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Sharon H, Agbaria Y, Brill S, de Santiago J, Hochberg U. Medical cannabis for refractory cancer-related pain in a specialised clinical service: a cross-sectional study. BMJ Support Palliat Care 2024; 14:345-352. [PMID: 37973200 DOI: 10.1136/spcare-2023-004421] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/03/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND AND OBJECTIVES Cancer-related pain management in advanced stages presents a significant challenge that often requires a multidisciplinary approach. Although advancements in pharmacological and interventional therapies, a considerable number of patients still suffer from refractory pain, leading to unmet clinical needs. This study shares our experience with medical cannabis (MC) as a potential therapy for this specific population of patients with cancer-related refractory pain. METHODS In a cross-sectional study, 252 consecutive refractory cancer-related pain patients (mean age=61.71, SD=14.02, 47.6% males) filled out detailed self-report questionnaires. Of these, 126 patients (55%) were treated with MC and 105 patients (45%) were not. RESULTS Most patients received pain management from their oncologist, not a pain specialist. MC was mainly started for pain relief, sleep difficulties and anorexia. About 70% of patients reported subjective improvement from MC, with almost 40% reporting a significant improvement in coping with their illness. Side effects were generally mild, with fatigue and dizziness being the most common (21.78% and 23.46%, respectively). No patient required dedicated medical care for side effects. Of non-users, 65% had tried MC before and stopped due to lack of effectiveness or side effects (39.7% and 34.6%, respectively). CONCLUSION Refractory cancer pain necessitates innovative approaches. This registry highlights that MC can effectively improve symptoms in non-responsive patients, with favourable safety profiles for this vulnerable population.
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Affiliation(s)
- Haggai Sharon
- Institute of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sagol Brain Institute, Wohl Institute for Advanced Imaging, Tel Aviv Sourasky Medical Center, Tel aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Yara Agbaria
- Sagol Brain Institute, Wohl Institute for Advanced Imaging, Tel Aviv Sourasky Medical Center, Tel aviv, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Silviu Brill
- Institute of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jesus de Santiago
- Department of Anesthesia and Chronic Pain Unit, Hospital Quirónsalud de Tenerife, Palmones, Spain
| | - Uri Hochberg
- Institute of Pain Medicine, Department of Anesthesia and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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2
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Khashan M, Strauss I, Hochberg Y, Brill S, Tellem R, Sharon H, Hochberg U. A nationwide neurosurgical inter-disciplinary service for cancer-related refractory pain. BMC Palliat Care 2024; 23:181. [PMID: 39033144 PMCID: PMC11264704 DOI: 10.1186/s12904-024-01501-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 07/04/2024] [Indexed: 07/23/2024] Open
Abstract
PURPOSE Neurosurgical ablative procedures, such as cordotomy and cingulotomy, are often considered irreversible and destructive but can provide an effective and individualized solution for cancer-related refractory pain, when all other approaches have been unsuccessful. This paper provides an in-depth exploration of a novel approach to managing refractory cancer pain. It involves an interdisciplinary team led by a neurosurgeon at a renowned national referral center. METHODS a retrospective analysis of the medical records of all sequential patients who underwent their initial evaluation at our interdisciplinary refractory cancer pain clinic from February 2017 to January 2023. RESULTS A total of 207 patients were examined in the clinic for a first visit during the study period. All patients were referred to the clinic due to severe pain that was deemed refractory by the referring physician. The mean age was 61 ± 12.3 years, with no significant sex difference (P = 0.58). The mean ECOG Performance Status score was 2.35. Conservative measures had not yet been exhausted in 28 patients (14%) and 9 patients were well controlled (4%). Neurosurgical ablative procedures were recommended for 151 (73%) of the patients. Sixty-six patients (32%) eventually underwent the procedure. 91 patients (44%) received a negative recommendation for surgery. Thirty-five patients (17%) were referred for further invasive procedures at the pain clinic. CONCLUSION An Interdisciplinary cooperation between palliative care specialists, pain specialists, and neurosurgeons ensures optimal patient selection and provides safe and effective neurosurgery for the treatment of refractory cancer-related pain.
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Affiliation(s)
- Morsi Khashan
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurosurgery, Spine Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ido Strauss
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Neurosurgery, Spine Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Silviu Brill
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Pain Medicine, Division of Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Rotem Tellem
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Palliative Care Service, Tel Aviv Sourasky Medical Center, 6 Weizmann Street, Tel Aviv, Israel
| | - Haggai Sharon
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Institute of Pain Medicine, Division of Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Uri Hochberg
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Institute of Pain Medicine, Division of Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
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3
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Akbaş M, Dağıstan G. Effectiveness of CT-guided percutaneous cordotomy in intractable cancer pain: Experience in 14 patients. Pain Pract 2024; 24:296-302. [PMID: 37846871 DOI: 10.1111/papr.13307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
BACKGROUND Severe and treatment-resistant pain is a major issue for patients with cancer. Cordotomy is an effective approach for addressing severe cancer-related pain. It is based on blocking the transmission of pain by damaging the lateral spinothalamic tract. METHODS Computed tomography guided cordotomy was performed on 14 patients who did not respond to medical and interventional pain management methods. RESULTS Fourteen patients with cancer pain underwent CT-guided percutaneous cordotomy. Pain relief was reported in 86% of the patients. The visual analog scale values before and after cordotomy were compared and a significant difference was found (p = 0.0001). The improvement in the Karnofsky Performance Scale score of the patients was found to be statistically significant (p = 0.0001). CONCLUSION We believe that CT-guided cordotomy, performed by experienced hands in a team of experienced individuals and applied to the right patients, is an effective treatment. However, it is crucial to exercise extreme caution regarding potential side effects and serious complications during the cordotomy procedure.
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Affiliation(s)
- Mert Akbaş
- Division of Algology, Anesthesiology and Reanimation Department, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Gözde Dağıstan
- Division of Algology, Anesthesiology and Reanimation Department, Faculty of Medicine, Akdeniz University, Antalya, Turkey
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Hochberg U, Ingelmo P, Solé E, Miró J, Rivera G, Perez J. Early Interventional Treatments for Patients with Cancer Pain: A Narrative Review. J Pain Res 2023; 16:1663-1671. [PMID: 37223437 PMCID: PMC10202202 DOI: 10.2147/jpr.s405808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/08/2023] [Indexed: 05/25/2023] Open
Abstract
Between 10% and 20% of patients with cancer-related pain cannot achieve adequate control following the three-step ladder guidelines by the World Health Organization. Therefore, a "fourth step", including interventional approaches, has been suggested for those cases. Systematic reviews support the early use of interventional procedures to treat refractory cancer pain, control symptoms and prevent opioid dose escalation. There is strong evidence of the efficacy of celiac plexus or splanchnic neurolysis, vertebroplasty, kyphoplasty and intrathecal drug delivery. Those procedures have been found to be associated with a decrease in the symptom burden and opioid consumption, improved quality of life, and suggested as having a potentially positive impact on survival. Several studies have recommended using specific interventional techniques at earlier stages, possibly even when opioid treatment is first being considered. Conversely, leaving these options as a last analgesic resource might not be advisable since the burden these procedures might impose on too ill patients is significant. The objective of this review was to collect the available evidence published on the use of interventional treatments for refractory cancer pain with a particular interest in comparing early versus late indications. The results of the search demonstrated a very low number and quality of articles particularly addressing this question. This scarce number of evidence precluded performing a systematic analysis. A detailed and narrative description of the potential benefits of integrating interventional techniques into clinical guidelines at the early stages of the disease is provided.
