Neuraxial pain relief for intractable cancer pain

IntroductionNeurosurgical ablative procedures can offer immediate and effective pain relief for patients suffering from refractory cancer pain. However, choosing the appropriate procedure for each patient may not be straightforward and warrants an interdisciplinary approach. The purpose of the current study was to evaluate the outcome of patients with cancer who were carefully selected for neurosurgical intervention by a dedicated interdisciplinary team composed of a palliative physician and nurse practitioner, a pain specialist and a neurosurgeon.MethodsA retrospective review was carried out on all patients who underwent neurosurgical ablative procedures in our institute between March 2015 and September 2019. All patients had advanced metastatic cancer with unfavorable prognosis and suffered from intractable oncological pain. Each treatment plan was devised to address the patients’ specific pain syndromes.ResultsA total of 204 patients were examined by our service during the study period. Sixty-four patients with localized pain and nineteen patients with diffuse pain syndromes were selected for neurosurgical interventions, either targeted disconnection of the spinothalamic tract or stereotactic cingulotomy. Substantial pain relief was reported by both groups immediately (cordotomy: Numerical Rating Scale (NRS) 9 ≥1, p=0.001, cingulotomy: NRS 9 ≥2, p=0.001) and maintained along the next 3-month follow-up visits.ConclusionsAn interdisciplinary collaboration designated to provide neurosurgical ablative procedures among carefully selected patients could culminate in substantial relief of intractable cancer pain.Trial registration numberIR0354-17.

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Computerized tomography-guided percutaneous extralemniscal myelotomy

Neurosurgical FOCUS ◽

10.3171/foc.1997.2.1.8 ◽

1997 ◽

Vol 2 (1) ◽

pp. E7 ◽

Cited By ~ 1

Author(s):

Yücel Kanpolat ◽

Ali Savas ◽

Sükrü Çaglar ◽

Serdar Akyar

Keyword(s):

Pain Relief ◽

Cancer Pain ◽

Computerized Tomography ◽

Intractable Pain ◽

Lesion Volume ◽

Neurophysiological Mechanism ◽

Ct Guided ◽

Cervicomedullary Junction ◽

Total Pain ◽

Intractable Cancer Pain

Extralemniscal myelotomy (ELM) is a procedure performed at the cervicomedullary junction of the spinal cord in which the central cord is lesioned to treat intractable pain. The neurophysiological mechanism of pain relief after ELM remains unclear. The authors present a series of 14 patients with intractable cancer pain who were managed by CT-guided, percutaneous ELM. In six of the cases (42.8%), total pain relief was achieved; partial satisfactory pain relief was attained in four cases (28.5%), and no pain control was achieved in four cases (28.5%). No complications due to ELM were observed. The authors believe that ELM is a safe and effective procedure in the management of intractable cancer pain for selected cases; computerized tomography guidance is an essential part of the procedure to achieve morphological localization of the target in the cervicomedullary junction. More research is needed to understand the neurophysiological mechanism of pain relief after ELM and to standardize the lesion volume.

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Peripheral and Neuraxial Chemical Neurolysis for the Management of Intractable Lower Extremity Pain in a Patient with Terminal Cancer

January 2018 - Pain Physician ◽

10.36076/ppj.2015/18/e651 ◽

2015 ◽

Vol 18;4 (4;18) ◽

pp. E651-E656 ◽

Cited By ~ 1

Author(s):

Mario De Pinto

Keyword(s):

Pain Relief ◽

Lower Extremity ◽

Cancer Pain ◽

Femoral Nerve ◽

Stage Iv ◽

Left Lower Extremity ◽

Complete Pain Relief ◽

Adequate Pain Relief ◽

Patient Reported ◽

Intractable Cancer Pain

We present the case of a 74-year-old man with Stage IV metastatic, multifocal, malignant fibrous histiocytoma (T2b, N1, M1, G4) invading the proximal area of the left lower extremity and resulting in intractable neuropathic pain along the distribution of the femoral nerve. He described the pain as being so severe to cause inability to ambulate without assistance or to sleep in a supine or prone position. After a spinal cord stimulation trial and a trial of intrathecal (IT) hydromorphone, both performed at an outside institution, had failed to achieve adequate pain relief, we decided to perform a femoral nerve chemical neurolysis with phenol under ultrasound (US) guidance. The intervention provided 6 months of almost complete pain relief. With the tumor spreading in girth distally and proximally to the scrotal and pelvic areas as well as to the lungs, and pain returning back to baseline, we proceeded with a second femoral nerve chemical neurolysis. Unfortunately we were not able to achieve adequate pain relief. Therefore we opted to proceed with a diagnostic injection of local anesthetic under fluoroscopic guidance at the left L2, L3, and L4 nerve roots level. This intervention provided 100% pain relief and was followed, a few days later, by chemical neurolysis with phenol 3%. The patient reported complete pain relief with the procedure and no sensory-motor related side effects or complications. He was able to enjoy the last 6 weeks of life with his wife and family, pain-free. With this report we add to the limited literature available regarding the management of intractable cancer pain with chemical neurolysis in and around the epidural space. Key words: Cancer, pain, chemical neurolysis, peripheral, neuraxial

