYSICS
OF
ALCOHOL
SUBARACHNOID
IN THE
SPACE
The specific gravity of the 95 per cent aIcoho1 used by me for intraspina1 injections is 0.806 to 0.810. It is much lighter than cerebrospina1 ffuid whose specific
NE\\ SERIFS
VOL. XXV,
No.
2
Stern-IntractabIe
gravity is 1.007. One can therefore float the aIcoho1 upon the cerebrospinal fIuid, and by having the patient flex the spine
FIG. 3. Best position
(c), with spine rotated
American Journal
Pain
of Surgrry
221
forward 45 degrees, the upper posterior roots are horizontal. By this method, one attempts to affect these posterior roots by
sIightIy forward, showing floating aIcoho1 affecting posterior roots and dorsal root gangIia.
IateraIIy, Iimit the spread of the aIcoho1 to a particuIar segment. This can be demonstrated in gIass tubes representing the spinal cana1. (Fig. 2.) The aIcoho1 used for this purpose can be coIored with a small amount of methyIene blue and its specific gravity wiI1 be onIy very sIightIy increased, so that it wiI1 serve as an aImost identica1 arrangement as when used in the actua1 procedure. By fiIIing the tubes with water, and then introducing the aIcoho1 stained with the methyIene bIue slowly through a capiIIary tube, one can study the distribution of the aIcoho1 within the tubes. By bending the tubes at different angIes one finds that there is naturaIIy a greater concentration of the aIcoho1 with the tubes bent at the sharper angIes. With the straightest tube, which wouId correspond to the spina cana in a horizonta1 position, there is the greatest amount of spread of aIcoho1. The posterior roots may be considered as Iying in two pIanes which are tangent to the posterior surface of the cord at 45 degrees and 13-j degrees respectiveIy (Fig. 3). Therefore, with the patient in a latera position and with the spine rotated
the floating aIcoho1. on the opposite side reIative angIe of go to be affected by the CLINICAL
The posterior roots are vertica1, or at a degrees to the roots floating aIcoho1.
OBSERVATIONS
SUBAKACHNOID
FOLLOWING
INJECTION
OF
THE
RLCOHOL
When the injection was we11 localized to the roots involved, in the manner just outIined, the relief of pain was quite remarkable. The patiets usually noticed this reIief immediately. OccasionaIIy, compIete reIief was not experienced unti1 from one to seven or more days after the DogIiotti reported cases not injection. relieved unti1 after a Iapse of twenty to thirty days fohowing the injection. The degree of reIief of pain varies with the accuracy of determining the nerve roots to be affected, and the care with which the procedure is carried out. Dogliotti reported the relief of pain up to six months. In my series of cases, a good number have had compIete relief Iasting from one to eight months. A few- had no relief, or very IittIe reIief. No percentage figures for the different types of cases treated can be given because of the smaI1
222
American Journal of Surgery
Stern-IntractabIe
number of cases in each type. However IO per cent of the injections given afforded no reIief, whiIe of the remainder, 70 per cent gave compIete reIief, and 30 per cent partia1 reIief. One shouId not expect, in every case, a dramatic reIief of pain as from a Iarge dose of morphine. When compIete relief was obtained immediateIy, the resuIt certainIy was most satisfactory. However, in some cases, it is advisable to inject cautiousIy with rather smaIIer doses, repeated if necessary after severa days. This method of “ feeIing ” one’s way to the exact nerve roots implicated shouId be expIained in advance to the patient and his doctor, so that neither becomes discouraged if compIete reIief is not immediateIy obtained. In the cases observed, foIIowing the injection of aIcoho1 into the subarachnoid space, there was a Ioss of epicritic sensation in the area affected. Sensation of superficia1 touch, pain, tactiIe discrimination, and temperature sense were Iost. There was usuaIIy a Ioss of pressure pain, as evidenced by loss of pain sense on pinching the skin. OccasionaIIy, a Ioss of vibratory sense was noted. The skin over the region usuaIIy became “numb” and there was a sensation of warmth over this area immediateIy upon