Introduction: People living with sickle cell disease (SCD) have an average of four to six pain crisis episodes requiring hospitalizations per year (Kidwell et al, PLoS One, 2021). While most interventions are focused on decreasing the frequency of crises, there is no published data on targeted interventions for pain in this population, specifically hip pain related to avascular necrosis (AVN) of the hip. NSAIDs followed by Opioids in a stepwise model are the standard treatment regimen for these cases. Beyond duloxetine, a serotonin and norepinephrine reuptake inhibitor (Brandow et al, Blood Adv, 2020), there is little progress on pain management for medication-resistant pain (Okpala et al, J R Soc Med, 2002). Current treatment relies on medical management and/or surgical decompression and hip replacement. Core decompression has shown mixed results in higher staged AVN in patients of median age 27 who are more likely ineligible for surgery due to complication rates and the need for further readmissions and surgery. Non-surgical options have heretofore been nonexistent (Adesina et al, Blood Adv, 2017). A localized analgesic block with ultrasound guidance to the pericapsular nerve group (PENG) that innervates sensory branches of the anterior hip has previously shown promising results in patients with arthritis (Girón-Arango et al., 2018). Cryoneurolysis is the process of freezing and thawing targeted sensory nerves to provide long-term pain relief for innervated structures. A similar treatment modality, radiofrequency ablation, does achieve analgesia but does not spare sensory nerves and has had many patient reports of paresthesia post procedure (Abd-Elsayed et al., 2024, Advances in Therapy). We hypothesize that using PENG block followed by cryoneurolysis can provide long term analgesia and sensory nerve sparing and the potential to offer less invasive options for this population of SCD patients living with AVN.

Objectives: The objective of this single-center prospective study was to gather foundational data to evaluate the efficacy of a novel application of the PENG Blockade in pain management for patients with SCD and AVN of the hip.

Methods: From September 2024 to April 2025, patients with sickle cell disease and refractory pain were referred to interventional radiology for PENG blockade. Each patient was experiencing refractory hip pain due to radiographically proven AVN without collapse. Under ultrasound guidance, the iliopubic eminence was identified and a solution of 0.25% ropivacaine and 40mg of Kenalog was injected at the target area using a 25-gauge needle. The needle entry point was anesthetized using 1% lidocaine. Patients with at least a 50% reduction in pain were offered cryoneurolysis.

Results: During the study period, 10 patients were treated with PENG block. Patients were referred for treatment if they had refractory hip pain due to AVN, no active infections, and absence of associated fracture. Planar radiographs were reviewed for each patient. Patient ages ranged from 27 to 62 years. Of the 10 patients, 8 experienced greater than 50% reduction in pain on the Numeric Rating Scale on post-op day 0. Duration of pain relief ranged from eight days to 12 days. There were no complications in the study cohort. Those patients were referred for cryoneurolysis. Three cryoneurolysis procedures were performed under deep sedation with no complications and sustained pain relief greater than 50% post ablation at 3-month follow-up.

Conclusions: A two-step approach to mitigating AVN-associated pain can provide sustained pain relief in patients with sickle cell disease. Specifically, cryoablation offers nerve-sparing sustained pain relief for patients who are not surgical candidates. Further work is needed to establish AVN-grade specific treatment approaches for this patient population.

This content is only available as a PDF.
2025
Sign in via your Institution