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Administration of Intraspinal Morphine Sulfate for the Treatment of Intractable Cancer Pain

Neurosurgery ◽

10.1227/00006123-198606000-00011 ◽

1986 ◽

Vol 18 (6) ◽

pp. 740-747 ◽

Cited By ~ 74

Author(s):

Andrew G. Shetter ◽

Mark N. Hadley ◽

Elizabeth Wilkinson

Keyword(s):

Drug Delivery ◽

Pain Relief ◽

Cancer Pain ◽

Morphine Sulfate ◽

Significant Difference ◽

Spinal Catheter ◽

Epidural Catheters ◽

Intractable Cancer Pain ◽

Preservative Free

Abstract A total of 24 patients with intractable cancer pain were evaluated as candidates for spinal morphine therapy. Temporary trials were carried out with bolus injections of preservative-free morphine sulfate via percutaneously inserted epidural catheters. Fourteen patients felt that pain relief was sufficient to warrant long term morphine application, and permanent drug delivery systems were implanted. These consisted of an Ommaya reservoir and an epidural spinal catheter in 6 patients and an Infusaid pump with either an epidural or subarachnoid spinal catheter in 8 patients. Pain relief with these systems was felt to be excellent in 7 patients, good in 4 patients, and fair in 3 patients. There was a statistically significant reduction in supplemental narcotic use between the pre- and postoperative periods (P < 0.001). Median survival after operation was 3.0 months (mean, 5.0 months), with a range of 1 to 23 months. Tolerance was seen in all patients regardless of the mode of drug delivery, but it occurred more quickly with bolus injections than with continuous infusion (statistically significant difference, P < 0.05). A persistent cerebrospinal fluid fistula developed in 1 patient; this required wound revision. No other serious complications or episodes of respiratory depression occurred. We conclude that intraspinal morphine sulfate is a beneficial treatment option for cancer patients in whom pain has become debilitating and unresponsive to oral or parenteral narcotic regimes.

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Neurosurgical ablative procedures for intractable cancer pain

Journal of Neurosurgery ◽

10.3171/2019.2.jns183159 ◽

2020 ◽

Vol 133 (1) ◽

pp. 144-151

Author(s):

Assaf Berger ◽

Uri Hochberg ◽

Alexander Zegerman ◽

Rotem Tellem ◽

Ido Strauss

Keyword(s):

Pain Relief ◽

Cancer Pain ◽

Patient Selection ◽

Metastatic Cancer ◽

Careful Consideration ◽

Neurosurgical Procedures ◽

Pain Pathways ◽

Good Pain Relief ◽

Intractable Cancer Pain

OBJECTIVECancer patients suffering from severe refractory pain may benefit from targeted ablative neurosurgical procedures aimed to disconnect pain pathways in the spinal cord or the brain. These patients often present with a plethora of medical problems requiring careful consideration before surgical interventions. The authors present their experience at an interdisciplinary clinic aimed to facilitate appropriate patient selection for neurosurgical procedures, and the outcome of these interventions.METHODSThis study was a retrospective review of all patients who underwent neurosurgical interventions for cancer pain in the authors’ hospital between March 2015 and April 2018. All patients had advanced metastatic cancer with limited life expectancy and suffered from intractable oncological pain.RESULTSSixty patients underwent surgery during the study period. Forty-three patients with localized pain underwent disconnection of the spinal pain pathways: 34 percutaneous-cervical and 5 open-thoracic cordotomies, 2 stereotactic mesencephalotomies, and 2 midline myelotomies. Thirty-nine of 42 patients (93%) who completed these procedures had excellent immediate postoperative pain relief. At 1 month the improvement was maintained in 30/36 patients (83%) available for follow-up. There was 1 case of hemiparesis.Twenty patients with diffuse pain underwent stereotactic cingulotomy. Nineteen of these patients reported substantial pain relief immediately after the operation. At 1 month good pain relief was maintained in 13/17 patients (76%) available for follow-up, and good pain relief was also found at 3 months in 7/11 patients (64%). There was no major morbidity or mortality.CONCLUSIONSWith careful patient selection and tailoring of the appropriate procedure to the patient’s pain syndrome, the authors’ experience indicates that neurosurgical procedures are safe and effective in alleviating suffering in patients with intractable cancer pain.