introducing the aIcoho1. A sharpIy demarcated cutaneous erythema, distributed segmentaIIy according to the region injected, was sometimes noticed. This was evidentIy due to a disturbance of the vasomotor nerves. These observations Ied me to use this method in an attempt to improve the circuIation in cases of periphera1 vascular disease. The effects produced, I beIieve, are due to the action of the alcohol on the posterior nerve roots and the posterior root gangIia, and not on the afferent pathways in the spina cord. In no case has there been any Ioss of muscIe, tendon, or joint sense; no IOSS of synergic controI of muscles; no loss of equihbrium; no Ioss of automatic contro1
Pain
of muscIe; and no trophic uIcerations of any kind.2 In no case has there been any motor paraIysis, aIthough transitory motor weakness may be complained of when the Iarger doses of aIcoho1 are used. A transitory sensory paraIysis of the bIadder and rectum may occur with injections between the second and third Iumbar spines. This can now be avoided by Iimiting the dose at this IeveI to 8~. The factor of drug addiction is a most important consideration in determining the percentage of reIief .obtained. It is advisabIe to inject the sufferer before he becomes addicted to drugs, for once the habit is obtained, the craving for the drugs is most diffIcuIt to contro1. FUNDAMENTAL TECHNIQUE
PRINCIPLES FOR
INJECTION
THE OF
OF
THE
INTRASPINAL ALCOHOL
I. Determine the IeveI, or IeveIs to be bIocked, taking into consideration the somatic as we11 as the sympathetic pathways invoIved in the particuIar case. 2. Take extreme care in putting the patient in the correct position, with the center of the area to be affected uppermost, in the horizonta1 IeveI. Keep the patient’s head Iower than the part of the spine which is to be injected. (Fig. 4.) 3. Under strict asepsis, introduce a fine Iumbar puncture needIe in the midIine of the back, into the subarachnoid space. Obtain free, cIear spina ffuid. Attach the tubercuIin syringe containing the exactIy measured amount of aIcoho1 to be used. If the intraspina1 pressure is low, try biIatera1 pressure on the juguIars, or have the patient cough severa times to increase the pressure. SpinaI fluid may be aspirated in cases of Iow pressure. Inject
* One very recent injection of 30 minims between the tenth and eleventh thoracic spines caused complete Ioss of muscle, tendon and joint sense and Ioss of controI of Iower limbs. Knee jerks and ankIe jerks were preserved. No positive Babinski reflex. The maximum safe dose is 16q.
I\lrn.
SEHI~S
VOL.
XXV,
No.
Stern-Intractable
2
between 4 and 16m. of sterile3 95 per cent aIcoho1, whose specific gravity has been measured and found to be below 0.816.
FIG. FIG.
Pain
Frc;.
for lumbar injection.
The dose depends on the Iocation of the injection and the effect desired. Inject the steriIe aIcoho1 very sIowIy, taking between three and four minutes to inject a 16~. dose. Do not barbitage. Inject no air. This causes rapid diffusion of the aIcoho1 in the spina fluid. 4. In cases of fusion of the particuIar part of the spina coIumn, making it dificuIt or impossibIe to enter the cana at the desired Ievel, enter the cana either at a Iower or higher IeveI, and tiIt the patient accordingIy. This will aIIow the aIcoho1 to rise to the desired area. 3. Remove the needIe, after the injection has been compIeted, warning the patient not to move. Maintain this same position of the patient, especiaIIy of the head, for ten minutes by the watch. Be personaIIy responsibIe for the maintenance of this position. 6. Then turn the patient flat on the back, with the foot of the bed eIevated from 4 to 8 inches. Keep the patient in this position for two hours, we11 covered, and protected from draughts. The head may be raised sIightIy after this, but the patient should not sit up unti1 four hours after the injection. 3ParticuIar care must be taken to use sterilized alcohol; 70 to 96 per cent aIcohoI picked at random may contain spore-bearing bnciIIi! The reader is referred to an editoria1 on the subject: Fallacy of considering alcohol an efficient sterilizing medium, New England J. Med. (July 7) 1932.
