scholarly journals Intracerebroventricular Pain Treatment with Analgesic Mixtures including Ziconotide for Intractable Pain

2016 ◽  
Vol 6;19 (6;7) ◽  
pp. E905-E915
Author(s):  
Hélène Staquet
Keyword(s):  
Neuropathic Pain ◽  
Side Effects ◽  
Cancer Pain ◽  
Rating Scale ◽  
Pain Treatment ◽  
Third Ventricle ◽  
High Dose ◽  
Intractable Pain ◽  
Intracerebroventricular Infusion ◽  
Intractable Cancer Pain

Intracerebroventricular (ICV) administration of opioids for control of intractable cancer pain has been used since 1982. We present here our experience of intracerebroventricular administration of pain treatments including ziconotide associated with morphine and ropivacaine for patients resistant to a conventional approach, with nociceptive, neuropathic, or mixed pain. These clinical cases were conducted with patients suffering from refractory pain, more than 6/10 on a numerical pain rating scale (NPRS) while on high-dose medical treatment and/ or intolerance with significant side effects from oral medication. The baseline study visit included a physical examination and an assessment of pain intensity on a NPRS. Under general anesthesia, a neuronavigation device was used to place the catheter on the floor of the third ventricle, supported by an endoscope. Then, drugs were injected in the cerebroventricular system, through a pump (external or subcutaneous). The primary objective was to measure pain evaluation with ICV treatment after a complete withdrawal of other medications. Four patients were enrolled: 3 with intractable cancer pain and one with central neuropathic pain. The median NPRS at baseline was 9.5 [8.5; 19]. The mean NPRS after one month was 3.5 [3; 4.5]. Ziconotide was initiated at 0.48 µg/dy and up to a median of 1.2 µg/dy [1.0; 1.56]. The median dose of morphine and ropivacaine used initially was respectively 0.36 mg/dy [0.24; 0.66] up to 0.6 mg/dy [0.45; 4.63] and 1.2 mg/dy [0; 2.4] up to 2.23 mg/dy [1.2; 3.35]. Minor side effects were initially observed but transiently. One psychiatric agitation required discontinuation of ziconotide infusion. For intractable pain, using ziconotide by intracerebroventricular infusion seems safe and efficient, specifically for chronic neoplastic pain of cervicocephalic, thoracic, or diffuse origin and also for pain arising from a central neuropathic mechanism. Key words: Intracerebroventricular infusion, ziconotide, intractable pain, nociceptive and neuropathic pain

scholarly journals Efficacious Dorsal Root Ganglion Stimulation for Painful Small Fiber Neuropathy: A Case Report

2017 ◽  
Vol 3 (20;3) ◽  
pp. E459-E463 ◽  
Author(s):  
Eva Koetsier
Keyword(s):  
Neuropathic Pain ◽  
Case Report ◽  
Dorsal Root Ganglion ◽  
Dorsal Root ◽  
Rating Scale ◽  
Pain Treatment ◽  
Small Fiber Neuropathy ◽  
Intractable Pain ◽  
Positive Trial ◽  
Small Fiber

Small fiber neuropathy is a disorder of the peripheral nerves with typical symptoms of burning, sharp, and shooting pain and sensory disturbances in the feet. Pain treatment depends principally on the underlying etiology with concurrent administration of antidepressants, anticonvulsants, opioids, and topical treatments like capsaicin and local anesthetics. However, treatments for pain relief in these patients frequently fail. We describe the first case of intractable painful small fiber neuropathy of the foot successfully treated with spinal cord stimulation of the left L5 dorsal root ganglion. A 74-year-old man presented at our clinic with severe intractable pain, dysesthesia, and allodynia of the left foot caused by idiopathic small fiber neuropathy, confirmed by skin biopsy. His pain score was 8 on a standard 0 – 10 numeric rating scale. As the pain was not satisfactorily controlled by conventional therapy, dorsal root ganglion stimulation was proposed to the patient and, after informed consent, a specifically designed percutaneous stimulation lead was placed over the left L5 dorsal root ganglion and connected to an external neurostimulator. After a positive trial of 10 days, a permanent neurostimulator was implanted. Twenty months post-implantation the patient continued to experience stimulation-induced paresthesia covering the entire pain area and reported a pain rating of 4. Results from the case report demonstrate that the dorsal root ganglion is a promising neural stimulation target to treat neuropathic pain due to intractable small fiber neuropathy. Prospective controlled studies are warranted to confirm the efficacy of this treatment as an option for the aforementioned condition. Key words: Dorsal root ganglion stimulation, small fiber neuropathy, neuropathic pain

scholarly journals Complications after Intrathecal Drug Delivery Due to the Underlying Malignancy in Two Patients with Intractable Cancer Pain