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Analgesia with Epidural Calcitonin in Cancer Patients

Tumori Journal ◽

10.1177/030089168907500222 ◽

1989 ◽

Vol 75 (2) ◽

pp. 183-184 ◽

Cited By ~ 9

Author(s):

Salvatore Miseria ◽

Umberto Torresi ◽

Andrea Piga ◽

Diego Tummarello ◽

Carla Belleggia ◽

...

Keyword(s):

Pain Relief ◽

Cancer Pain ◽

Cancer Patients ◽

Clinical Utility ◽

Morphine Treatment ◽

Routine Procedure ◽

Substantial Evidence ◽

Analgesic Drugs ◽

Nocturnal Pain ◽

Intractable Cancer Pain

We evaluated the analgesic effect of salmon calcitonin (sCT) on 14 patients with intractable cancer pain. The drug was administered by epidural infusion (4–8 bolus administrations in 48 h); the dosage was 100 IU/48 h in 5 patients and 400 IU/48 h in 9 patients. Significant, although limited, pain relief and nocturnal pain relief were obtained; the requirement for conventional analgesic drugs was substantially reduced. The treatment was well tolerated and no side effect was recorded. However, only in 3/14 patients did pain relief result in improvement of mobility, with two patients becoming able to ambulate; no patient experienced absence of pain. In general, the treatment produced only limited benefit and subsequent morphine treatment was required in all instances. Widespread use of epidural sCT in intractable cancer pain is not justified as a routine procedure and more substantial evidence is required to support the clinical utility of such an approach.

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Efficacy and Safety of Ropivacaine Addition to Intrathecal Morphine for Pain Management in Intractable Cancer

Mediators of Inflammation ◽

10.1155/2015/439014 ◽

2015 ◽

Vol 2015 ◽

pp. 1-6 ◽

Cited By ~ 5

Author(s):

Ying Huang ◽

Xihan Li ◽

Tong Zhu ◽

Jian Lin ◽

Gaojian Tao

Keyword(s):

Pain Relief ◽

Adverse Effects ◽

Cancer Pain ◽

Barthel Index ◽

Rating Scale ◽

Numerical Rating Scale ◽

Intrathecal Morphine ◽

Drug Infusion ◽

Intrathecal Catheter ◽

Intractable Cancer Pain

Objective. Although intrathecal drug infusion has been commonly adopted for terminal cancer pain relief, its adverse effects have made many clinicians reluctant to employ it for intractable cancer pain. The objective of this study is to compare the efficacy and security of an intrathecal continuous infusion of morphine and ropivacaine versus intrathecal morphine alone for cancer pain.Methods. Thirty-six cancer patients received either a continuous morphine (n=19) or morphine and ropivacaine (n=17) infusion using an intrathecal catheter through a subcutaneous port. Numerical Rating Scale (NRS) scores and the Barthel Index were analyzed. Adverse effects and complications on postoperative days 1, 3, 7, and 15 were also analyzed.Results. All patients experienced pain relief. Compared to those who received morphine alone, patients receiving morphine and ropivacaine had significantly lower postoperative morphine requirements and higher Barthel Index scores on the 15th postsurgical day (P<0.05). Patients receiving morphine and ropivacaine had lower NRS scores than patients receiving morphine alone on postoperative days 1, 3, 7, and 15 (P<0.05). Negative postsurgical effects were similar in both groups.Conclusions. Morphine and ropivacaine administration through intrathecal access ports is efficacious and safe and significantly improves quality of life.

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Epidural analgesia for intractable cancer pain - An old story used until now

Archives of Public Health ◽

10.3889/aph.2020.5198 ◽

2020 ◽

Vol 12 (2) ◽

pp. 15-24

Author(s):

Marija Sholjakova ◽

Biljana Kuzmanovska ◽

Vesna Durnev ◽

Adrijan Kartalov ◽

Rozalinda Isjanovska

Keyword(s):

