Tailoring of neurosurgical ablative procedures in the management of refractory cancer pain

2020 ◽  
Vol 45 (9) ◽  
pp. 696-701
Author(s):  
Uri Hochberg ◽  
Asaf Berger ◽  
Miri Atias ◽  
Rotem Tellem ◽  
Ido Strauss
Keyword(s):  
Pain Relief ◽  
Cancer Pain ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Treatment Plan ◽  
Metastatic Cancer ◽  
Spinothalamic Tract ◽  
Pain Syndromes ◽  
Intractable Cancer Pain ◽  
Ablative Procedures

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.

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

2015 ◽  
Vol 2015 ◽  
pp. 1-6 ◽  
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.

scholarly journals Interventional Pain Management for Cancer Pain: An Analysis of Outcomes and Predictors of Clinical Response

2020 ◽  
Vol 5;23 (9;5) ◽  
pp. E451-E459
Author(s):  
Uri Hochberg
Keyword(s):  
Pain Management ◽  
Pain Relief ◽  
Cancer Pain ◽  
Chart Review ◽  
Rating Scale ◽  
Treatment Plan ◽  
Retrospective Chart Review ◽  
Well Being ◽  
Management Procedures ◽  
Interventional Pain Management

Background: Interventional procedures are offered routinely to patients seen in McGill University’s interdisciplinary cancer pain management program. However, publications on these procedures are scarce, making it difficult to predict which patients may benefit from them. Objectives: We hypothesized that interventional pain procedures offered to cancer patients could provide relief of pain as well as other symptoms. Furthermore, some variables may predict the efficacy of such procedures. Study Design: We conducted a retrospective chart review of interventional pain management procedures. Setting: The procedures reviewed were conducted at the Cancer Pain Program and performed at the interventional suites of the McGill University Health Centre. Methods: The retrospective chart review included interventional pain management procedures performed between June 2015 and March 2017. Demographic data, details about the underlying cancer and about the procedure and peripTrocedural patients’ reported outcomes were recorded for analysis. Results: Eighty-two of 126 procedures were included for analysis. Most patients presented with metastatic disease (75%). Eighty percent of the patients reported pain relief, with the average pain severity decreasing by more than 2 points on a 0-to-10 Numeric Rating Scale for pain (from 6.5 of 10 to 4.2 of 10). Forty-three percent of patients were considered responders (≥ 50% pain relief). Responders also reported a significant decrease in fatigue, depression, anxiety, drowsiness, and improved well-being. Among responders, average daily opioid use decreased significantly, by 60% on average. None of the analyzed variables correlated with the response; however, psychosocial variables like anxiety and depression showed a nonsignificant trend towards predicting procedure failure. Limitations: The core limitations of this study are its size and retrospective nature. Conclusions: In this cohort of cancer pain patients, interventional cancer pain procedures provided effective pain relief and other benefits, including pain relief, reduced burden of symptoms, and reduction of opioid intake, while demonstrating a favorable safety profile. Patients with poorer ratings of depression and fatigue derived less benefit from procedures, suggesting that offering such procedures as part of patients’ treatment plan would be sensible, rather than leaving interventions for later stages. Key words: Cancer pain, pain management, pain intractable, treatment outcomes, palliative care, advanced cancer, cancer, evidence-based madicine

Neurosurgical ablative procedures for intractable cancer pain

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.

Comparing the efficacy of nebulized morphine with intravenous morphine in traumatic musculoskeletal pain management

2020 ◽  
Vol 8 (1) ◽  
pp. 21-21
Author(s):  
Mani Mofidi ◽  
Ali Dashti ◽  
Mahdi Rezai ◽  
Niloufar Ghodrati ◽  
Hoorolnesa Ameli ◽  
...  
Keyword(s):  
Pain Management ◽  
Pain Relief ◽  
Musculoskeletal Pain ◽  
Normal Saline ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Vital Signs ◽  
Categorical Variables ◽  
Intravenous Morphine ◽  
Numerical Rating

Introduction: This study was designed to compare the effectiveness of intravenous morphine with nebulized morphine in pain relief of patients referring to the emergency setting with traumatic musculoskeletal pain. Methods: This randomized, placebo-controlled and double-blind clinical study evaluated 160 patients 18 to 65 years of age with acute traumatic pain, who attended the emergency department during 2019. Subjects were assessed with Numerical Rating Scale based on inclusion and exclusion criteria and randomly divided into two groups. In one group, 80 patients received IV morphine (0.1 mg/kg+5 mL normal saline) plus an equivalent volume of IV placebo. In the second group, 80 patients received nebulized morphine (0.2 mg/kg+5 mL normal saline) plus nebulized placebo. Pain score was monitored in all patients with Numerical Rating Scale before and after intervention at baseline, 15, 30, 45, and 60-minute intervals. Patients’ vital signs and possible adverse events were evaluated in each observation time points. Finally, all participants were assessed for their satisfaction with pain management. Data were analyzed using repeated measure analysis for continuous variables and Binomial test for categorical variables Results: There was no significant difference between the demographic characteristics of patients in study groups. Pain relief between the two groups was similar during the observation (0, 15, 30, 45, 60 min) (P>0.05). There were no changes in vital signs between two groups, although the nebulized group had lower systolic blood pressure at the time-point of 15 minutes after the treatment initiation (P=0.03). Conclusion: Although Nebulized morphine has similar efficacy in comparison with IV route, nebulization might be considered as the clinically efficacious route of morphine administration with minimal side effects, providing optimal pain relief in patients.

