American Society of Regional Anesthesia and Pain Medicine August 2018 - 20
to 2.4, p < 0.05) and oral morphine consumption decreased from
98 mg to 32 mg daily (p < 0.05). No complications or serious side
effects were noted.14
Peripheral nerve blocks are playing a larger role in managing
cancer pain, particularly as ultrasound-guided blocks are becoming
popular in both the perioperative and pain clinic settings. The
role of truncal blocks, including erector spinae, serratus anterior,
pectoralis nerve I and II, transverse abdominis plane, and quadratus
lumborum are still being evaluated. These are particularly useful
in postmastectomy neuralgias, chest wall tumors, radiation burns,
and extensive abdominal surgeries with residual neuropathic and
somatic pain.
Finally, neuraxial treatments continue to play a central role in managing
complex pain syndromes. Epidural catheters are a useful option for
managing thoracic and abdominal pain in malignancies. Because pain
is expected to continue beyond hospitalization, options to prolong the
epidural include tunneling epidural catheters for home infusions of
local and opioids. Benefits include ease of placement and ability to
target specific dermatomes. However, infection risks associated with
tunneled catheters limit the option to those at the end of life.15
For patients with longer expected life spans, intrathecal drug
delivery systems (IDDS) can deliver opioids, local anesthetics,
and adjuvants such as clonidine directly to the intrathecal space
with excellent efficacy. Lower volumes are required than with an
epidural; thus, patients can go for months without refilling the
drug reservoir. In one randomized controlled trial by Smith et al,16
IDDS was compared to comprehensive medical management in
143 patients with cancer and initial visual analog scale score
greater than 5. The IDDS group had more successful pain relief
with more patients having a greater than 20% reduction in pain
(57.7% vs 37.5%, p = 0.02). The IDDS group also had significantly
less drug toxicity, including reduced fatigue and depressed level
of consciousness. Interestingly, although it was not statistically
significant, the IDDS patients had a trend toward improved survival,
with 53.9% alive at 6 months compared to 37.2% of the medically
managed group (p = 0.06).16 Other studies have also shown
improved pain scores, decreased opioid use, and improved quality
of life.17,18 Commonly infused drugs include opioids (eg, morphine,
fentanyl, hydromorphone), local anesthetics, clonidine, baclofen,
and ziconotide. Another neuraxial treatment, albeit less commonly
used in end-stage cancer patients, is intrathecal neurolysis.
Although data consist mostly of case reports describing the
technique, it has been shown to be effective for patients as a last
resort as an end of life palliative treatment.19,20
These methods are a small sampling of the procedural
armamentarium available to the modern interventional pain
physician. Opioids will always have a role in managing cancer
pain for the foreseeable future, but the opioid epidemic is shining
20
a spotlight on what is dangerous about opioids, and the same
concerns extend to using opioids in patients with cancer pain.
Earlier interventions can minimize opioid consumption and improve
outcomes, as shown in recent research. Although every procedure
has potential risks, they must be weighed against the risks of
continuing high-dose opioids and inadequate pain control. The
literature in oncology and palliative care specialties is noticing
the advantage of early interventions and maximizing non-opioid
medications. Continuing to educate our colleagues in other
specialties about what options we can offer would go a long way
toward improving access to appropriate interventions for patients
with cancer.
REFERENCES
1.
Bhatnagar S, Gupta M. Evidence-based clinical practice guidelines for
interventional pain management in cancer pain. Indian J Palliat Care.
2015;21(2):137-147.
2.
Frankish H. 15 million new cancer cases per year by 2020, says WHO. Lancet.
2003;361(9365):1278.
3.
Crofford LJ. Adverse effects of chronic opioid therapy for chronic
musculoskeletal pain. Nat Rev Rheumatol. 2010;6(4):191-197.
4.
Chu LF, Angst MS, Clark D. Opioid-induced hyperalgesia in humans: molecular
mechanisms and clinical considerations. Clin J Pain. 2008;24(6):479-496.
5.
Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med.
2003;349(20):1943-1953.
6.
Grandhi RK, Lee S, Abd-Elsayed A. Does opioid use cause angiogenesis and
metastasis? Pain Med. 2017;18(1):140-151.
7.
Vissers KC, Besse K, Wagemans M, et al. Pain in patients with cancer. Pain
Pract. 2011;11(5):453-475.
8.
Zhong W, Yu Z, Zeng JX, et al. Celiac plexus block for treatment of pain associated
with pancreatic cancer: a meta-analysis. Pain Pract. 2014;14(1):43-51.
9.
Amr YM, Makharita MY. Neurolytic sympathectomy in the management of cancer
pain-time effect: a prospective, randomized multicenter study. J Pain Symptom
Manage. 2014;48(5):944-956 e942.
10. Wong GY, Schroeder DR, Carns PE, et al. Effect of neurolytic celiac plexus block
on pain relief, quality of life, and survival in patients with unresectable pancreatic
cancer: a randomized controlled trial. JAMA. 2004;291(9):1092-1099.
11. Mishra S, Bhatnagar S, Rana SP, Khurana D, Thulkar S. Efficacy of the anterior
ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain
in advanced gynecological cancer patients. Pain Med. 2013;14(6):837-842.
