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Intraspinal analgesia for Cancer Pain

Intraspinal analgesia for Cancer Pain. Ri 錢穎群 劉耀臨. Indications. The 4th step in managing pain of malignant origin Unsuccessful treatment with sequential strong systemic opioid drug trials despite escalating doses

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Intraspinal analgesia for Cancer Pain

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  1. Intraspinal analgesia for Cancer Pain Ri 錢穎群 劉耀臨

  2. Indications • The 4th step in managing pain of malignant origin • Unsuccessful treatment with sequential strong systemic opioid drug trials despite escalating doses • Treatment with systemic opioids with effective pain relief but with unacceptable side effects

  3. Advantages • Lower dose than systemic use (1/10 rule for morphine) • Longer analgesic effect • Fewer opioid side effects

  4. Adverse effects and Complications • Same as systemic opioids but less severe • Tolerance Best Practice & Research Clinical Anaesthesiology Vol.16, NO.4, pp.651-665, 2002

  5. Catheter placement • Percutaneous: simple, cheap, risk of infection, high failure rate • Tunnelled: more helpful, providing months of effective analgesia • Implantable programmable infusion pump: expensive, continuous infusion, good daily activity, good quality of life (for long-term analgesia, >3 months)

  6. Implantable intrathecal pump • A multicenter, prospective clinical study • Numeric Analog Scale↓ • opioid use↓ • Opioid side effect index↓ • “breakthrough” pain The Journal of Pain, Vol 4, No 8 (October), 2003: pp 441-447

  7. Intrathecal vs Epidural Best Practice & Research Clinical Anaesthesiology Vol.16, NO.4, pp.651-665, 2002

  8. Continuous infusion vs intermittent bolus Best Practice & Research Clinical Anaesthesiology Vol.16, NO.4, pp.651-665, 2002

  9. single-shot epidural or intrathecal opioids may serve as an indicator to the future success of continuous infusions or patient-controlled analgesia using opioids. • Adequate relief of pain with trial spinal oipoids is mandatory before proceeding to more permanent procedures for long-term treatment.

  10. Opioid agents • Morphine • Hydromorphone • Fentanyl • Meperidine • Methadone • The exact dose comparison for different opioids for intraspinal use is not available

  11. Non-opioid agents • sodium channel antagonist: bupivacaine, ropivacaine • α2 agonist: clonidine • N-type voltage-gated calcium-channel antagonist: Ziconotide • NMDA receptor antagonist: Ketamine • GABA agonist, adenosine agonist, cholinesterase inhibitor

  12. Bupivacaine, Ropivacaine • Local anesthetics • Combination with opioids • Synergistic effect • No significant side effect • Ropivacaine is more selective for sensory versus motor nerves between the sensory and motor blockade

  13. Clonidine • Approved by FDA for epidural analgesia • Action on α2-adrenergic receptors in superficial dorsal horn region of the spinal cord • Combination with opioids • Side effects: hypotension, bradycardia, sedation

  14. Zinconotide • Adventage: no development of tolerance like opioids after prolonged use • Intrathecal delivery provided clinically and statisticlly analgesia in patients with pain from cancer and AIDS • Side effects: confusion, dizziness, urinary retention, constipation, nystagmus, ataxia, convulsion JAMA. 2003;291:63-70

  15. Others • Baclofen • Midazolam • Adenosine • neostigmine

  16. The efficacy of intraspinally administered agents need to be studied in different type of cancer pain syndrome.

  17. Case 1 • 60y/o male • C.C.: face swelling, right flank pain • First admitted on 4/21 • Right supraclavicular lymph node biopsy: adenocarcinoma • Diagnosis: NSCLC, stage IV • SVC syndrome s/p stenting on 4/23 • Discharged on 4/30 • Admitted again on 5/21 due to abdominal pain

  18. Acute pancreatitis with abdominal pain on 5/18, recurred on 6/17 (pancreatic metastasis) • T12~L1 right paraspinal mass, right adrenal mass were noted on CT • Chemotherapy of weekly Gemzar was started on 6/11 • Palliative radiotherapy to the RUL mass was performed on 6/18

  19. Pain profile • Right flank pain since 4/13 • 4/21住院workup，接受biopsy, 放stent • 4/30出院，出院止痛處方： durogesic(2.5mg/patch) q3d codeine (15mg) 1# po q6h naposine (250mg)1# po TID • 5/18出現abdominal pain，來到ER，診斷為pancreatitis

  20. 5/21再度住院，止痛處方： durogesic (2.5mg/patch) q3d codeine (30) 1# po q6h demerol ½ amp IV q6h prn when pain • 5/31 morphine sol. (0.1%) 10 ml po q6h • 6/3 照會麻醉科做epidural analgesia • 6/11 PCEA • 6/15 Intrathecal analgesia (morphine 0.5mg/5ml + marcaine 2.5mg, q12h)

  21. Discussion • The cause of right flank pain？ • Oral morphine Titration？ • Durogesic的使用？ • Demerol及codeine的使用？ • Adjuvant的使用？ • 考慮使用spinal analgesia的理由 • 更頻繁的疼痛控制評估？ • implantable pump？

  22. Case 2 • 75 year-old woman • Chief Complaint: Progressive abdominal distension, poor appetite and weight loss in recent one month • Pain tomography: left flank pain, left lower extremity pain, abd pain

  23. Lt RCC s/p radical nephrectomy, splenectomy, and distal pancreatectomy in 1997-08, s/p C/T • RCC recurrence with iliacus muscle and iliac bone involvement s/p re-op since 2001-09 • Osteoporosis with T12 to L3 compression fracture • Chronic renal insufficiency

  24. Pain Control • ~04-21: NSAID (Naposin) • 04-21: Temgesic 1# SL q2h prn shift to: Depain X 1# HS PO Paramol 1# PO prn Morphine (0.1%) 5cc q6h PO • 04-30: RT • 06-08: epidural analgesia • 06-15: intrathecal analgesia • 06-19: hold IT morphine

  25. Discussion • The cause of pain on injection? • Another way to relieve her pain? • Intractable intractable cancer pain? • Timing of consultation with anesthesiologist?

  26. Encapsulation • Symptoms: • Pain on injection • Increasing need for analgesics • Sign: • Inability to aspirate CSF from the catheter • Increased serum levels of morphine and increased levels of M-3-G in the CSF Pain 1992;49(3):369–371 Pain 103 (2003) 217–220

  27. Palliative Radiation therapy (1) • Biological basis of analgesia following radiation is not fully understood • 75 to 100 percent of patients with diffuse metastatic bone pain respond to hemibody radiation • Pain relief within 24 hours • Nausea, diarrhea, bone marrow depression, fatal radiation pneumonitis Clin Orthop 1995 Mar;(312):105-19

  28. Palliative Radiation therapy (2) • Tumor type and treatment regimen may not predict the response to radiotherapy • RCC of the kidney, non-small cell carcinomas of the lung. • Vertebral body collapse and spinal instability are best treated with surgical fixation Radiother Oncol 1989 Feb;14(2):95-101

  29. Chromaffin Cell Allografts into the CSF • Chromaffin cells in the medullary portion of the adrenal glands • Producing and releasing high levels of opioid peptides and catecholamines • Patients responding to intrathecal morphine • Significant reductions in complementary opioid intake Pain 87 (2000) 19-32

  30. Transdermal fentanyl • Effective alternative to oral morphine • Best reserved for patients whose opioid requirements are stable • less constipation than morphine (Megens et al, 1998) British Journal of Cancer (2001) 84(5), 587–593

  31. Thanks for your attention!!

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