Intraoperative Neurophysiology for Optimization of Percutaneous Spinothalamic Cordotomy for Intractable Cancer Pain

2020 ◽  
Author(s):  
Yechiam Sapir ◽  
Akiva Korn ◽  
Yifat Bitan-Talmor ◽  
Irina Vendrov ◽  
Assaf Berger ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Cancer Pain ◽  
Motor Deficit ◽  
Intensity Difference ◽  
Sensory Threshold ◽  
Intractable Pain ◽  
Spinothalamic Tract ◽  
Intramedullary Spinal Cord ◽  
Stimulation Intensity ◽  
Intractable Cancer Pain

Abstract BACKGROUND Percutaneous ablation of the cervical spinothalamic tract (STT) remains a therapeutic remedy for intractable cancer pain. However, it is accompanied by the risk of collateral damage to essential spinal cord circuitry, including the corticospinal tract (CST). Recent studies describe threshold-based mapping of the CST with the objective of motor bundle preservation during intramedullary spinal cord and supratentorial surgery. OBJECTIVE To assess the possibility that application of spinal cord mapping using intraoperative neuromonitoring in percutaneous cordotomy procedures may aid in minimizing iatrogenic motor tract injury. METHODS We retrospectively reviewed the files of 11 patients who underwent percutaneous cervical cordotomy for intractable oncological pain. We performed quantitative electromyogram (EMG) recordings to stimulation of the ablation needle prior to the STT-ablative stage. We compared evoked motor and sensory electrical thresholds, and the electrical span between them as a reliable method to confirm safe electrode location inside the STT. RESULTS Quantified EMG data were collected in 11 patients suffering from intractable cancer pain. The threshold range for evoking motor activity was 0.3 to 1.2 V. Stimulation artifacts were detected from trapezius muscles even at the lowest stimulation intensity, while thenar muscles were found to be maximally sensitive and specific. The minimal stimulation intensity difference between the motor and the sensory threshold, set as “Δ-threshold,” was 0.26 V, with no new motor deficit at 3 days or 1 month postoperatively. CONCLUSION Selective STT ablation is an effective procedure for treating intractable pain. It can be aided by quantitative evoked EMG recordings, with tailored parameters and thresholds.

scholarly journals Postendodontic Pain after Pulpotomy or Root Canal Treatment in Mature Teeth with Carious Pulp Exposure: A Multicenter Randomized Controlled Trial

2020 ◽  
Vol 2020 ◽  
pp. 1-14
Author(s):  
Mohammad Jafar Eghbal ◽  
Ali Haeri ◽  
Arash Shahravan ◽  
Ali Kazemi ◽  
Fariborz Moazami ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Pain Relief ◽  
Root Canal ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Controlled Trial ◽  
Mineral Trioxide Aggregate ◽  
Preoperative Pain ◽  
Multicenter Randomized Controlled Trial ◽  
The Mean

This equivalence, randomized, clinical trial aimed to compare the postoperative pain of root canal therapy (RCT) with pulpotomy with mineral trioxide aggregate (PMTA) or calcium-enriched mixture (PCEM) in permanent mature teeth. In seven academic centers, 550 cariously exposed pulps were included and randomly allocated into PMTA (n = 188), PCEM (n = 194), or RCT (n = 168) arms. Preoperative “Pain Intensity” (PI) on Numerical Rating Scale and postoperative PIs until day 7 were recorded. Patients’ demographic and pre-/intra-/postoperative factors/conditions were recorded/analysed. The arms were homogeneous in terms of demographics. The mean preoperative PIs were similar (P=0.998), the mean sum PIs recorded during 10 postoperative intervals were comparable (P=0.939), and the trend/changes in pain relief were parallel (P=0.821) in all study arms. The incidences of preoperative moderate-severe pain in RCT, PMTA, and PCEM arms were 56.5%, 55.7%, and 56.7%, which after 24 hours considerably decreased to 13.1%, 10.6%, and 12.9%, respectively (P=0.578). The time span of endodontic procedures was statistically different; RCT = 69.73, PMTA = 35.37, and PCEM = 33.62 minutes (P<0.001). Patients with greater preoperative pain, symptomatic apical periodontitis, or presence of PDL widening suffered more pain (P=0.002, 0.035, and 0.023, resp.); however, other pre-/intra-/postoperative factors/conditions were comparable. Pulpotomy with MTA/CEM and RCT demonstrate comparable and effective postoperative pain relief.