Pain Relief ◽

Epidural Analgesia ◽

Cancer Pain ◽

Intractable Pain ◽

Morphine Group ◽

Urine Retention ◽

Pain Scores ◽

Chronic Severe Pain ◽

Intractable Cancer Pain ◽

The University

Intractable cancer pain is a chronic severe pain, affecting patient’s quality of life and presents aheavy health, social and family problem in many countries. Different methods for pain relief are proposed by the WHO. Epidural analgesia with opioids is one of the proposed methods. Aim of the study was to determine the effects of morphine, fentanyl and butorphanol used for epidural analgesia in intractable pain and to comment our experiences over a five-year-period, with regard to its actuality nowadays. Material and methods: Retrospective longitudinal observational study was carried at the University Clinic for Anesthesiology, Reanimation and Intensive Care in Skopje, Macedonia, between 2005-2010 and evaluated in 2017-2018. A total of 116 patients suffering from intractable pain were enrolled in the study. Exclusion criteria were: infective and metastatic processes in the spine, allergy to opioids, psychological problems and language barrier. After the pretreatment evaluation of the pain, patients were randomly assigned to receive three different opioids through epidural catheter placed from Th8-10 or L2-3. Results: There were no differences in pretreatment pain scores between the three groups (p>0.05). A significant onset of analgesia after 15 minutes was found for butorphanol, 20 minutes for fentanyl and 30 minutes for morphine group (p<0.05). The duration of the pain relief of butorphanol vs. fentanyl vs. morphine was 6h vs. 8h vs. 24 hours respectively. Morphine had the longest duration of pain relief (p<0.05). Because of an increase in the pain threshold, the need of an increase of opioid doses was necessary. The most often patient’s reports of side effects were: itching, constipation, urine retention and bradypnea and there were no reports of nausea and vomiting. Conclusions: It was concluded that epidural analgesia with opioids is an effective and safe method for suppression of intractable pain. In spite of the other alternatives in treatment of cancer pain, epidural analgesia with opioids still has an eminent place and its use is a challenge for professionals

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Cancer pain management

Orvosi Hetilap ◽

10.1556/oh.2014.29808 ◽

2014 ◽

Vol 155 (3) ◽

pp. 93-99

Author(s):

Péter Heigl

Keyword(s):

Quality Of Life ◽

Pain Management ◽

Pain Relief ◽

Life Expectancy ◽

Cancer Pain ◽

Cancer Pain Management ◽

Medical Activity ◽

Short Summary ◽

Adequate Quality

Pain is a significant and alarming symptom of cancer seriously affecting the activity and quality of life of patients. Recent research proved that inadequate analgesia shortens life expectancy. Therefore, pain relief is not only a possibility but a professional, ethical and moral commitment to relieve patients from suffering, as well as ensure their adequate quality of life and human dignity. Proper pain relief can be achieved with medical therapy in most of the cases and the pharmacological alternatives are available in Hungary. Yet medical activity regarding pain relief is far from the desired. This paper gives a short summary of the guidelines on medical pain management focusing particularly on the use of opioids. Orv. Hetil., 2014, 155(3), 93–99.

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The Prevalence and Characteristics of Breakthrough Cancer Pain in Patients Receiving Low Doses of Opioids for Background Pain

Cancers ◽

10.3390/cancers13051058 ◽

2021 ◽

Vol 13 (5) ◽

pp. 1058

Author(s):

Sebastiano Mercadante ◽

Marco Maltoni ◽

Domenico Russo ◽

Claudio Adile ◽

Patrizia Ferrera ◽

...

Keyword(s):

Pain Relief ◽

Cancer Pain ◽

Oral Morphine ◽

Epidemiological Data ◽

Low Doses ◽

Advanced Cancer Patients ◽

Breakthrough Cancer Pain ◽

Background Pain ◽

The Mean ◽

Oral Morphine Equivalent

The aim of this study was to assess the prevalence and characteristics of breakthrough cancer pain (BTcP) in patients receiving low doses of opioids for background pain. A consecutive sample of advanced cancer patients receiving less than 60 mg/day of oral morphine equivalent (OME) was selected. Epidemiological data, background pain intensity, and current analgesic therapy were recorded. The presence of BTcP was diagnosed according to a standard algorithm. The number of BTcP episodes, intensity of BTcP, its predictability and triggers, onset duration, interference with daily activities, BTcP medications, satisfaction with BTcP medication, and time to meaningful pain relief were collected. A total of 126 patients were screened. The mean intensity of background pain was 2.71 (1.57), and the mean OME was 28.5 mg/day (SD15.8). BTP episodes were recorded in 88 patients (69.8%). The mean number/day of BTP episodes was 4.1 (SD 7.1, range 1–30). In a significant percentage of patients, BTcP was both predictable and unpredictable (23%). The BTcP onset was less than 20 min in the majority of patients. The mean duration of untreated episodes was 47.5 (SD 47.6) minutes. The mean time to meaningful pain relief after taking a BTcP medication was >20 min in 44.5% of patients. The efficacy of BTcP medication was not considered good in more than 63% of patients. Gender (females) (OR = 4.16) and lower Karnofsky (OR = 0.92) were independently associated with BTcP. A higher number of BTcP episodes/day was associated with gender (females) (p = 0.036), short duration of BTcP (p = 0.005), poorer efficacy of BTcP medication (none or mild) (p = 0.001), and late meaningful pain relief (p = 0.024). The poor efficacy of BTcP medication was independently associated with a higher number of episodes/day (OR = 0.22). In patients who were receiving low doses of opioids, BTcP prevalence was 69.8%. Many patients did not achieve a sufficient level of satisfaction with BTcP medications, particularly with oral morphine. Data also suggest that better optimization of background analgesia, though apparently acceptable, may limit the number of BTcP episodes.

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