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Pain Medicine 2014; 15: 333–343
Wiley Periodicals, Inc.
LETTERS TO THE EDITOR
Successful Treatment of Persisting Neck Pain after Radical Neck
Dissection Using Prism Glasses
Dear Editor
We report the successful treatment with prism glasses of
a patient with chronic, intractable, right-sided neck pain
after radical neck dissection.
Persisting neck and shoulder pain are well-recognized
complications of neck dissection for malignant disease [1].
During neck dissection, the sternocleidomastoid muscle is
usually removed. Given the sternocleidomastoid muscle’s
important role in head and neck proprioception [2], the
possibility exists that persisting pain after a radical neck
dissection might also represent a “phantom muscle” phenomenon. If this was the situation, then interventions
similar to mirror therapy that are used to treat phantom
limb pain [3] might have a role in treating persisting neck
pain after radical neck dissection.
A 72-year-old, retired, Indian, vegetarian male presented
in November 2009 complaining of right-sided neck pain.
He had undergone a right radical neck dissection and right
hemiglossectomy for squamous cell carcinoma of the right
lateral tongue in India in 2005. The right neck pain, rated
“8–9 out of 10” in severity, had been present since this
time and had not responded to previous medical interventions. He had a peripheral neuropathy managed with
nortriptylline 20 mg nocte and gabapentin 300 mg tds. He
was also on treatment for type II diabetes mellitus and
dyslipidaemia as well as aspirin 100 mg daily and cholecalciferol 50,000 IU monthly. He was an ex-smoker who
drank alcohol very occasionally.
Examination of his neck revealed significant tenderness to
palpation in trigger points in the right trapezius, right
levator scapulae, and the right suboccipital muscles. The
surgical scar was diffusely tender to palpation. He had a
full range of right shoulder movement with no evidence of
damage to the right accessory nerve. He had had a right
hemiglossectomy. Initial blood investigations revealed a
vitamin B12 deficiency (115 pmol/L).
He was diagnosed with a central sensitization of the right
neck secondary to his previous neck dissection. His
vitamin B12 deficiency was corrected with minimal
improvement in his pain. He was trialled on tramadol
50 mg qid with no change in his reported pain levels.
Local anaesthetic scar injection, later combined with injection of the right semispinalis muscle, provided temporary
relief for up to 24 hours. He was instructed on selfmassage to trigger points in his right neck and shoulder
muscles with no success. In December 2012, he commenced a regime of soft tissue massage and cervical
spine mobilization combined with a trial of prism glasses.
When wearing the prism glasses, if he touched the left
side of his neck, he felt visually that he was touching the
right side of his neck. He was shown a range of desensitization techniques but settled on stroking and touching
the left side of his neck and face. During this, he reported
feeling “burning” and “tingling” sensations on the right
side. He used this desensitization technique one to two
times daily, four to five times a week. He reported developing headaches if he used the glasses for any longer
than 10 minutes at a time and limited his use to less
than this.
Two months later, he reported that the numbness in his
right neck was “30% better.” Five months after commencing treatment, he reported “virtually nonexistent” pain at
the scar site on his neck. His range of cervical spine
motion had increased to 65° rotation and 20° side flexion
on the left and 70° rotation on the right, with a slight
reduction to 25° side flexion on the right.
The successful treatment using prism glasses in this
case history suggests that persisting pain after radical
neck dissection might be due to a phantom muscle
phenomenon. The origin of phantom pain is poorly
understood, but the degree of phantom pain correlates
with the degree of maladaptive reorganization of the
somatosensory pathways [4]. Case studies and anecdotal data support the use of mirror therapy to relieve
phantom-limb pain [3,5]. In mirror therapy, the mirror
image helps reorganize and reintegrate the mismatch
between proprioception and the visual feedback of the
removed part [3]. Prism glasses are based on the principles of mirror therapy but allow portable treatments,
which can be performed more regularly. They utilize
a wedge prism to add visual displacement toward the
affected side, while the vision in the other eye is
blocked. When the patient moves the nonaffected
limb, the prism inverts the image to appear although
the affected limb is moving. The sternocleidomastoid
muscles are not the only muscles that contribute proprioceptive input—the central nervous system would
appear able to adapt to alternations in proprioceptive
input from the sternocleidomastoid muscles [2]. Visual
input has been shown to dominate touch and proprioception [3]. The introduction of a visual stimulus could
aid in proprioception re-education.
