Ultrasound-Guided Suprascapular Nerve Pulsed Radiofrequency with Perineural Ropivacaine–Triamcinolone Injection for Multisite Advanced Cancer Pain: Localized Analgesia Without Reduced Opioid Requirement - A Case Report

Abstract

Background: Targeted pain interventions may relieve a specific pain generator, but their effect on total opioid requirements is uncertain when several painful sites remain active. Case presentation: A 30-year-old woman with advanced epithelioid hemangioendothelioma had severe bilateral shoulder pain together with thoracic, abdominal, and pelvic pain despite multimodal analgesia. Treatment was complicated by opioid-related adverse effects, dysphagia, renal dysfunction associated with selective cyclooxygenase-2 inhibitor therapy, thrombocytopenia, vertebral metastases, and progressive systemic illness. The overall Numerical Rating Scale (NRS; 0–10) score was approximately 8–10 with six to eight breakthrough episodes daily despite continuous intravenous fentanyl 600 µg/24 h with 25-µg nurse-administered rescue boluses (total daily fentanyl exposure 1,200 µg including rescue). Because the shoulders were the most severely painful and anatomically accessible sites, bilateral ultrasound-guided suprascapular diagnostic blocks were performed; shoulder pain decreased by more than 50% within 10 minutes of lidocaine injection. This was followed in the same session by bilateral suprascapular nerve pulsed radiofrequency at 42 °C for two 3-minute cycles per side and perineural injection of 2 mL 0.1875% ropivacaine with 5 mg triamcinolone per side. Shoulder pain decreased to near zero during the first 24 hours and remained controlled during the documented five-day follow-up. However, breakthrough pain at other sites persisted and the overall opioid requirement did not decrease; an attempted fentanyl taper was reversed on the following day. Follow-up ended when the patient was transferred to the intensive care unit on post-procedure day 5 because of massive gastrointestinal bleeding. Conclusion: Combined suprascapular nerve pulsed radiofrequency and perineural local anesthetic–steroid injection provided substantial localized analgesia without reducing systemic opioid requirements. Regional and global outcomes should be assessed separately when targeted interventions are used for multisite cancer pain; an unchanged opioid requirement does not invalidate a successful targeted regional intervention.