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

2015 ◽  
Vol 18;4 (4;18) ◽  
pp. E651-E656 ◽  
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

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 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.

scholarly journals Intrathecal Analgesia Via a Percutaneous Port For the Management of Movement-Evoked Breakthrough Cancer Pain of Refractory Lower Extremity Cancer Pain: A Retrospective Review and Commentary

2021 ◽  
Author(s):  
Liang Zhou ◽  
Zhenggang Guo
Keyword(s):  
Lower Extremity ◽  
Cancer Pain ◽  
Pain Intensity ◽  
Breakthrough Pain ◽  
Infusion Therapy ◽  
The Mean ◽  
Intractable Cancer Pain ◽  
Time To Onset ◽  
Morphine Equivalent ◽  
Intrathecal Analgesia

Abstract Background and Objectives: Intrathecal analgesia (ITA) is a trusty treatment option for refractory and intractable cancer pain. However, there is still no general consensus on the analgesic effect of movement-evoked breakthrough pain (MEBTP) in the ITA setting. This study examined the effect of patient-controlled intrathecal analgesia (PCIA) on analgesic efficacy, emphasizing movement evoked breakthrough pain (MEBTP) in patients with refractory lower extremity cancer pain. Methods: A retrospective chart review included all patients with refractory lower extremity cancer pain who received Intrathecal morphine infusion therapy via percutaneous port (IMITPP) at our hospital between January 2017 and December 2020. Data on the numerical pain rating scales (NRS) scores, opioid doses, and complications were collected from medical records prior to IMITPP and at a one-month postimplant visit.Results: A total of 16 patients were included in the study group. Mean SRPI (spontaneous resting pain intensity) decreased from 8.75 pre- IMITPP to 3.75 post- IMITPP, (P < 0.001); mean MEPI (movement-evoked breakthrough pain intensity) fell from 8.83 pre- IMITPP to 4.25 post- IMITPP (P < 0.001); mean daily morphine equivalent dosing decreased from 360 mg/d to 48mg/d (P< 0.001); mean daily morphine equivalent dosing for MEBTP decreased from 87 mg/d to 6 mg/d (P< 0.001). Both total and breakthrough dosing of conventional opioid medications significantly decreased following the initiation of ITT with PCIA. The mean perceived time to onset with conventional movement evoked breakthrough medications was 38 minutes, and the mean perceived time to onset with PCIA was 8 minutes (P < 0.001). Conclusions: IMITPP was associated with improved pain control in patients with refractory lower extremity cancer pain. Compared with conventional MEBTP medication, appropriate PCIA provided superior analgesia and a much faster onset of action.

scholarly journals Ultrasound-Guided Superficial Serratus Plane Block for Persistent Post-Mastectomy Pain: Four Case Reports

2021 ◽  
Author(s):  
Qian Liu ◽  
Khanna Ashish ◽  
Michael Stubblefield ◽  
Guanghui Yue ◽  
Didier Allexandre
Keyword(s):  
Breast Cancer ◽  
Pain Relief ◽  
Breast Cancer Survivors ◽  
Case Reports ◽  
Anesthetic Technique ◽  
Multiple Modalities ◽  
Adequate Pain Relief ◽  
Patient Reported ◽  
Intercostobrachial Nerve ◽  
Regional Anesthetic

Abstract Background: Persistent post-mastectomy pain (PPMP) is common after surgery. Although multiple modalities have been used to treat this type of pain, including physical medicine, physical therapy and interventional approaches, managing PPMP may be still a challenge for breast cancer survivors. Currently, serratus plane block (SPB) as a novel regional anesthetic technique shows promising results for controlling chronic pain. Methods: We report four cases of patients with PPMP that were performed using superficial serratus plane block (SSPB) at our clinic. A retrospective review of effect of pain relief was collected through postprocedure interviews.Results: We found that two of our patients were successfully treated with SSPB for pain after treatment for breast cancer. The third patient had an intercostobrachial nerve block that produced incomplete pain relief, but had adequate pain relief with a SSPB. However, the fourth patient reported no pain relief after SSPB.Conclusion: These cases illustrate that the patients with PPMP could benefit from SSPB. Particularly, we find patients with a subjective sense of “tightness” relating to reconstructive surgeries may be a good candidate for SSPB. Further studies are warranted to evaluate this block for PPMP, as it is low risk and relatively simple to perform.