A previous case history of a patient with early complex
regional pain syndrome managed with prism glasses and
mirrors has been reported [6]. Following activities involving
the prism glasses, the patient noted a decrease in pain,
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Restrepo-Garces et al.
swelling, and temperature, and improvement in range of
motion of the limb. After 9 days of treatment, the patient
was pain-free.
The response to prism glass treatment could also be
attributed to a placebo response or other therapeutic
interventions. However, to some extent, the patient has
already served as his own control for over 7 years. He has
had numerous other medical and procedural interventions, all of which could potentially have had a placebo
response. Part of the physiotherapy treatment also
included cervical spine mobilization, which would have
contributed to improved proprioceptive input. There was
also been a gradual improvement with the introduction of
the prism glasses and cervical spine mobilization in
keeping with neurological reprogramming.
This case history indicates that a “phantom muscle” phenomenon is an alternative explanation for the pain seen
after neck dissection. Considering the limited efficacy of
conventional musculoskeletal interventions [7], this technique offers an alternative approach that needs to be
explored further. It could also lead to a better understanding of the underlying pathophysiology and the introduction
of a range of better therapeutic options.
JIM BARTLEY, FRACS, FFPMANZCA,*
ALLAN PLANT, BSc,* and ANGELA SPURDLE, BHSc†
*Department of Surgery, University of Auckland,
Auckland; †Chronic Pain Service, Counties Manukau
Health, Auckland, New Zealand
References
1 Bradley PJ, Ferlito A, Silver CE, et al. Neck treatment
and shoulder morbidity: Still a challenge. Head Neck
2011;33:1060–7.
2 Bove M, Brichetto G, Abbruzzese G, Marchese R,
Schieppati M. Neck proprioception and spatial orientation in cervical dystonia. Brain 2004;127(Pt 12):2764–
78.
3 Ramachandran VS, Altschuler EL. The use of visual
feedback, in particular mirror visual feedback, in restoring brain function. Brain 2009;132(Pt 7):1693–710.
4 Flor H, Elbert T, Knecht S, et al. Phantom-limb pain as
a perceptual correlate of cortical reorganization following arm amputation. Nature 1995;375:482–4.
5 Moseley GL, Gallace A, Spence S. Is mirror therapy all
it is cracked up to be? Current evidence and future
directions. Pain 2008;138:7–10.
6 Bultitude JH, Rafal RD. Derangement of body representation in complex regional pain syndrome: Report of a
case treated with mirror and prisms. Exp Brain Res
2010;204:409–18.
7 Carvalho A, Vital F, Soares B. Exercise interventions
for shoulder dysfunction in patients treated for head
and neck cancer. Cochrane Database Syst Rev 2012;
(18):CD008693.
Ganglion Impar Phenol Injection in a Pediatric Patient with Refractory
Cancer Pain
Dear Editor,
Cancer pain is still a major issue despite the World Health
Organization ladder. Up to 30% of the patients experience
poor pain control, especially at late stages and during the
last year of life [1]. While opioids are the gold standard for
treatment of moderate to severe cancer pain, at least
10–15% may benefit from interventional procedures [2,3].
The main reason to advocate interventional pain management (IPM) is either a lack of efficacy of the opioids and
the co-adjuvant therapy or intolerable side effects of
such therapy.
IPM includes neurolytic procedures (celiac plexus neurolysis, superior hypogastric neurolysis, and impar ganglion
neurolysis), continuous epidural and intrathecal analgesia
radiofrequency, and vertebral or bone cement augmentation [4]. Most of the IPM experience has been done on
adult population, and the information in pediatric population is limited.
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Neurolytic injection on the impar ganglion is reported since
1990. This ganglion is a single retroperitoneal structure,
marking the end of the paired paravertebral sympathetic
chains. It is responsible for visceral-perineal pain that is
sympathetically maintained [5]. There are no reports of
neurolytic impar ganglion injection in pediatrics. There is
only one case report to our knowledge of impar ganglion
injection but only with local anesthetics in a teenager with
persistent coccygodynia [6].
We would like to report our experience in a toddler with
refractory perineal-cancer-related pain in whom we
performed an impar ganglion neurolysis as a part of his
pain management. A 3-year-old patient was referred
to our Pain Clinic due to severe pain related to an
embryonal bladder/prostate rhabdomyosarcoma. The
main complaint was a painful tenesmus secondary to the
pelvic floor invasion of the mass, leading to a severe
discomfort. There was no surgical or radiotherapy
treatment offered at that time. Pain management
was based on a morphine continuous infusion plus