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Affiliation(s)
- Uri Hochberg
- Pain Institute of the Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Pablo Ingelmo
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
- Edwards Family Interdisciplinary Centre for Complex Pain, Montreal Children’s Hospital McGill University Health Centre, Montreal, Quebec, Canada
- Research Institute, McGill University Health Center, Montreal, Quebec, Canada
| | - Ester Solé
- Universitat Rovira i Virgili, Tarragona, Spain
| | - Jordi Miró
- Universitat Rovira i Virgili, Tarragona, Spain
- Chair in Pediatric Pain, Center for Behavior Assessment (CRAMC), Department of Psychology, Institut d’Investigació Sanitària Pere Virgili, Tarragona, Spain
| | - Gonzalo Rivera
- Hospital de Niños Luis Calvo Mackenna, Santiago de Chile, Chile
- Clínica las Condes, Santiago de Chile, Chile
| | - Jordi Perez
- Alan Edwards Centre for Research on Pain, McGill University, Montreal, Quebec, Canada
- Edwards Family Interdisciplinary Centre for Complex Pain, Montreal Children’s Hospital McGill University Health Centre, Montreal, Quebec, Canada
- Cancer Pain Clinic, Cedars Cancer Center, McGill University Health Centre, Montreal, Quebec, Canada
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Muacevic A, Adler JR. Fluoroscopy-Guided Splanchnic Nerve Block for Cancer-Associated Pain. Cureus 2022; 14:e30944. [PMID: 36465781 PMCID: PMC9712079 DOI: 10.7759/cureus.30944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 10/31/2022] [Indexed: 01/25/2023] Open
Abstract
Pain associated with abdominal malignancies or metastasis can be very severe and can be intractable and resistant to conventional pharmacologic therapies. Typically, narcotics and non-narcotics are used in combination to alleviate the cancer pain, but these are often unsuccessful. Neurolysis and radio-frequency ablation of the celiac plexus and splanchnic nerves is being used with great success for management of the pain associated with abdominal malignancies with added advantages of improving quality of life, pain relief and decreased narcotic consumption. The tumor or associated lymphadenopathy may result in distortion of the celiac plexus anatomy, thus making it hard to reach the celiac plexus. In such cases, splanchnic nerve block can be employed with relative ease as compared to celiac plexus block. Given the nature of the debilitating pain associated with these conditions and inadequate pain relief with narcotics, these blocks are a boon in disguise to such patients with altered anatomy. Post administration of the splanchnic block, the functioning and quality of life of patients with abdominal malignancies improve. Hence, these blocks can be used to decrease the morbidity associated with abdominal malignancies.
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Arora P, Dey S. Redefining pain interventions: Call it right! INDIAN JOURNAL OF PAIN 2022. [DOI: 10.4103/ijpn.ijpn_126_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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7
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Noninvasive celiac plexus radiosurgery in palliative treatment for patients with symptomatic pancreatic cancer. Contemp Oncol (Pozn) 2021; 25:140-145. [PMID: 34667441 PMCID: PMC8506435 DOI: 10.5114/wo.2021.107689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 04/24/2021] [Indexed: 11/17/2022] Open
Abstract
Advanced pancreatic cancer is commonly associated with significant visceral pain, radiating in a belt-like distribution to the upper abdomen, referring to the lower back, and significantly affecting patients' quality of life (QoL). The pain is often poorly controlled by pharmacotherapy, or the doses necessary to control the pain produce substantial adverse effects. Other available pain management options include invasive celiac plexus block or neurolysis, palliative radiotherapy, and systemic chemotherapy, all with limited efficacy. In this case report, we present the first non-invasive celiac plexus radiosurgery performed in Europe in a patient with pancreatic cancer, demonstrating that significant pain relief can be achieved through a non-invasive procedure performed within 2 outpatient visits.
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Kwon HJ, Jang K, Leem JG, Shin JW, Kim DH, Choi SS. Factors associated with successful response to neurolytic celiac plexus block in patients with upper abdominal cancer-related pain: a retrospective study. Korean J Pain 2021; 34:479-486. [PMID: 34593666 PMCID: PMC8494952 DOI: 10.3344/kjp.2021.34.4.479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/05/2021] [Accepted: 07/13/2021] [Indexed: 12/04/2022] Open
Abstract
Background Prior studies have reported that 40%-90% of the patients with celiac plexus-mediated visceral pain benefit from the neurolytic celiac plexus block (NCPB), but the predictive factors of response to NCPB have not been evaluated extensively. This study aimed to identify the factors associated with the immediate analgesic effectiveness of NCPB in patients with intractable upper abdominal cancer-related pain. Methods A retrospective review was performed of 513 patients who underwent NCPB for upper abdominal cancer-related pain. Response to the procedure was defined as (1) a decrease of ≥ 50% or ≥ 4 points on the numerical rating scale (NRS) in pain intensity from the baseline without an increase in opioid requirement, or (2) a decrease of ≥ 30% or ≥ 2 points on the NRS from the baseline with simultaneously reduced opioid consumption after NCPB. Logistic regression analysis was performed to determine the factors associated with successful responses to NCPB. Results Among the 513 patients included in the analysis, 255 (49.8%) and 258 (50.2%) patients were in the non-responder and responder group after NCPB, respectively. Multivariable logistic regression analysis showed that diabetes (odds ratio [OR] = 0.644, P = 0.035), history of upper abdominal surgery (OR = 0.691, P = 0.040), and celiac metastasis (OR = 1.496, P = 0.039) were the independent factors associated with response to NCPB. Conclusions Celiac plexus metastases, absence of diabetes, and absence of prior upper abdominal surgery may be independently associated with better response to NCPB for upper abdominal cancer-related pain.
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Affiliation(s)
- Hyun-Jung Kwon
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyunghwan Jang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Gil Leem
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin-Woo Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Doo-Hwan Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seong-Soo Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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9
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Dupoiron D. Cancer Pain Management-A European Perspective. Cancer Treat Res 2021; 182:39-55. [PMID: 34542875 DOI: 10.1007/978-3-030-81526-4_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cancer pain management is a major challenge in both Europe and the United States. Recent studies show that the incidence of cancer pain remains high and even increases at an advanced stage of the disease.
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Affiliation(s)
- Denis Dupoiron
- Anesthesia and Pain Department, Institut de Cancérologie de l'Ouest, Rue Boquel, 49055, Angers, France.
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10
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Park JM, Hwang SM. Inferior mesenteric plexus block under computed tomography guidance: A case report. Medicine (Baltimore) 2021; 100:e25866. [PMID: 34106636 PMCID: PMC8133031 DOI: 10.1097/md.0000000000025866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/21/2021] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Inferior mesenteric plexus block is indicated for left-sided lower abdominal pain. However, in patients with terminal cancer, severe abdominal pain can prevent the patient from maintaining the necessary posture during the procedure, and considerable anatomic deformation owing to extensive growth, invasion, and metastasis of the tumor in the abdominal cavity can make the procedure difficult. In these cases, performing the procedures under computed tomography (CT) guidance can ensure greater safety and accuracy. PATIENT CONCERNS A 63-year-old man was referred for severe left-sided lower abdominal pain. He was unable to lie prone owing to severe lower abdominal pain and right hip surgery performed 15 years ago. His visual analog scale score was 9 out of 10. DIAGNOSES The patient had terminal pancreatic tail cancer. Compared with abdominal CT findings obtained 50 days ago, hepatic metastasis and peritoneal seeding were still present, infiltration to the tissues around the pancreas and retrogastric area was increased, and most of the abdominal aorta was encased. In addition, metastatic lymph nodes were identified in several areas on the left including the left para-aortic area. However, the lesion causing the pain could not be identified. Therefore, an inferior mesenteric plexus block was performed according to the patient's complaint. INTERVENTIONS Epidural patient-controlled analgesia was performed first. The patient's pain consequently reduced to a certain level, and the prone position became possible to some extent, so a CT-guided inferior mesenteric plexus block was performed 2 days later. OUTCOMES After the CT-guided inferior mesenteric plexus block, it became possible to control the patient's pain with a fentanyl patch 75 mcg/hour only, and his visual analog scale score was reduced to 4. After 4 weeks, the patient died without complaints of severe pain as before. LESSONS CT-guided inferior mesenteric plexus block can be performed in patients with left-sided lower abdominal pain, enabling a safer and more accurate procedure especially in patients with terminal cancer who are unable to lie prone owing to severe lower abdominal pain or with considerable anatomic deformation due to extensive growth, invasion, and metastasis of the tumor in the abdominal cavity.