12. Agarwal-Kozlowski K, Lorke DE, Habermann CR, Am Esch JS, Beck H. CT-guided
blocks and neuroablation of the ganglion impar (Walther) in perineal pain:
anatomy, technique, safety, and efficacy. Clin J Pain. 2009;25(7):570-576.
13. Eker HE, Cok OY, Kocum A, Acil M, Turkoz A. Trans-sacrococcygeal approach to
ganglion impar for pelvic cancer pain: a report of 3 cases. Reg Anesth Pain Med.
2008;33(4):381-382.
14. Ahmed DG, Mohamed MF, Mohamed SA. Superior hypogastric plexus combined
with ganglion impar neurolytic blocks for pelvic and/or perineal cancer pain
relief. Pain Physician. 2015;18(1):E49-E56.
15. Smitt PS, Tsafka A, Teng-van de Zande F, et al. Outcome and complications
of epidural analgesia in patients with chronic cancer pain. Cancer.
1998;83(9):2015-2022.
16. Smith TJ, Staats PS, Deer T, et al. Randomized clinical trial of an implantable
drug delivery system compared with comprehensive medical management for
refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin
Oncol. 2002;20(19):4040-4049.
American Society of Regional Anesthesia and Pain Medicine
2018
Table of Contents for the Digital Edition of American Society of Regional Anesthesia and Pain Medicine August 2018
American Society of Regional Anesthesia and Pain Medicine August 2018 - 1
American Society of Regional Anesthesia and Pain Medicine August 2018 - 2
American Society of Regional Anesthesia and Pain Medicine August 2018 - 3
American Society of Regional Anesthesia and Pain Medicine August 2018 - 4
American Society of Regional Anesthesia and Pain Medicine August 2018 - 5
American Society of Regional Anesthesia and Pain Medicine August 2018 - 6
American Society of Regional Anesthesia and Pain Medicine August 2018 - 7
American Society of Regional Anesthesia and Pain Medicine August 2018 - 8
American Society of Regional Anesthesia and Pain Medicine August 2018 - 9
American Society of Regional Anesthesia and Pain Medicine August 2018 - 10
American Society of Regional Anesthesia and Pain Medicine August 2018 - 11
American Society of Regional Anesthesia and Pain Medicine August 2018 - 12
American Society of Regional Anesthesia and Pain Medicine August 2018 - 13
American Society of Regional Anesthesia and Pain Medicine August 2018 - 14
American Society of Regional Anesthesia and Pain Medicine August 2018 - 15
American Society of Regional Anesthesia and Pain Medicine August 2018 - 16
American Society of Regional Anesthesia and Pain Medicine August 2018 - 17
American Society of Regional Anesthesia and Pain Medicine August 2018 - 18
American Society of Regional Anesthesia and Pain Medicine August 2018 - 19
American Society of Regional Anesthesia and Pain Medicine August 2018 - 20
American Society of Regional Anesthesia and Pain Medicine August 2018 - 21
American Society of Regional Anesthesia and Pain Medicine August 2018 - 22
American Society of Regional Anesthesia and Pain Medicine August 2018 - 23
American Society of Regional Anesthesia and Pain Medicine August 2018 - 24
American Society of Regional Anesthesia and Pain Medicine August 2018 - 25
American Society of Regional Anesthesia and Pain Medicine August 2018 - 26
American Society of Regional Anesthesia and Pain Medicine August 2018 - 27
American Society of Regional Anesthesia and Pain Medicine August 2018 - 28
American Society of Regional Anesthesia and Pain Medicine August 2018 - 29
American Society of Regional Anesthesia and Pain Medicine August 2018 - 30
American Society of Regional Anesthesia and Pain Medicine August 2018 - 31
American Society of Regional Anesthesia and Pain Medicine August 2018 - 32
American Society of Regional Anesthesia and Pain Medicine August 2018 - 33
American Society of Regional Anesthesia and Pain Medicine August 2018 - 34
American Society of Regional Anesthesia and Pain Medicine August 2018 - 35
American Society of Regional Anesthesia and Pain Medicine August 2018 - 36
American Society of Regional Anesthesia and Pain Medicine August 2018 - 37
American Society of Regional Anesthesia and Pain Medicine August 2018 - 38
American Society of Regional Anesthesia and Pain Medicine August 2018 - 39
American Society of Regional Anesthesia and Pain Medicine August 2018 - 40
American Society of Regional Anesthesia and Pain Medicine August 2018 - 41
American Society of Regional Anesthesia and Pain Medicine August 2018 - 42
http://www.brightcopy.net/allen/asra/18-04
http://www.brightcopy.net/allen/asra/18-3
http://www.brightcopy.net/allen/asra/18-2
http://www.brightcopy.net/allen/asra/18-1
http://www.brightcopy.net/allen/asra/17-4
http://www.brightcopy.net/allen/asra/17-3
http://www.brightcopy.net/allen/asra/17-2
http://www.brightcopy.net/allen/asra/17-1
http://www.brightcopy.net/allen/asra/16-4
http://www.brightcopy.net/allen/asra/16-3
http://www.brightcopy.net/allen/asra/16-2
http://www.brightcopy.net/allen/asra/16-1
http://www.brightcopy.net/allen/asra/15-4
http://www.brightcopy.net/allen/asra/15-3
https://www.nxtbook.com/allen/asra/15-2
https://www.nxtbook.com/allen/asra/15-1
https://www.nxtbookmedia.com