2013 ◽  
Vol 2;16 (2;3) ◽  
pp. E107-E111
Author(s):  
Thomas Chai
Keyword(s):  
Drug Delivery ◽  
Side Effects ◽  
Cancer Pain ◽  
Systemic Absorption ◽  
Pain Patient ◽  
Drug Side Effects ◽  
Intrathecal Drug Delivery ◽  
Underlying Malignancy ◽  
History Of ◽  
Intractable Cancer Pain

Intrathecal drug delivery is a mode of analgesic delivery that can be considered in those experiencing both refractory pain and excessive side effects from opioid and adjuvant analgesic use. Delivery of analgesic agents directly to the cerebral spinal fluid allows binding of the drug to receptors at the spinal level. Therefore, a reduced analgesic dosage can be afforded, resulting in reduction of drug side effects due to decreased systemic absorption. Drug delivery into the intrathecal space provides this benefit, yet it does not eliminate the possibility of drug side effects or risks of complications. Complications from this route of administration may be seen in the perioperative period or beyond, including infection, inflammatory mass, bleeding, and catheter or pump dysfunction, among others. This may manifest as new/worsening pain or as a neurologic deficit, such as a sensorimotor change and bladder/bowel dysfunction. Urgent evaluation with a detailed physical examination, device interrogation, and other workup including imaging is called for if symptoms suspicious for device-related problems arise. For the cancer pain patient, the underlying malignancy should also be considered as a potential cause for these new symptoms after intrathecal system implantation. We present 2 such cases of complications in the cancer pain patient after intrathecal drug delivery due to progression of the underlying malignant process rather than to surgical or device-related problems. The first patient had a history of metastatic osteosarcoma who, shortly after undergoing an intrathecal drug delivery trial with external pump, presented with new symptoms of both pain and neurologic changes. The second patient with a history of chondrosarcoma developed new symptoms of pain and sensorimotor change several days after intrathecal drug delivery system implantation. Key words: Intrathecal analgesia, intrathecal drug delivery, perioperative complications, cancer pain, malignant pain, pain pump

Opioid Pharmacology

2008 ◽  
Vol 2s;11 (3;2s) ◽  
pp. S133-S153 ◽  
Author(s):  
Andrea M. Trescot
Keyword(s):  
Side Effects ◽  
Pain Treatment ◽  
Volume Of Distribution ◽  
Opiate Withdrawal ◽  
Pharmacokinetic Parameters ◽  
Intractable Pain ◽  
Advantages And Disadvantages ◽  
Withdrawal Syndromes ◽  
The Individual ◽  
Mu Agonists

Background: Mu agonists have been an important component of pain treatment for thousands of years. The usual pharmacokinetic parameters (half-life, clearance, volume of distribution) of opioids have been known for some time. However, the metabolism has, until recently, been poorly understood, and there has been recent interest in the role of metabolites in modifying the pharmacodynamic response in patients, in both analgesia and adverse effects. A number of opioids are available for clinical use, including morphine, hydromorphone, levorphanol, oxycodone, and fentanyl. Advantages and disadvantages of various opioids in the management of chronic pain are discussed. Objective: This review looks at the structure, chemistry, and metabolism of opioids in an effort to better understand the side effects, drug interactions, and the individual responses of patients receiving opioids for the treatment of intractable pain. Conclusion: Mu receptor agonists and agonist-antagonists have been used throughout recent medical history for the control of pain and for the treatment of opiate induced side effects and even opiate withdrawal syndromes. Key words: Opioid metabolism, opioid interactions, morphine, codeine, hydrocodone, oxycodone, hydromorphone, methadone, intractable pain, endorphins, enkephalins, dynorphins, narcotics, pharmacology, propoxyphene, fentanyl, oxymorphone, tramadol

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.

Continuous Subcutaneous Infusion of Ketorolac in Cancer Neuropathic Pain Unresponsive to Opioid and Adjuvant Drugs. A Case Report

1996 ◽  
Vol 82 (4) ◽  
pp. 413-415 ◽  
Author(s):  
Carla Ripamonti ◽  
Chiara Ticozzi ◽  
Ernesto Zecca ◽  
Carlos H. Rodriguez ◽  
Franco De Conno
Keyword(s):  
Neuropathic Pain ◽  
Case Report ◽  
Side Effects ◽  
Cancer Patient ◽  
Cancer Pain ◽  
Antidepressant Drugs ◽  
Analgesic Efficacy ◽  
Subcutaneous Infusion ◽  
Continuous Subcutaneous Infusion ◽  
Nonopioid Analgesic