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Affiliation(s)
- Jun-Mo Park
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital, Daegu, South Korea
| | - Seong-Min Hwang
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital, Daegu, South Korea
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Xie P, Li Z, Yang J, Wu Y. Study on the prevention of infection in terminal cancer patients applying epidural analgesia by adding cefazolin to anesthetics: a randomized controlled trial. Jpn J Clin Oncol 2020; 50:867-872. [PMID: 32409838 DOI: 10.1093/jjco/hyaa060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 04/14/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To observe the antibacterial effect of adding cefazolin into anesthetics in patients with terminal cancer undergoing long-term epidural analgesia. METHODS Patients undergoing epidural analgesia with terminal cancer were randomly divided into two groups: the conventional drug group (group C) and the cefazolin group (group G). Both groups were given levobupivacaine and morphine, while cefazolin was added to group G. The mean arterial pressure (MAP), heart rate (HR), respiratory rates (R), visual analogue scale (VAS) scores, satisfaction and complications of patients in the two groups were observed. 3 ml of the used analgesic was taken for bacterial culture when replacing the new analgesic case. RESULTS HR, MAP, R, VAS scores, dosages of morphine, satisfaction of the analgesic and the complications were not significantly different between the two groups (P > 0.05). The overall satisfaction of patients in group G was significantly higher than that in group C (P < 0.05). One patient's anesthetics in group C were infected with colibacillus. Four patients in group C got infected in their epidural puncture sites. There was no infection in group G (P < 0.05). CONCLUSION Adding cefazolin to local anesthetics could effectively prevent bacterial infection and ensured the safety of epidural analgesia for patients with terminal cancer.
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Affiliation(s)
- Pengcheng Xie
- Department of Anesthesiology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, Shanghai, China
| | - Zhanfang Li
- Department of Anesthesiology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, Shanghai, China
| | - Jingli Yang
- Department of Anesthesiology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, Shanghai, China
| | - Yiming Wu
- Department of Anesthesiology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Pudong, Shanghai, China
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12
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Hochberg U, Berger A, Atias M, Tellem R, Strauss I. Tailoring of neurosurgical ablative procedures in the management of refractory cancer pain. Reg Anesth Pain Med 2020; 45:696-701. [PMID: 32699105 DOI: 10.1136/rapm-2020-101566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/03/2020] [Accepted: 06/09/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Neurosurgical 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. METHODS A 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. RESULTS A 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. CONCLUSIONS An interdisciplinary collaboration designated to provide neurosurgical ablative procedures among carefully selected patients could culminate in substantial relief of intractable cancer pain. TRIAL REGISTRATION NUMBER IR0354-17.
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Affiliation(s)
- Uri Hochberg
- Institute of Pain Medicine, Division of Anesthesiology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel .,Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Asaf Berger
- Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel.,Deparment of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Miri Atias
- Deparment of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Rotem Tellem
- Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel.,The Palliative Care Service, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ido Strauss
- Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel.,Department of Neurosurgery, Neuromodulation Unit, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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13
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Berger A, Hochberg U, Zegerman A, Tellem R, Strauss I. Neurosurgical ablative procedures for intractable cancer pain. J Neurosurg 2020; 133:144-151. [PMID: 31075782 DOI: 10.3171/2019.2.jns183159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cancer 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. METHODS This 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. RESULTS Sixty 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. CONCLUSIONS With 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.
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Affiliation(s)
- Assaf Berger
- 1Department of Neurosurgery
- 6Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Hochberg
- 4Institute of Pain Medicine; and
- 6Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Zegerman
- 5Division of Anesthesiology, Tel Aviv Medical Center; and
- 6Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rotem Tellem
- 3The Palliative Care Service
- 6Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Strauss
- 1Department of Neurosurgery
- 2Neuromodulation Unit
- 6Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Poolman M, Makin M, Briggs J, Scofield K, Campkin N, Williams M, Sharma ML, Laird B, Mayland CR. Percutaneous cervical cordotomy for cancer-related pain: national data. BMJ Support Palliat Care 2020; 10:429-434. [PMID: 32220943 PMCID: PMC7691804 DOI: 10.1136/bmjspcare-2019-002057] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/06/2020] [Accepted: 02/11/2020] [Indexed: 11/23/2022]
Abstract
Objectives Percutaneous 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. Methods Analysis 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. Results Data 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. Conclusions PCC 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.
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Affiliation(s)
- Marlise Poolman
- Bangor Institute for Health and Medical Research, Bangor University, Bangor, Gwynedd, UK
| | | | - Jess Briggs
- The Christie NHS Foundation Trust, Manchester, UK
| | | | - Nick Campkin
- Queen Alexander Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Michael Williams
- Queen Alexander Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Manohar Lal Sharma
- Department of Pain Medicine, Walton Centre NHS Foundation Trust, Liverpool, UK
| | - Barry Laird
- St Columba's Hospice, Edinburgh, UK.,Institute of Genetics and Molecular Medicine, The University of Edinburgh, Edinburgh, UK
| | - Catriona R Mayland
- Department of Oncology and Metabolism, The University of Sheffield, Sheffield, UK .,Palliative Care Institute, University of Liverpool, Liverpool, Merseyside, UK
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15
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Curing Opioid Toxicity with Intrathecal Targeted Drug Delivery. Case Rep Med 2019; 2019:3428576. [PMID: 31223311 PMCID: PMC6541971 DOI: 10.1155/2019/3428576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/16/2019] [Accepted: 05/02/2019] [Indexed: 11/24/2022] Open
Abstract
Pain is one of the most feared symptoms that concern cancer patients and their families. Despite well-established guidelines set forth by the World Health Organization (WHO) on the treatment of cancer pain, nearly half of cancer patients report poorly controlled pain. One of the most serious side effects of systemic oral opioid use is neurotoxicity, which is characterized by altered mental status and systemic neurologic impairments. Treatment strategies are supportive in nature and focused on reducing or changing the offending opioid and correcting any metabolic deficiencies. Herein, we discuss a case of opioid-induced neurotoxicity treated with intrathecal targeted drug delivery (TDD). The timing and implementation of advanced therapies such as intrathecal TDD is not well delineated. More importantly, patients and their oncologic providers are often unaware of this useful tool in treating challenging cancer-associated pain and significantly minimizing systemic opioid side effects. To ensure that patients have comprehensive oncologic care, best-practice guidelines suggest involvement of an interdisciplinary team and coordinated care. Early referral to a pain and palliative specialist may allow for improved patient outcomes and removal of unnecessary barriers to optimal patient care.