Jcturnal
01 Slil gcrv
223
;. Keep the patient in bed at least twenty-four hours. Catheterize if necessary. 8. Tide t.he patient over an\’ post-
4A.
4. A. Position
hmrricxn
R. Position
q3.
fox upper thoracic
injection.
injectiona reaction of headache and pain, by the IiberaI use of sedatives. 9. If the patient is unreIieved of pain, and there is no headache, after five or six days inject one or two segments above or beIow the IeveI first injected, depending upon the segments affected as shown by the skin tests. Sometimes the pain Iingers for as Iong as two weeks after an injection, but then the patient may be compIeteIy relieved of pain. IO. Never insert the needIe above the first throacic vertebra. The maximum amount of aIcoho1 which shouId be injected between the first and second thoracic vertebrae shouId not exceed 8nl. When injections are given to affect the brachial pIexus, be extremely carefu1 not to raise the patient’s head. I I. For biIatera1 pain, or pain requiring biIateraI bIock, inject first to affect the side which pains the most. Repeat in six da,ys to affect the other side. 12. It may be necessary to repeat a bIock severa times at the same IeveI unti1 reIief is obtained. This may be due to the fact that the needIe point may enter the subarachnoid space beIow the dorsa1 suspensory Iigament of the spina cord previousIy described. This Iigament may act as a midIine partition through the subarachnoid space. In this event, the aIcoho1 may be Iimited to the lower haIf of the segment under this septum, instead of the
224
Stern-IntractabIe
American Journal of Surgery
upper haIf, aIong the dorsaI nerve roots to be affected. Chart I shows the segments of the spina cord which receive afferent fibers from the various organs and structures which may give rise to pain. This outIine is most important, and is obtained from a carefu1 study of the autonomic innervation of these organs. CHART I AFFERENT
(SENSORY)
INNERVATION
OF
INTERNAL
ORGANS
Diaphragm.
Lungs.. Heart.. Pleura. Aorta SpIeen
..
. . . . . . . _ C 3, 4 (PIeura covering centraI tendon of diaphragm) T I, 2, 3, 4, 5 T I, 2, 3, 4, 5 T I to 12 (inc.)
................
T I to IO (inc.)
Stomach Liver . . , , Pancreas Small intestine) Ascending and transverse colon.. . Descending colon. Rectum, interna sphincter anus.. . Kidney.. . _. Ovaries and testicIes1 Uterus and tubes Ureters SeminaI vesicles J Bladder Urethra . . . . . . . .._...__...
T 5, 6 7, 8, 9
T 2 to T 7 to
12 12
(inc.)
(inc.)
Pain
AUGUST,
I 934
eighth thoracic spines. His pain was reIieved, and he was abIe to eat and take fluids. Morphine was stopped. He gained I o lbs. in eighteen days. Another injection of I I m. was given between the tweIfth thoracic and first lumbar spines eighteen days Iater for some residual pain over the epigastrium and Ieft side of the abdomen. This compIeteIy relieved the patient for about three months. He continued to put on weight, was abIe to get out of bed and heIp himself. The patient, who was actuaIIy a “IifeIess bag of bones” before the first injection, was seen eight months Iater. He had put on weight, was free of pain, had better coIor, and was able to get about. A woman lifty-two years oId, with an inoperable carcinoma of the stomach and marked ascites, had severe pain in the Ieft side of the chest and in the right Iower quadrant. Sixteen minims of 95 per cent aIcoho1 were injected between the right eighth and ninth thoracic spines. Her pain was relieved in both regions after a few days. She died from the carcinoma about two months later. Carcinoma of the Cervix (3 Cases)
The technique as presented in this paper was deveIoped by the author from the cIinicaI experiences of fifty injections.
