BACKGROUND: Bulky metastatic cervical lymphadenopathy and prior radiotherapy can distort anterior neck anatomy and make conventional access to the cervical sympathetic chain unsafe, limiting interventional options in severe refractory malignant pain.

CASE REPORT: A 76-year-old man with metastatic lung cancer (diagnosed July 2023; prior chemotherapy and radiotherapy) presented with 3 weeks of severe right-sided cervical pain radiating to the preauricular region and right shoulder (numeric rating scale [NRS] score of 8–10/10) with spontaneous breakthrough pain, despite oral morphine (240 mg/day) complicated by severe constipation and somnolence, plus gabapentin, acetaminophen, and amitriptyline. Computed tomography showed extensive nodal metastatic disease involving the sternocleidomastoid region, hyoid area, and deep prevertebral musculature (longus colli), precluding a conventional technique. In October 2024, fluoroscopy-guided chemical neurolysis targeting the cervical sympathetic plexus was performed via a posterior atlanto-axial transarticular approach using 10% phenol mixed with contrast (total injectate, 7 mL). At 72 hours, pain resolved (NRS 0/10) without reported complications; benefit persisted to 12 weeks (NRS 3/10) with opioid reduction.

CONCLUSIONS: This approach may be considered in highly selected cases when conventional access is not feasible. The report does not establish its safety or effectiveness for routine use.

KEYWORDS: Cancer pain, atlanto-axial approach, cervical sympathetic chain, fluoroscopy, neurolysis, phenol, stellate ganglion, sympathetic plexus