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16
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Huygen F, Kallewaard JW, van Tulder M, Van Boxem K, Vissers K, van Kleef M, Van Zundert J. "Evidence-Based Interventional Pain Medicine According to Clinical Diagnoses": Update 2018. Pain Pract 2019; 19:664-675. [PMID: 30957944 PMCID: PMC6850128 DOI: 10.1111/papr.12786] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/28/2019] [Accepted: 03/31/2019] [Indexed: 01/01/2023]
Abstract
Introduction Between 2009 and 2011 a series of 26 articles on evidence‐based medicine for interventional pain medicine according to clinical diagnoses were published. The high number of publications since the last literature search justified an update. Methods For the update an independent 3rd party, specialized in systematic reviews was asked in 2015 to perform the literature search and summarize relevant evidence using Cochrane and GRADE methodology to compile guidelines on interventional pain management. The guideline committee reviewed the information and made a last update on March 1st 2018. The information from new studies published after the research performed by the 3th party and additional observational studies was used to incorporate other factors such as side effects and complications, invasiveness, costs and ethical factors, which influence the ultimate recommendations. Results For the different indications a total of 113 interventions were evaluated. Twenty‐seven (24%) interventions were new compared to the previous guidelines and the recommendation changed for only 3 (2.6%) of the interventions. Discussion This article summarizes the evolution of the quality of evidence and the strength of recommendations for the interventional pain treatment options for 28 clinical pain diagnoses.
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Affiliation(s)
- Frank Huygen
- Department of Anesthesiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Maurits van Tulder
- Department of Epidemiology and Biostatistics, Vrije Universiteit Medical Centre Amsterdam, Amsterdam, The Netherlands
| | - Koen Van Boxem
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium
| | - Kris Vissers
- Department of Pain and Palliative Pain Medicine, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Maarten van Kleef
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Van Zundert
- Department of Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Belgium.,Department of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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17
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Fallon M, Giusti R, Aielli F, Hoskin P, Rolke R, Sharma M, Ripamonti CI. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv166-iv191. [PMID: 30052758 DOI: 10.1093/annonc/mdy152] [Citation(s) in RCA: 416] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- M Fallon
- Edinburgh Cancer Research Centre, IGMM, University of Edinburgh, Edinburgh, UK
| | - R Giusti
- Medical Oncology Unit, Sant'Andrea Hospital of Rome, Rome
| | - F Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - P Hoskin
- Mount Vernon Cancer Centre, Northwood, Hertfordshire, UK
| | - R Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - M Sharma
- The Walton Centre NHS Foundation Trust, Liverpool, UK
| | - C I Ripamonti
- Department of Onco-Haematology, Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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18
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Sayed D, Monroe F, Orr WN, Phadnis M, Khan TW, Braun E, Manion S, Nicol A. Retrospective Analysis of Intrathecal Drug Delivery: Outcomes, Efficacy, and Risk for Cancer-Related Pain at a High Volume Academic Medical Center. Neuromodulation 2018; 21:660-663. [PMID: 29446171 DOI: 10.1111/ner.12759] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 12/14/2017] [Accepted: 01/04/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Cancer pain is common and difficult to treat, as conservative medical management fails in approximately 20% of patients for reasons such as intolerable side-effects or failure to control pain. Intrathecal drug delivery systems (IDDS), while underutilized, can be effective tools to treat intractable cancer pain. This study aims to determine the degree of pain relief, efficacy, and safety of patients who underwent IDDS implantation at a multidisciplinary pain clinic. MATERIALS AND METHODS A retrospective review was conducted of patients with an intrathecal pain pump implanted for malignant pain. Charts were reviewed for demographics, cancer type, pain scores before and after implantation, and intrathecal drugs utilized. A Wilcoxon Signed-Rank test was conducted on the paired differences of pain scores before and after implant. A regression analysis was conducted using a linear model to assess effects of demographic variables on change in pain scores. RESULTS 160 patients were included in analysis. The median pain score was 7.1 at time of implantation and 5.0 at one-month postimplantation. For patients with both baseline and one-month pain scores available, the median decrease in pain was 2.5 (p < 0.0001). Pain scores three-month postimplantation did not significantly differ from one-month postimplantation. Median longevity was 65 days. Five patients had pumps explanted due to infection with a median time to pump extraction of 28 days. CONCLUSIONS IDDS has the potential to improve cancer pain in a variety of patients and should be strongly considered as an option for those with cancer pain intractable to conservative medical management.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Forrest Monroe
- Department of Anesthesiology and Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Walter N Orr
- Department of Anesthesiology and Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Milind Phadnis
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Talal W Khan
- Department of Anesthesiology and Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Edward Braun
- Department of Anesthesiology and Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Smith Manion
- Department of Anesthesiology and Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Andrea Nicol
- Department of Anesthesiology and Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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19
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Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations. Scand J Pain 2017; 17:150-151. [PMID: 28950244 DOI: 10.1016/j.sjpain.2017.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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20
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Lin JH, Chien LN, Tsai WL, Chen LY, Chiang YH, Hsieh YC. Early vertebroplasty associated with a lower risk of mortality and respiratory failure in aged patients with painful vertebral compression fractures: a population-based cohort study in Taiwan. Spine J 2017; 17:1310-1318. [PMID: 28483705 DOI: 10.1016/j.spinee.2017.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 03/31/2017] [Accepted: 05/02/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Whether early vertebroplasty (VP) (within 3 months) offers extra benefit to aged patients older than 70 years with painful vertebral compression fractures (PVCF) in terms of mortality and respiratory-related morbidity remains unknown, given that the elderly is associated with higher surgical risks. PURPOSE To elucidate the benefits of an early VP intervention for aged patients with a PVCF by comparing the risks of mortality and respiratory-related morbidity. STUDY DESIGN A retrospective propensity score matched cohort. PATIENT SAMPLE PVCF patients with an early VP and without an early VP intervention. OUTCOME MEASURES Death, pneumonia, and respiratory failure. METHODS A total of 10,785 PVCF patients who used analgesic injection during admission from 2000 through 2013 were selected from the National Health Insurance Research Database in Taiwan. After matching, there were 1773 VP patients and 5324 non-VP patients included in this study. Conditional Cox proportional hazard models were used to determine the risk of death and respiratory complications. RESULTS The incidences of death at 1 year of VP and non-VP patients were 0.46 (95% confidence interval [CI]: 0.38-0.56) and 0.63 (95% CI: 0.57-0.70) per 100 person-months, respectively. We observed a hazard ratio (HR) of 1.39 (95% CI: 1.09-1.78, p=.008) when comparing non-VP to VP patients. This phenomenon was seen when estimating the benefits of respiratory failure (HR: 1.46; 95% CI: 1.04-2.05, p=.028). CONCLUSION The results showed that VP was associated with lower risks of mortality and respiratory failure in aged patients with a PVCF. VP should be considered a priority for the aged patients with a PVCF requiring admission and analgesics.
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Affiliation(s)
- Jiann-Her Lin
- The PhD Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan; Division of Neurosurgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Li-Nien Chien
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei 11031, Taiwan
| | - Wan-Ling Tsai
- The PhD Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan; Graduate Institute of Injury Prevention and Control, College of Public Health and Nutrition, Taipei Medical University, Taipei 11031, Taiwan
| | - Li-Ying Chen
- Health and Clinical Research Center, College of Public Health and Nutrition, Taipei Medical University, Taipei 11031, Taiwan
| | - Yung-Hsiao Chiang
- The PhD Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; Department of Neurosurgery, Taipei Medical University Hospital, Taipei 11031, Taiwan; Division of Neurosurgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Yi-Chen Hsieh
- The PhD Program for Neural Regenerative Medicine, College of Medical Science and Technology, Taipei Medical University, Taipei 11031, Taiwan; Program in Biotechnology Research and Development, College of Pharmacy, Taipei Medical University, Taipei 11031, Taiwan.