There were 5 cases, nearIy a11 with the same type of pains in the Iower abdomen, Iower back, and in the Iower extremities. Al1 were completely relieved. Those with unilateral pain received one injection; those with biIatera1 pain each received two injections. One injection was given between the twelfth thoracic and first lumbar spines, three between the first and second Iumbar, two between the second and third Iumbar, and one between the third and fourth Iumbar spines. The best resuIts were obtained when the injections were given between the spines of the upper Iumbar vertebra. The ages of the patients were thirtythree, forty-two, forty-nine, fifty-two, and fifty-three years respectivejy.
Cczrcinoma of the Stomach (2 Cases)
Carcinoma of the Prostate (4 Cases)
The lirst case injected was an inoperabIe carcinoma of the stomach, near the cardia. This patient, aged fifty-two years, was markedIy emaciated on account of severe pain on attempting to eat food or even swaIlow Iiquids. He aIso had severe pains over the Ieft side of the abdomen, especialIy the left upper quadrant. An intraspina1 subarachnoid injection of 8m. of 95 per cent aIcoho1 was given on November 2, 1932 between the seventh and
There were 4 cases with metastases to the peIvic bones or lower spine. The pains were usuaIly over the crest of the ilium, in the groin, across the lower back, in the hip and knee, or the patients had radiating pains down both Iower extremities. The relief obtained was considerabIe, but not as marked as in the cervix cases. One injection was given between the tenth and eIeventh thoracic spines, two between the
... . .
L I, 2, 3 T IO, II, 12, L I T IO, II,
12,
L I, 2, 3, 4
L 1, 2, 3, S 2, 39 4
For purposes of bIocking pain by aIcoho1 injections, the entire body is divided according to Chart II. CASE
REPORTS
Stern-IntractabIe
OUTLlNE
Pain
CHART II FOR REGIONAL ALCOHOL PAIN BLOCKIW* -I‘rigeminal
, II, (a) (b) ic)
b&k
(a) Paravertebral, between first and second ribs (b) Subarachnoid T 1-2. Especiallv important in connection with trig&nit1 pain or neuraIgia.
Head
ganglion bIock
Neck
3ervicaI pIexus bIock
Upper extremity
3uharachnoid
Chest
III divisions: Terminal nerves SubgangIionic block Gasserian ganglion block
sym,
‘aravertebral T 2-3 ExceptionaI,
block
Larynx Trachea Bronchi Lungs Heart?
T 3-4
Aorta. Esophagus.
Subarachnoid
bIock
PIeura
Jpper part >ower part
T 3-4 T 8-9
Entire Jpper part Lower part
T 6-7 or T 7-8 T 3-4 T 8-9
Aorta* Spleen
Abdomen
T j-6
Stomach. Liver. P ancreas. SmaII intestine.
T 67 Subarachnoid
PeIvis
Ovaries Testicles Uterus* Tubes Ureters S eminal vesicIes Prostate. Urethra. Bladder* _
4scending
T I 1-12 or T 12-1-1 and transverse colon T 4-5 T 11-12
gIand
T rz-LI Subarachnoid
and L 4-5
block
Rectum-anus. Lower extremity
or T 7-8
bIock
co1on*
Kidney-suprarenal
T 1-2
L 4-f Subarachnoid
bIock
r I 1-12 (sympathetic)
* Notes: I. l Lesions affecting these organs usuaIIy invoIve the sympathetic
and L 1-2 (somatic)
nerves of both sides. BiIatrraI (right and left) injections should be given in these cases. 2. I” bIocking the long viscera, aorta, small and Iarge intestines, or in specia1 cases, it may be necessary to repeat the bIock one or severa segments higher or Iower than the IevcIs given above. 3. This outline applies only to the adult body.
