Radiofrequency Thermal Ablation in Painful Myeloma of the Clavicle
The patient was a 57-year-old man with a history of coming into contact with chemical gases during the war of 1981. He was referred to the emergency room (ER) with an acute abdomen and hemorrhage about 6 years ago. At that time, the diagnosis was acute renal failure and myeloma. The patient's blood abnormality was treated very well in the hematology department and he went under dialysis. He did not come back to the hematology department for myeloma maintenance therapy until four months ago when he came to the ER with hoarseness, tenderness in a hind limb, bone pains, movement limitation in the forelimbs with severe pain (VAS 6) in the left clavicle. He underwent 10 sessions of clavicle radiotherapy before admission to the pain clinic. His clavicular pain did not respond to radiotherapy and opioids.\nIn the physical examination, the patient complained of generalized bone pain especially in left clavicle. There was a 5 × 7 cm mass in 1/3 of the internal part of the clavicle (). There was no redness or edema and the mass was fixed to the bone and in pain on palpation. It was a new localized, deep, uncomfortable pain in the left clavicle.\nBoth shoulders and arms were tender with movement limitation. Bilateral limited elbow extension and flexion deformity were seen. Hind limbs force was decreased (2 from 5). There was no sensory deficit. In the shoulder examination, there was no hypertrophy, heat, erythema and tenderness. Clavicle conventional radiofrequency was chosen as a treatment. The patient's blood test and coagulation test were normal (platelet counts = 7,400 per microliter). In the plain radiography other than widespread lytic myeloma lesions especially in the shoulders and arms, there was a big lesion in the left clavicle which was also detected in the chest X-ray and chest CT scan ().\nAfter IV sedation (midazolam 1 mg and fentanyl 50 mg), prep & drape were done in the supine position. The clavicular mass was antisepticised and the anesthetic was lidocaine 1%. Two radiofrequency needles (OWL, Diros Technology Inc., Ontario, Canada. sharp, 20 gauge, 100 mm, active tip 10 mm), 1.5 cm from each other were inserted into the mass. Under the guide of the fluoroscopy, the needles were inserted into the middle part of the mass and during the pass, the needles were aspirated for any possibility of blood. And then, after passing the bone and feeling a sense of pop in the non-ionic water, 3 ml of soluble contrast media (Iodixanol 320) were injected and its distribution was seen directly and the contours of mass were clear. The patient informed us of any shooting pain in the upper extremity during the procedure. After placing the pads on the patient's arm, the stylet was pulled out and the radiofrequency probe was inserted. Then, two times a radiofrequency current at 90℃ was applied for 60 seconds at the two points 1cm apart from each other. After that, 2 ml of 0.5% ropivacaine along with triamcinolone 40 mg were injected in each needle and then the needle and the probe were pulled out together (-). The procedure went very smoothly without any pain or need for more analgesic injection. In the recovery room, VAS dropped to zero and movement of the hands improved. He could move his shoulder and arms more comfortably. There was no hematoma or sensory and motor deficits or any kind of radiating pain in the extremity. The visual analogue pain score (VAS from 0 to 10) decreased from 8 to 0. In the next 3 months of follow-up, the patient was very satisfied with the procedure and there was no pain at the clavicular site and did not need any analgesic for it. The mass gradually became smaller. There were no complications. He did not suffer from any pain at the clavicular site until he died after 3 months.