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21
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Hu Y, Kodithuwakku ND, Zhou L, Li C, Han D, Fang W, Liu J, Li Y. Levo-Corydalmine Alleviates Neuropathic Cancer Pain Induced by Tumor Compression via the CCL2/CCR2 Pathway. Molecules 2017; 22:molecules22060937. [PMID: 28587280 PMCID: PMC6152665 DOI: 10.3390/molecules22060937] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 05/02/2017] [Accepted: 06/02/2017] [Indexed: 12/17/2022] Open
Abstract
Background: Tumor compression-induced pain (TCIP) is a complex pathological cancer pain. Spinal glial cells play a critical role in maintenance of cancer pain by releasing proinflammatory cytokines and chemokines. In this study, we verified the role of levo-corydalmine (l-CDL) on TCIP. Methods: Spontaneous pain, paw withdrawal threshold and latency were assessed using TCIP mouse model. Immunofluorescence was used to identify the reactions of glia. RT-PCR and western blot or ELISA were used to determine mRNA or protein expression of tumor necrosis factor-α (TNF-α), interlukin-1β (IL-1β), CC chemokine ligand 2 (CCL2) and chemotactic cytokine receptor 2 (CCR2) in vivo and in vitro. Results: l-CDL significantly attenuated TCIP hypersensitivity, accompanying with downregulation of TNF-α and IL-1β expression levels and declined astrocytes and microglial activation. It also significantly decreased the expression of the mRNA and protein level for CCL2 and CCR2. Further, l-CDL could suppress TNF-α-induced astrocytes activation and IL-1β expression through downregulating the CCL2/CCR2. Besides, CCL2-induced BV-microglia activation and inflammatory factors secretion were suppressed by l-CDL via CCR2. Conclusions: Suppression of CCL2/CCR2 by l-CDL may contribute to alleviate TCIP, offering an alternative medication for TCIP.
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Affiliation(s)
- Yahui Hu
- State Key Laboratory of Natural Medicines, Department of Physiology, China Pharmaceutical University, Nanjing 210009, China.
| | | | - Lin Zhou
- State Key Laboratory of Natural Medicines, Department of Physiology, China Pharmaceutical University, Nanjing 210009, China.
| | - Chengyuan Li
- State Key Laboratory of Natural Medicines, Department of Physiology, China Pharmaceutical University, Nanjing 210009, China.
| | - Dan Han
- State Key Laboratory of Natural Medicines, Department of Physiology, China Pharmaceutical University, Nanjing 210009, China.
| | - Weirong Fang
- State Key Laboratory of Natural Medicines, Department of Physiology, China Pharmaceutical University, Nanjing 210009, China.
| | - Jihua Liu
- State Key Laboratory of Natural Medicines, School of Traditional Chinese Medicine, China Pharmaceutical University, Nanjing 210009, China.
| | - Yunman Li
- State Key Laboratory of Natural Medicines, Department of Physiology, China Pharmaceutical University, Nanjing 210009, China.
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22
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Hochberg U, Elgueta MF, Perez J. Interventional Analgesic Management of Lung Cancer Pain. Front Oncol 2017; 7:17. [PMID: 28261561 PMCID: PMC5306685 DOI: 10.3389/fonc.2017.00017] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/25/2017] [Indexed: 12/31/2022] Open
Abstract
Lung cancer is one of the four most prevalent cancers worldwide. Comprehensive patient care includes not only adherence to clinical guidelines to control and when possible cure the disease but also appropriate symptom control. Pain is one of the most prevalent symptoms in patients diagnosed with lung cancer; it can arise from local invasion of chest structures or metastatic disease invading bones, nerves, or other anatomical structures potentially painful. Pain can also be a consequence of therapeutic approaches like surgery, chemotherapy, or radiotherapy. Conventional medical management of cancer pain includes prescription of opioids and coadjuvants at doses sufficient to control the symptoms without causing severe drug effects. When an adequate pharmacological medical management fails to provide satisfactory analgesia or when it causes limiting side effects, interventional cancer pain techniques may be considered. Interventional pain management is devoted to the use of invasive techniques such as joint injections, nerve blocks and/or neurolysis, neuromodulation, and cement augmentation techniques to provide diagnosis and treatment of pain syndromes resistant to conventional medical management. Advantages of interventional approaches include better analgesic outcomes without experiencing drug-related side effects and potential for opioid reduction thus avoiding central side effects. This review will describe various pain syndromes frequently described in lung cancer patients and those interventional techniques potentially indicated for those cases.
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Affiliation(s)
- Uri Hochberg
- Cancer Pain Program, McGill University Health Centre , Montreal, QC , Canada
| | | | - Jordi Perez
- Cancer Pain Program, McGill University Health Centre, Montreal, QC, Canada; Alan Edwards Pain Management Unit, McGill University Health Centre, Montreal, QC, Canada
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23
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Abstract
Interventional oncologists are playing an ever greater role in improving the quality of life of their patients through minimally invasive procedures, many of which can be performed on an outpatient basis. Some of the most common palliative procedures currently performed will be discussed including management of intractable ascites and pleural effusions, neurolytic plexus blocks, and palliation of pain and bleeding associated with metastatic tumors.
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Synergistic combinations of the dual enkephalinase inhibitor PL265 given orally with various analgesic compounds acting on different targets, in a murine model of cancer-induced bone pain. Scand J Pain 2016; 14:25-38. [PMID: 28850427 DOI: 10.1016/j.sjpain.2016.09.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/14/2016] [Accepted: 09/30/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND The first line pharmacological treatment of cancer pain is morphine and surrogates but a significant pain relief and a reduction of the side-effects of these compounds makes it necessary to combine them with other drugs acting on different targets. The aim of this study was to measure the antinociceptive effect on cancer-induced bone pain resulting from the association of the endogenous opioids enkephalin and non-opioid analgesic drugs. For this purpose, PL265 a new orally active single dual inhibitor of the two degrading enkephalins enzymes, neprilysin (NEP) and aminopeptidase N (APN) was used. It strictly increased the levels of enkephalin at their sites of releases. The selected non-opioid compounds are: gabapentin, A-317491 (P2X3 receptor antagonist), ACEA (CB1 receptor antagonist), AM1241 (CB2 receptor antagonist), JWH-133 (CB2 receptor antagonist), URB937 (FAAH inhibitor), and NAV26 (Nav1.7 channel blocker). METHODS Experiments. Experiments were performed in 5-6 weeks old (26-33g weight) C57BL/6 mice. Cell culture and cell inoculation. B16-F10 melanoma cells were cultured and when preconfluent, treated and detached. Finally related cells were resuspended to obtain a concentration of 2×106 cells/100μL. Then 105 cells were injected into the right tibial medullar cavity. Control mice were treated by killed cells by freezing. Behavioural studies. Thermal withdrawal latencies were measured on a unilatered hot plate (UHP) maintained at 49±0.2°C. Mechanical threshold values were obtained by performing the von Frey test using the "up and down" method. To evaluate the nature (additive or synergistic) of the interactions between PL265 and different drugs, an isobolographic analysis following the method described by Tallarida was performed. RESULTS The results demonstrate the ability of PL265, a DENKI that prevents the degradation of endogenous ENKs, to counteract cancer-induced bone thermal hyperalgesia in mice, by exclusively stimulating peripheral opioid receptors as demonstrated by used of an opioid antagonist unable to enter the brain. The development of such DENKIs, endowed with druggable pharmacokinetic characteristics, such as good absorption by oral route, can be considered as an important step in the development of much needed novel antihyperalgesic drugs. Furthermore, all the tested combinations resulted in synergistic antihyperalgesic effects. As shown here, the greatest synergistic antinociceptive effect (doses could be lowered by 70%) was produced by the combination of PL265 with the P2X3 receptor antagonist (A-317491), cannabinoid CB1 receptor agonist (exogenous, ACEA and endogenous URB937-protected-AEA) and Nav1.7 blocker (NAV26) whose mechanism of action involves the direct activation of the enkephalinergic system. CONCLUSIONS These multi-target-based antinociceptive strategies using combinations of non-opioid drugs with dual inhibitors of enkephalin degrading enzymes may bring therapeutic advantages in terms of efficacy and safety by allowing the reduction of doses of one of the compounds or of both, which is of the utmost interest in the chronic treatment of cancer pain. IMPLICATIONS This article presents synergistic antinociceptive effect produced by the combination of PL265 with non-opioid analgesic drugs acting via unrelated mechanisms. These multi-target-based antinociceptive strategies may bring therapeutic advantages by allowing the reduction of doses, which is of great interest in the chronic treatment of cancer pain.