226
American Journal of Surgery
Stern-IntractabIe
twelfth thoracic and first Iumbar, one between the first and second lumbar, and three between the second and third lumbar. Best resuIts were obtained between the tweIfth thoracic and first Iumbar, or first and second Iumbar. Sensory paraIysis of the rectum and bIadder are apt to occur between the second and third Iumbar spines, especiaIIy with doses greater than 8r(l. The ages of these patients were fifty, fifty-six, sixty-eight, and sixty-eight respectiveIy. Carcinoma of the Rectum (4 Cases) There were 4 such cases, each with excruciating pains in the rectum and ana regions. One injection of 16nl. between the second and third lumbar spines reIieved the patient, but caused sensory bIadder paraIysis for one week. One injection was given between the third and fourth Iumbar spines, with considerable reIief. Two of 16’1Q. each were given between the fourth and fifth Iumbar spines, with compIete reIief and no bIadder or recta1 comp1ication.s. One case had severe dysuria from a complicating cystitis, for which an injection of 16l?l.. between the first and second lumbar spines on one side gave some relief. The best resuIts were obtained between the fourth and fifth Iumbar spines. Not onIy was the painreIieved but recta1 tenesmus was stopped aIlowing thorough recta1 examinations and cIeansing, and faciIitating the direct appIication of radium. The ages of these patients were thirtyfive, forty-eight, fifty-seven and sixty-five respectiveIy. Sarcoma
of the Pelvic Bones (2 Cases)
One case was that of an osteogenic sarcoma of the Ieft pubic bone in a woman sixty years oId. She had excruciating pains over the Ieft groin and Ieft Iower quadrant, and aIso over the anterior part of the Ieft thigh, knee and ankIe. An injection of 8m. between the first and second Iumbar spines gave considerabIe relief for four months. The pubic region became absoIuteIy insensitive after the injection. Another case of Ewing’s sarcoma, in a man twenty-six years oId, presented a Iarge painfu1 mass over the Ieft ilium. Injection of 16?ll. between the tweIfth thoracic and first Iumbar spines gave considerabIe reIief, enabIing the patient to Iie on his Ieft side without having any pain.
Pain Carcinoma of the Lung (I Case) A case of bronchiogenic carcinoma with metastases occurred in a man forty-seven years of age, who had severe pains over both sides of the abdomen, and over the Iower back. An injection of 8?ll. between the eighth andninth thoracic spines for the right side, reIieved the pain on the right side of his back and both sides of his abdomen. He stiI1 had pains over the Ieft side of his back. This observation is comparabIe to that of the second case of carcinoma of the stomach recorded, in which pain on the right side of the abdomen was relieved by an injection between the eighth and ninth thoracic spines on the opposite side. This fact may be expIained by a crossing of the afferent spIanchnit innervation of the abdomina1 viscera. Sarcoma of the Tibia (I Case) A man, thirty-one years oId, with a sarcoma of the left ankIe and metastases to his Iungs, had a very painfu1 x-ray uIceration of the Ieft inner maIIeoIus. He was unabIe to bear weight on this foot, no Iess have the uIcer touched. A recent injection of 161fl. between the 2nd and 3rd lumbar spines gave him immediate reIief of pain. Ten d ays Iater he was compIeteIy reIieved, and abIe to put his weight on that foot. The uIcer, which previousIy had shown no signs of heaIing began to hea after the injection. Twenty-sixinjections of aIcoho1 were done in this group of Ig cancer cases. Twenty-four other injections were given for severe pain caused by conditions other than cancer. These cases wiI1 be reported at a Iater date under their respective CIassifications. SUMMARY I. CIinicaI observations foIIowing fifty intraspina1 subarachnoid injections of 95 per cent aIcoho1 * demonstrate that the procedure is a practica1 and safe one when done properIy. As shown experimentaIIy, it is dangerous to Iife when done improperly. * The author has obtained somewhat better resuIts recently with the use of absoIute akohol instead of 0.