Do Waveforms Matter? Yes They Do! A Case in Point

2020 ◽  
Vol 44 (4) ◽  
pp. 192-197
Author(s):  
Jessica Kralec
Keyword(s):  
Lower Extremity ◽  
Continuous Flow ◽  
Pregnant Patient ◽  
Iliac Vein ◽  
Leg Pain ◽  
Common Iliac Vein ◽  
Venous Flow ◽  
Left Lower Extremity ◽  
Patient Reported ◽  
Spectral Doppler

A 38-year-old G1P0 presented to the Vascular Lab at 32 weeks gestation for evaluation of persistent left lower extremity edema. The patient reported a 1-month history of left leg pain and swelling after a long car trip. Of note, she had 3 negative lower extremity ultrasounds at outside imaging facilities over the previous 6 weeks. Left lower extremity venous duplex was performed with B-mode, color, power, and spectral Doppler using a linear 12-3 MHz transducer and curvilinear 5-1 MHz transducer. Images were documented using Intersocietal Accreditation Commission Vascular Testing (IAC VT) protocol. Left lower extremity duplex revealed continuous flow in the bilateral common femoral veins. Right common iliac and external iliac vein Doppler waveforms demonstrated spontaneous and phasic flow. Left proximal common iliac and external iliac veins revealed continuous flow. Acute, occlusive deep venous thrombosis (DVT) was identified in the left distal common iliac vein. The left common iliac vein was enlarged, measuring 2.2 cm compared with the contralateral common iliac vein measuring 1.4 cm. Ultrasonographic infrainguinal demonstration of acute DVT is straightforward and usually achievable with standard ICA VT protocol. However, imaging of the proximal pelvic venous circulation can be more elusive, particularly in the pregnant patient. Therefore, it is imperative to assess the spectral Doppler waveforms and to investigate pelvic venous flow. Because of the sonographer’s attention to the common femoral waveforms, additional focused pelvic imaging was performed and located acute, occlusive iliac DVT as the cause of significant edema.

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

Neurosurgery ◽  
1986 ◽  
Vol 18 (6) ◽  
pp. 740-747 ◽  
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 &lt; 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 &lt; 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.

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.

Analgesia with Epidural Calcitonin in Cancer Patients

1989 ◽  
Vol 75 (2) ◽  
pp. 183-184 ◽  
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.

scholarly journals Stereotactic radiosurgery for idiopathic glossopharyngeal neuralgia: an international multicenter study

2016 ◽  
Vol 125 (Supplement_1) ◽  
pp. 147-153 ◽  
Author(s):  
Hideyuki Kano ◽  
Dusan Urgosik ◽  
Roman Liscak ◽  
Bruce E. Pollock ◽  
Or Cohen-Inbar ◽  
...  
Keyword(s):  
Pain Relief ◽  
Stereotactic Radiosurgery ◽  
Gamma Knife ◽  
Glossopharyngeal Neuralgia ◽  
Pain Intensity Score ◽  
Nerve Blocks ◽  
Duration Of Symptoms ◽  
Complete Pain Relief ◽  
Adequate Pain Relief

OBJECTIVEThe goal of this study was to evaluate the outcomes of Gamma Knife stereotactic radiosurgery (SRS) when used for patients with intractable idiopathic glossopharyngeal neuralgia.METHODSSix participating centers of the International Gamma Knife Research Foundation identified 22 patients who underwent SRS for intractable glossopharyngeal neuralgia between 1998 and 2015. The median patient age was 60 years (range 34–83 years). The median duration of symptoms before SRS was 46 months (range 1–240 months). Three patients had unsuccessful prior surgical procedures, including microvascular decompression (MVD) (n = 2) and balloon compression (n = 1). The radiosurgical target was the glossopharyngeal meatus. The median maximum dose was 80 Gy.RESULTSThe median follow-up was 45 months after SRS (range 6–120 months). Twelve patients (55%) had < 4 years of follow-up. Thirteen patients (59%) had initial complete pain relief at a median of 12 days after SRS (range 1–60 days). Three patients (14%) had partial pain relief at a median of 70 days after SRS (range 60–90 days). Six patients (27%) had no pain relief. Among 16 patients with initial pain relief, 5 maintained complete pain relief without medication (Barrow Neurological Institute [BNI] pain intensity score Grade I), 1 maintained occasional pain relief without medication (BNI Grade II), 3 maintained complete pain relief with medication (BNI Grade IIIb), and 7 patients had pain recurrence at a median of 20 months after SRS (range 6–120 months). The rates of maintenance of adequate pain relief (BNI Grades I–IIIb) were 63% at 1 year, 49% at 2 years, 38% at 3 years, 38% at 5 years, and 28% at 7 years. When 7 patients without pain recurrence within 4 years of follow-up were excluded, the rates of maintenance of adequate pain relief were 38% at 5 years and 28% at 7 years. Ten patients required additional procedures (MVD, n = 4; repeat SRS, n = 5; glossopharyngeal nerve block, n = 1). Four of 5 patients who underwent repeat SRS maintained pain relief (BNI Grade I, n = 3; and BNI Grade IIIb, n = 1). No adverse effects of radiation were observed after a single SRS. Two patients developed hyperesthesia in the palatoglossal arch 5 and 8 months after repeat SRS, respectively.CONCLUSIONSStereotactic radiosurgery for intractable, medically refractory glossopharyngeal neuralgia provided lasting pain reduction in 55% of patients after 1 or 2 SRS procedures. Patients who had a poor response or pain recurrence may require additional procedures such as repeat SRS, MVD, nerve blocks, or nerve section. No patient developed changes in vocal cord function or swallowing disorders after SRS in this study.

Sign in / Sign up

Export Citation Format

Share Document