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25
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Abstract
: It is estimated that more than 1.6 million new cases of cancer were diagnosed in the United States in 2014. Among patients with cancer, moderate to severe pain is prevalent and can be refractory, even with the use of systemic opioids, which may cause adverse effects that are difficult to manage at the doses required to control pain. When delivered intrathecally, however, opioids and adjuvant analgesics may provide greater pain relief at dramatically lower doses and with fewer adverse effects. Although the use of intrathecal drug delivery systems for cancer pain management has increased dramatically over the past several years and is expected to continue growing, patients with intrathecal pumps often report interactions with nurses unfamiliar with the technology. This article provides an overview of intrathecal pump therapy and explains how it prolongs duration of action and improves the efficacy of certain analgesics while reducing their adverse effects. The author discusses the costs involved, the patients most likely to derive benefit, the types of pumps currently used in the United States, the medications that can be delivered intrathecally, the potential risks and complications associated with intrathecal therapy, and the nursing care required by patients who use an intrathecal pump.
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26
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Higaki N, Yorozuya T, Nagaro T, Tsubota S, Fujii T, Fukunaga T, Moriyama M, Yoshikawa T. Usefulness of cordotomy in patients with cancer who experience bilateral pain: implications of increased pain and new pain. Neurosurgery 2015; 76:249-56; discussion 256; quiz 256-7. [PMID: 25603110 PMCID: PMC4337588 DOI: 10.1227/neu.0000000000000593] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND: Although mirror pain occurs after cordotomy in patients experiencing unilateral pain via a referred pain mechanism, no studies have examined whether this pain mechanism operates in patients who have bilateral pain. OBJECTIVE: To assess the usefulness of cordotomy for bilateral pain from the viewpoint of increased pain or new pain caused by a referred pain mechanism. METHODS: Twenty-six patients who underwent percutaneous cordotomy through C1-C2 for severe bilateral cancer pain in the lumbosacral nerve region were enrolled. Pain was dominant on 1 side in 23 patients, and pain was equally severe on both sides in 3 patients. Unilateral cordotomy was performed for the dominant side of pain, and bilateral cordotomy was performed for 13 patients in whom pain on the nondominant side developed or remained severe after cordotomy. RESULTS: After unilateral cordotomy, 19 patients (73.1%) exhibited increased pain, which for 14 patients was as severe as the original dominant pain. After bilateral cordotomy, 7 patients (53.4%) exhibited new pain, which was located cephalad to the region rendered analgesic by cordotomy and was better controlled than the original pain. No pathological organic causes of new pain were found in any patient, and evidence of a referred pain mechanism was found in 3 patients after bilateral cordotomy. CONCLUSION: These results show that a referred pain mechanism causes increased or new pain after cordotomy in patients with bilateral pain. Nevertheless, cordotomy can still be indicated for patients with bilateral pain because postoperative pain is better controlled than the original pain.
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Affiliation(s)
- Nobuhiro Higaki
- *Department of Anesthesia and Perioperative Medicine, Ehime University Graduate School of Medicine, Ehime, Japan; ‡Department of Palliative Care Medicine, Matsuyama Bethel Hospital, Ehime, Japan; §Department of Anesthesiology, Uwajima City Hospital, Ehime, Japan; ¶Department of Palliative Care Medicine, Japanese Red Cross Society Himeji Hospital, Hyogo, Japan; ‖Pain Clinic Unit, Nakatani Hospital, Hyogo, Japan
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Deer TR, Mekhail N, Provenzano D, Pope J, Krames E, Leong M, Levy RM, Abejon D, Buchser E, Burton A, Buvanendran A, Candido K, Caraway D, Cousins M, DeJongste M, Diwan S, Eldabe S, Gatzinsky K, Foreman RD, Hayek S, Kim P, Kinfe T, Kloth D, Kumar K, Rizvi S, Lad SP, Liem L, Linderoth B, Mackey S, McDowell G, McRoberts P, Poree L, Prager J, Raso L, Rauck R, Russo M, Simpson B, Slavin K, Staats P, Stanton-Hicks M, Verrills P, Wellington J, Williams K, North R. The appropriate use of neurostimulation of the spinal cord and peripheral nervous system for the treatment of chronic pain and ischemic diseases: the Neuromodulation Appropriateness Consensus Committee. Neuromodulation 2015; 17:515-50; discussion 550. [PMID: 25112889 DOI: 10.1111/ner.12208] [Citation(s) in RCA: 310] [Impact Index Per Article: 34.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 01/07/2014] [Accepted: 02/28/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) evaluated evidence regarding the safety and efficacy of neurostimulation to treat chronic pain, chronic critical limb ischemia, and refractory angina and recommended appropriate clinical applications. METHODS The NACC used literature reviews, expert opinion, clinical experience, and individual research. Authors consulted the Practice Parameters for the Use of Spinal Cord Stimulation in the Treatment of Neuropathic Pain (2006), systematic reviews (1984 to 2013), and prospective and randomized controlled trials (2005 to 2013) identified through PubMed, EMBASE, and Google Scholar. RESULTS Neurostimulation is relatively safe because of its minimally invasive and reversible characteristics. Comparison with medical management is difficult, as patients considered for neurostimulation have failed conservative management. Unlike alternative therapies, neurostimulation is not associated with medication-related side effects and has enduring effect. Device-related complications are not uncommon; however, the incidence is becoming less frequent as technology progresses and surgical skills improve. Randomized controlled studies support the efficacy of spinal cord stimulation in treating failed back surgery syndrome and complex regional pain syndrome. Similar studies of neurostimulation for peripheral neuropathic pain, postamputation pain, postherpetic neuralgia, and other causes of nerve injury are needed. International guidelines recommend spinal cord stimulation to treat refractory angina; other indications, such as congestive heart failure, are being investigated. CONCLUSIONS Appropriate neurostimulation is safe and effective in some chronic pain conditions. Technological refinements and clinical evidence will continue to expand its use. The NACC seeks to facilitate the efficacy and safety of neurostimulation.