scholarly journals Percutaneous cervical cordotomy for cancer-related pain: national data

2020 ◽  
Vol 10 (4) ◽  
pp. 429-434 ◽  
Author(s):  
Marlise Poolman ◽  
Matthew Makin ◽  
Jess Briggs ◽  
Kate Scofield ◽  
Nick Campkin ◽  
...  
Keyword(s):  
Cancer Pain ◽  
Rating Scale ◽  
Pain Treatment ◽  
Numerical Rating Scale ◽  
Improve Patient Care ◽  
Data Repository ◽  
Primary Malignancy ◽  
International Consensus ◽  
Opioid Dose

ObjectivesPercutaneous cervical cordotomy (PCC) is an interventional ablative procedure in the armamentarium for cancer pain treatment, but there is limited evidence to support its use. This study aimed to assess the effectiveness and safety of PCC.MethodsAnalysis was undertaken of the first national (UK) prospective data repository of adult patients with cancer undergoing PCC for pain treatment. The relationship between pain and other outcomes before and after PCC was examined using appropriate statistical methods.ResultsData on 159 patients’ PCCs (performed from 1 January 2012 to 6 June 2017 in three centres) were assessed: median (IQR) age was 66 (58–71) years, 47 (30%) were female. Mesothelioma was the most common primary malignancy (57%). The median (IQR) time from cancer diagnosis to PCC assessment was 13.3 (6.2–23.2) months; PCC to follow-up was 9 (8–25) days; and survival after PCC was 1.3 (0.6–2.8) months. The mean (SD) for ‘average pain’ using a numerical rating scale was 6 (2) before PCC and 2 (2) at follow-up, and for ‘worst pain’ 9 (1) and 3 (3), respectively. The median (IQR) reduction in strong opioid dose at follow-up was 50% (34–50). With the exception of ‘activity’, all health-related quality of life scores (5-level version of EuroQol-5 Dimension) either improved or were stable after PCC. Six patients (4%) had PCC-related adverse events.ConclusionsPCC is an effective treatment for cancer pain; however, findings in this study suggest PCC referrals tended to be late in patients’ disease trajectories. Further study into earlier treatment and seeking international consensus on PCC outcomes will further enhance opportunities to improve patient care.

Nebulized morphine for analgesia in an emergency setting

2018 ◽  
Vol 5 (1) ◽  
pp. 23 ◽  
Author(s):  
Vincent Bounes, MD ◽  
Jean Louis Ducassé, MD ◽  
Annie Momo Bona, MD ◽  
Florent Battefort, MD ◽  
Charles-Henri Houze-Cerfon, MD ◽  
...  
Keyword(s):  
Pain Relief ◽  
Acute Pain ◽  
Rating Scale ◽  
Numerical Rating Scale ◽  
Statistical Significance ◽  
A Priori ◽  
Primary Outcome Measure ◽  
Point Estimate ◽  
Emergency Setting ◽  
Significant Difference

Objective: To evaluate the efficacy and safety of inhaled morphine delivered in patients experiencing severe acute pain in an emergency setting.Patients and Methods: Patients were eligible for inclusion if they were aged 18 years or older, with a severe acute pain defined by a numerical rating scale (NRS) score of 60/100 or higher. The intervention involved administering a single dose of 0.2 mg/kg morphine nebulized using a Misty-Neb nebulizer system. NRSs were recorded and were repeated at 1, 3, 5, and 10 minute after the end of inhalation (T10). The protocol-defined primary outcome measure was pain relief (defined by an NRS score of 30/100 or lower) at T10. Secondary outcomes included differences between pain scores at baseline and at T10 and incidence of adverse events.Results: A total of 28 patients were included in this study. No patient experienced pain relief 10 minutes after the end of inhalation, and no adverse effects were recorded. Respective initial and final median NRS scores were 80 (70-90) and 70 (60-80), p < 0.0001. Despite achieving statistical significance, the value of this point estimate is less than the 14 NRS difference that was defined a priori as representing a minimum clinically significant difference in pain severity.Conclusion: 0.2 mg/kg nebulized morphine is not effective in managing acute pain in an emergency setting. In spite of the potential advantages of the pulmonary route of administration, opioids should be intravenous prescribed at short fixed intervals to control severe acute pain in an emergency setting.

scholarly journals Computerized tomography-guided percutaneous extralemniscal myelotomy

1997 ◽  
Vol 2 (1) ◽  
pp. E7 ◽  
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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