Ketorolac is a new non-steroidal anti-inflammatory drug (NSAID) having a potent nonopioid analgesic activity. Administered by continuous subcutaneous infusion (CSI), its analgesic efficacy has been documented in the treatment of somatic and visceral cancer pain whilst it has been shown to be ineffective in the treatment of neuropathic pain. Here is a description of a cancer patient with neuropathic pain unresponsive to anticonvulsant or antidepressant drugs administered in association or not with oral opioids but who was successfully treated with ketorolac alone via CSI. Furthermore, the analgesia lasted over 75 days of treatment without any significant renal and gastric side effects.

scholarly journals Check the effects: systematic assessment of antipsychotic side-effects in an inpatient cohort

2020 ◽  
Vol 10 ◽  
pp. 204512532095711
Author(s):  
Caroline Hynes ◽  
Stephen McWilliams ◽  
Mark Clarke ◽  
Ita Fitzgerald ◽  
Larkin Feeney ◽  
...  
Keyword(s):  
Side Effects ◽  
Rating Scales ◽  
Rating Scale ◽  
Standard Dose ◽  
Well Being ◽  
High Dose ◽  
Negative Consequences ◽  
Adherence Assessment ◽  
Dose Combination ◽  
Antipsychotic Side Effects

Background: Antipsychotics are associated with a range of side-effects that can influence patients’ subjective well-being negatively resulting in poor adherence. In order to limit the negative consequences of side-effects, they should be regularly systematically assessed. The aim of this study was to systematically assess antipsychotic side-effects in an inpatient cohort using validated rating scales. Methods: Eligible individuals prescribed an antipsychotic for at least 2 weeks were invited to have their side-effects assessed systematically. Results: A total of 208 individuals were assessed systematically for antipsychotic side-effects; 71.5% ( n = 138) stated that they had not reported side-effects to their clinician prior to the assessment. The most commonly reported side-effects were daytime drowsiness (75%), dry mouth (58.2%) and weight gain (50.0%), while the most distressing side-effects reported were erectile dysfunction (35.0%), sexual dysfunction (26.3%) and amenorrhoea (26.3%). There was no evidence of an association between side-effect severity/number of side-effects reported/distress caused by those taking high dose/combination antipsychotics versus standard dose monotherapy. Conclusion: Side-effects must be regularly and systematically assessed using a validated rating scale. As distress caused by side-effects plays a major role in non-adherence, assessment should examine distress and data on distressing side-effects should be available to those choosing an antipsychotic. Given the lack of correlation between high dose/combination antipsychotics and side-effects, treatment should be tailored to the individual based on response/tolerance and dose reduction/avoidance of polypharmacy should not be recommended to minimise side-effects.

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 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.

Intramuscular maintenance treatment with ultra-high-dose long-acting injectable aripiprazole in an elderly patient suffering from chronic refractory schizophrenia: A case report

2016 ◽  
Vol 33 (S1) ◽  
pp. S573-S573 ◽  
Author(s):  
L. Bartova ◽  
M. Dold ◽  
N. Praschak-Rieder ◽  
A. Naderi-Heiden ◽  
S. Kasper
Keyword(s):  
Side Effects ◽  
Maintenance Treatment ◽  
Rating Scale ◽  
Antipsychotic Treatment ◽  
High Dose ◽  
Symptom Scale ◽  
Meaningful Improvement ◽  
Plasma Level Monitoring ◽  
Competing Interest ◽  
Long Acting

Long-acting injectable (LAI) aripiprazole is increasingly appreciated in the course of a maintenance treatment of schizophrenia due to efficacy in delaying – and decreasing relapse, and low rates of feared side effects. In line with the prescribing information, the maximal starting – as well as maintenance dose was restricted to 400 mg following a 26-day interval between the single doses.We present a 72-year-old female inpatient (66 kg) with an acute exacerbation of chronic refractory schizophrenia, exhibiting primarily positive symptoms including excessive persecutory delusions, self-care deficit, poor insight and insufficient adherence to continuous intake of oral medication. Since she developed a post-injection syndrome after an accidental intravascular administration of olanzapine LAI 405 mg, the antipsychotic treatment was switched to aripiprazole LAI 300 mg once monthly. Due to insufficient clinical response, aripiprazole LAI was gradually increased up to 1200 mg per month under continuous plasma level monitoring. Here, 2 single injections of aripiprazole LAI 300 mg were delivered into both gluteal muscles concurrently, every 14 days.Consequently, we observed a clinically meaningful improvement (a total-score reduction from 111 to 75 on the Positive and Negative Syndrome Scale), as well as no objectifiable side effects, assessed by “The Dosage Record Treatment Emergent Symptom Scale” and “The Barnes Akathisia Rating Scale”, despite multi-morbidity and rather advanced age of the patient.Our safe experience with applying the almost threefold higher monthly dose over 12 weeks may encourage researchers to further investigate the efficacy, tolerability as well as handling of highly dosed aripiprazole LAI in refractory schizophrenia.Disclosure of interestThe authors have not supplied their declaration of competing interest.

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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