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Hosking SPM, Franco ME, Poon P, William L. Bilateral cordotomy post-failure of intrathecal analgesia in a palliative care setting. Intern Med J 2015; 45:586-7. [PMID: 25955466 DOI: 10.1111/imj.12743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 10/02/2014] [Indexed: 11/27/2022]
Affiliation(s)
- S P M Hosking
- Supportive and Palliative Care Unit, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia
| | - M E Franco
- Supportive and Palliative Care Unit, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Monash University, Melbourne, Victoria, Australia
| | - P Poon
- Supportive and Palliative Care Unit, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Monash University, Melbourne, Victoria, Australia.,Eastern Palliative Care Association, Melbourne, Victoria, Australia
| | - L William
- Supportive and Palliative Care Unit, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Monash University, Melbourne, Victoria, Australia.,Palliative Care Department, Eastern Health, Melbourne, Victoria, Australia
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Micheli L, Di Cesare Mannelli L, Guerrini R, Trapella C, Zanardelli M, Ciccocioppo R, Rizzi A, Ghelardini C, Calò G. Acute and subchronic antinociceptive effects of nociceptin/orphanin FQ receptor agonists infused by intrathecal route in rats. Eur J Pharmacol 2015; 754:73-81. [PMID: 25704616 DOI: 10.1016/j.ejphar.2015.02.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 02/06/2015] [Accepted: 02/11/2015] [Indexed: 12/11/2022]
Abstract
Severe pain occurs in the context of many diseases and conditions and is a leading cause of disability. Nociceptin/orphanin FQ (N/OFQ) is the endogenous ligand of the N/OFQ peptide (NOP) receptor. This peptidergic system controls pain transmission and in particular spinally administered N/OFQ has robust antinociceptive properties. The aim of this study was to investigate the spinal antinociceptive properties of NOP peptide agonists after acute and subchronic treatment in rats. Doses unable to alter motor coordination were selected. UFP-112 (full NOP agonist) and UFP-113 (partial NOP agonist) were administered intrathecally (i.t.) by spinal catheterization. Acute injection of UFP-112 induced antinociceptive response at lower dosages (0.03-1nmol i.t.) compared to morphine and similar to N/OFQ. UFP-113 was effective in a 0.001-1nmol i.t. dose range. The antinociceptive effects of NOP ligands were no longer evident in rats knockout for the NOP gene, while those of morphine were maintained. The continuous spinal infusion (by osmotic pumps) of 0.1nmol/h UFP-112 and UFP-113 showed antinociceptive action comparable to 1-3nmol/h morphine or N/OFQ. The antinociceptive effect of morphine progressively decreased and was no longer significant after 6 days of treatment. Similar results were obtained with N/OFQ, UFP-112, and UFP-113. The acute i.t. injection of morphine in animals tolerant to N/OFQ and UFP-112 evoked analgesic effects. Neither morphine nor N/OFQ induced antinociceptive effects in morphine- and UFP-113-tolerant rats. In conclusion this study highlights the analgesic efficacy and potency of UFP-112 and UFP-113 underlining the relevance of NOP system in analgesia.
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Affiliation(s)
- Laura Micheli
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Lorenzo Di Cesare Mannelli
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy.
| | - Remo Guerrini
- Department of Chemical and Pharmaceutical Sciences and LTTA, University of Ferrara, Ferrara, Italy
| | - Claudio Trapella
- Department of Chemical and Pharmaceutical Sciences and LTTA, University of Ferrara, Ferrara, Italy
| | - Matteo Zanardelli
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Roberto Ciccocioppo
- School of Pharmacy, Pharmacology Unit, University of Camerino, Camerino, Italy
| | - Anna Rizzi
- Department of Medical Sciences, Section of Pharmacology and National Institute of Neuroscience, University of Ferrara, Italy
| | - Carla Ghelardini
- Department of Neuroscience, Psychology, Drug Research and Child Health - Neurofarba - Pharmacology and Toxicology Section, University of Florence, Florence, Italy
| | - Girolamo Calò
- Department of Medical Sciences, Section of Pharmacology and National Institute of Neuroscience, University of Ferrara, Italy
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Bhatnagar S, Gupta M. Evidence-based Clinical Practice Guidelines for Interventional Pain Management in Cancer Pain. Indian J Palliat Care 2015; 21:137-47. [PMID: 26009665 PMCID: PMC4441173 DOI: 10.4103/0973-1075.156466] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Intractable cancer pain not amenable to standard oral or parenteral analgesics is a horrifying truth in 10-15% of patients. Interventional pain management techniques are an indispensable arsenal in pain physician's armamentarium for severe, intractable pain and can be broadly classified into neuroablative and neuromodulation techniques. An array of neurolytic techniques (chemical, thermal, or surgical) can be employed for ablation of individual nerve fibers, plexuses, or intrathecalneurolysis in patients with resistant pain and short life-expectancy. Neuraxial administration of drugs and spinal cord stimulation to modulate or alter the pain perception constitutes the most frequently employed neuromodulation techniques. Lately, there is a rising call for early introduction of interventional techniques in carefully selected patients simultaneously or even before starting strong opioids. After decades of empirical use, it is the need of the hour to head towards professionalism and standardization in order to secure credibility of specialization and those practicing it. Even though the interventional management has found a definite place in cancer pain, there is a dearth of evidence-based practice guidelines for interventional therapies in cancer pain. This may be because of paucity of good quality randomized controlled trials (RCTs) evaluating their safety and efficacy in cancer pain. Laying standardized guidelines based on existing and emerging evidence will act as a foundation step towards strengthening, credentialing, and dissemination of the specialty of interventional cancer pain management. This will also ensure an improved decision-making and quality of life (QoL) of the suffering patients.
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Affiliation(s)
- Sushma Bhatnagar
- Department of Onco-Anaesthesia, Pain and Palliative Care, Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Maynak Gupta
- Department of Anaesthesia, Shri Guru Rai Institute of Medical and Health Sciences, Shri Mahant Indiresh Hospital, Dehradun, Uttarakhand, India
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Abdolmohammadi S, Hétu PO, Néron A, Blaise G. Efficacy of an intrathecal multidrug infusion for pain control in older adults and in end-stage malignancies: A report of three cases. Pain Res Manag 2015; 20:118-22. [PMID: 25996762 PMCID: PMC4447152 DOI: 10.1155/2015/405630] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The aim of the present study was to explore the effectiveness of an alternative method to manage pain based on a time-limited intrathecal (IT) infusion of an analgesic medication mixture. Three patients (69, 64 and 94 years of age) with intractable and poorly controlled pain due to bed sores, pelvic metastatic mass, and thoracic vertebra and rib fractures, respectively, were treated. Daily doses of opioids could not be increased due to side effects. An IT catheter (20 G) was placed by percutaneous approach in the lumbar area while advancing toward the thoracic region, and was then tunnelled and fixed subcutaneously. It was connected to an external infusion pump with a mixture of bupivacaine 1 mg⁄mL, naloxone 0.02 ng⁄mL, ketamine 100 µg⁄mL, morphine 0.01 mg⁄mL and clonidine 0.75 µg⁄mL. The starting rate was 1 mL⁄h. The pain was mostly controlled at a rate of <1 mL⁄h. Opioid consumption was reduced dramatically. The catheter was kept in place for one month in the first and third patients, and for six months in the second patient, until his death. Major side effects, such as hypotension, constipation, muscle weakness, sphincter dysfunction, and cognitive or mood deterioration, were not observed with this approach. One patient experienced a urinary tract infection followed by sepsis and meningitis, which was cured by antibiotics. The catheter was removed in this patient. IT infusion with a low-concentration multidrug mixture could be considered as an alternative modality for intractable pain relief in older adults or in malignancies.