~ Der cent aIcoho1. This aIcoho1. fiItered and boiIed // is avaiIabIe in convenient steriIe under pressure, ampuIes containing 2 C.C. each. I
Stern-IntractabIe 2. Used properly, aIcoho1 usualIy rehe\-es intractabIe pain, and may cause onIy partiaI anesthesia, but does not paraIyze muscIes. 3. The fundamenta1 principIes of technique for the intraspina1 subarachnoid injection of aIcoho1 are given. _c. Abstracts of 19 cases of cancer are given, as foIIows: Carcinoma of stomach.. . . . . . 2 Carcinoma of cervix. . . . $ Carcinoma of prostate. . .. . 4 Carcinoma of rectum.. . . 4 Sarcoma of peIvic bones. 2 Bronchiogenic carcinoma of Iung. . . I Sarcoma of tibia with x-ray uIceration. . . I 5. The procedure when successfu1 is invaIuabIe in the reIief of chronic, painfur conditions. A singIe, subarachnoid aIcoho1 injection may give reIief for as Iong as It obviates the necessity eight months. for using narcotics in Iarge doses, and diminishes the possibiIity of making drug
REFERENCES
Open pneumo-thorax; its relation to the treatment of empyema. Am. J. M. SC., 156: 839, 1918. BERRY, F. B., and CHILDS, E. P. The fissures of the Iungs. Ann. Surg., 96: 961, 1932. BETTMAN, R. B. The treatment of acute empyema. Surg. Gynec. Ohst., 54: 39, 1932. COHEN, M. Acute suppurative pIeurisy in children. Surg. Gynec. Obst., 54: 696, 1932. DAXA, J. A. Some principles involved in the pathoIogy and treatment of empyema thoracis with particuIar reference to treatment by periodic aspiration or evacuation with air repIacement without drainage. Surg. Gynec. Obst., 54: 296, 1932. GRAHAM, E. A. Principles invoIved in the treatment of acute and chronic empyema. Surg. Gynec. Obst., 38: 466, 1924. * Continued
BELL and GRAHAM.
Pain fiends of chronic invalids. Bv reIieving it aIIows more intensive x-ray, pain, radium, or other medica treatment to be given, and so tends to proIong Iife. 6. There is some cIinica1 e\-idence that sympathetic fibers are affected b\- 94 per cent aIcoho1 when introduced into the subarachnoid space. This method therefore promises to be one of vaIue in the treatment of diseases and disorders of the sympathetic nervous system. Through the courtesy of the New ‘r’ork City Cancer Institute, Dr. Ira I. KapIan, Director, the author was prkileged to apply this method on 9 patients at the Welfare Island Cancer Hospital. These cases are incIuded in this report. Appreciation for this courtesy is herewith acknowIedged. I am aIso indebted to Dr. Q’m. )I. Rogers of the Department of Anatomy at the CoIIege of Physicians and Surgeons, for his TaIuabIe assistance in the experimental in\-estigations and in the preparation of this paper.
OF
DR.
FRANK*
HART, D. Treatment of chronic empycma by tidal irrigation, suction and thoracoplasty. J. 7%oracic Surg., 2: 157, 1932. HEAD, J. R. Empyema with bronchia tistula simuIating Iung abscess and bronchiectasis. Surg. Gynec. Obst.. 53: 691, 1931. HEDBLOM, C. A. Treatment of empyema. J. A. ,M. A., 97: 1943, ‘931. hlLLLER, G. P. Mortality of empyema. J. Tboracic Surg., 1: 15, ‘932. OCHSNER, A., and GAGE, J. hl. Acute empyema thoracis. Trans. South. Surg. Assn., rq.: 451, 1901. PACKARD, G. B., JR. Empyema in chiIdren. Surg. Gynec. Obst., 53: 255, 1931. WILLIS, B. C. Diagnosis and treatment of empyema in chiIdren. Southern M. J., 24: 785. from p. 216.