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Affiliation(s)
- Sadegh Abdolmohammadi
- Department of Anesthesiology and Pain Clinic, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
| | - Pierre-Olivier Hétu
- Department of Biochemistry, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
| | - Andrée Néron
- Department of Pharmacy, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
| | - Gilbert Blaise
- Department of Anesthesiology and Medicine, Pain Clinic, Centre hospitalier de l’Université de Montréal (CHUM), University of Montreal, Montreal, Quebec
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Ma S, Zhang Y, Li X, Zhang H, Jia Y. Analgesic effect of Chinese herbal formula Hua-Jian-Ba-Du ointment on visceral pain in mice induced by acetic acid. Integr Cancer Ther 2015; 14:282-90. [PMID: 25601969 DOI: 10.1177/1534735414568722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION Visceral pain is one of the most important pains caused by cancer or other diseases, and most of the medications may lead to tolerance, addiction, and toxic side effects. Hua-Jian-Ba-Du Ointment (HJBDO), which is a commonly used conjugate based on traditional Chinese medicine theory, has been effective against visceral pain. Here, we verify the efficacy and underlying mechanism of HJBDO in an acetic-acid induced visceral pain model. METHODS Mice were subjected to acetic acid with or without HJBDO. Hua-Jian-Ba-Du Ointment at low (7.5 mL/kg•d), moderate (15 mL/kg•d), and high (30 mL/kg•d) dosages was applied on the abdomen, 3 times per day for 3 days. The acetic acid writhing test was used to evaluate antinociception. Interleukin-2 (IL-2) in serum, tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), and prostaglandin E2 (PGE2) in peritoneal fluid were detected by ELISA. 5-hydroxytryptamine (5-HT), norepinephrine (NE), dopamine (DA), and β-endorphin (β-EP) were examined by high performance liquid chromatography and radioimmunoassay, respectively. N-methyl-D-aspartic acid receptor (NMDAR1) and c-fos expressions in both rostral ventromedial medulla (RVM) and spinal dorsal horn were determined by western blot. RESULTS Hua-Jian-Ba-Du Ointment at 3 dosage levels produced dose-dependent antinociception and shortened the latent time. Hua-Jian-Ba-Du Ointment at high or moderate dosage inhibited the release of TNF-α, IL-6, and PGE2, as well as increased the release of IL-2. Hua-Jian-Ba-Du Ointment could also increase NE and 5-HT contents and decrease the NE content. No effect of HJBDO at 3 dosages on the DA system was detected. Furthermore, HJBDO could suppress the expressions of NMDAR and c-fos in both RVM and spinal dorsal horn. CONCLUSION Our results exhibited the analgesic effect of HJBDO on visceral pain in mice, and this effect might be mediated by the regulation of inflammation and neurotransmitters.
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Affiliation(s)
- Shaojun Ma
- Department of Oncology, Tianjin Nankai Hospital, Nan Kai District, Tianjin, China
| | - Ying Zhang
- Department of Oncology, First Affiliated Hospital to Tianjin University of Traditional Chinese Medicine, Nan Kai District, Tianjin, China
| | - Xiaojiang Li
- Department of Oncology, First Affiliated Hospital to Tianjin University of Traditional Chinese Medicine, Nan Kai District, Tianjin, China
| | - He Zhang
- Department of Oncology, Tianjin Nankai Hospital, Nan Kai District, Tianjin, China
| | - Yingjie Jia
- Department of Oncology, First Affiliated Hospital to Tianjin University of Traditional Chinese Medicine, Nan Kai District, Tianjin, China
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Abstract
Advances in intrathecal analgesia and intrathecal drug delivery systems have allowed for a range of medications to be used in the control of pain and spasticity. This technique allows for reduced medication doses that can decrease the side effects typically associated with oral or parenteral drug delivery. Recent expert panel consensus guidelines have provided care paths in the treatment of nociceptive, neuropathic, and mixed pain syndromes. While the data for pain relief, adverse effect reduction, and cost-effectiveness with cancer pain control are compelling, the evidence is less clear for noncancer pain, other than spasticity. Physicians should be aware of mechanical, pharmacological, surgical, and patient-specific complications, including possible granuloma formation. Newer intrathecal drug delivery systems may allow for better safety and quality of life outcomes.
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Affiliation(s)
- Michael M Bottros
- Division of Pain Medicine, Department of Anesthesiology, Washington University School of Medicine, St Louis, MO, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Restrepo-Garces CE, Saldarriaga NE, Jaramillo S, Gomez CM, Vargas JF, Ramirez LJ. Ganglion impar phenol injection in a pediatric patient with refractory cancer pain. PAIN MEDICINE 2013; 15:334-6. [PMID: 24224948 DOI: 10.1111/pme.12274] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Carlos Eduardo Restrepo-Garces
- Surgical Department & Image Guided Service, Hospital Pablo Tobon Uribe, Medellin, Antioquia, Colombia; Anesthesia & Pain Clinic, Clinica Las Americas, Medellin, Antioquia, Colombia
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Ver Donck A, Vranken JH, Puylaert M, Hayek S, Mekhail N, Van Zundert J. Intrathecal drug administration in chronic pain syndromes. Pain Pract 2013; 14:461-76. [PMID: 24118774 DOI: 10.1111/papr.12111] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 07/29/2013] [Indexed: 01/01/2023]
Abstract
Chronic pain may recur after initial response to strong opioids in both patients with cancer and patients without cancer or therapy may be complicated by intolerable side effects. When minimally invasive interventional pain management techniques also fail to provide satisfactory pain relief, continuous intrathecal analgesic administration may be considered. Only 3 products have been officially approved for long-term intrathecal administration: morphine, baclofen, and ziconotide. The efficacy of intrathecal ziconotide for the management of patients with severe chronic refractory noncancer pain was illustrated in 3 placebo-controlled trials. A randomized study showed this treatment option to be effective over a short follow-up period for patients with pain due to cancer or AIDS. The efficacy of intrathecal opioid administration for the management of chronic noncancer pain is mainly derived from prospective and retrospective noncontrolled trials. The effect of intrathecal morphine administration in patients with pain due to cancer was compared with oral or transdermal treatment in a randomized controlled trial, which found better pain control and fewer side effects with intrathecal opioids. Other evidence is derived from cohort studies. Side effects of chronic intrathecal therapy may either be technical (catheter or pump malfunction) or biological (infection). The most troublesome complication is, however, the possibility of granuloma formation at the catheter tip that may induce neurological damage. Given limited studies, the evidence for intrathecal drug administration in patients suffering from cancer-related pain is more compelling than that of chronic noncancer pain.
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Bredlau AL, Thakur R, Korones DN, Dworkin RH. Ketamine for pain in adults and children with cancer: a systematic review and synthesis of the literature. PAIN MEDICINE 2013; 14:1505-17. [PMID: 23915253 DOI: 10.1111/pme.12182] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Chronic cancer pain is often refractory and difficult to treat. Ketamine is a medication with evidence of efficacy in the treatment of chronic pain. DESIGN This article presents a synthesis of the data on ketamine for refractory cancer pain in adults and children. RESULTS There are five randomized, double-blind, controlled trials of ketamine use in cancer pain that demonstrate improvement in pain for some patients. There are six prospective, uncontrolled trials in cancer pain that also demonstrate improvement in pain scores for some patients. There are no randomized, controlled trials in children with cancer pain, although there are a few studies reflecting improved pain control with ketamine for children with cancer pain. Adverse events for adults on ketamine are most commonly somnolence, feelings of insobriety, nausea/vomiting, hallucinations, depersonalization/derealization, and drowsiness. However, when ketamine is combined with benzodiazepines, feelings of insobriety, hallucinations, and depersonalization/derealization are not reported. Children on ketamine have had few reported adverse effects, which include sedation, anorexia, urinary retention, and myoclonic movements. Recommended ketamine infusion dosages are from 0.05 to 0.5 mg/kg/h (intravenous or subcutaneous). Recommended oral dosages of ketamine are 0.2-0.5 mg/kg/dose two to three times daily with a maximum of 50 mg/dose three times daily. CONCLUSIONS Despite limitations in the breadth and depth of data available, there is evidence that ketamine may be a viable option for treatment-refractory cancer pain.
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Affiliation(s)
- Amy Lee Bredlau
- Departments of Pediatrics and Neurosciences, Medical University of South Carolina, Charleston, South Carolina
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Bain E, Hugel H, Sharma M. Percutaneous cervical cordotomy for the management of pain from cancer: a prospective review of 45 cases. J Palliat Med 2013; 16:901-7. [PMID: 23819730 DOI: 10.1089/jpm.2013.0027] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Percutaneous cervical cordotomy (PCC) is a well recognized but infrequently performed procedure for the relief of unilateral intractable pain from malignancy. There is a paucity of data regarding efficacy and safety of PCC. OBJECTIVES The study's objectives were to demonstrate the efficacy and safety of PCC in cancer pain. DESIGN The study was a prospective review of 45 cases undergoing PCC at a tertiary referral center over a three-year period. SETTINGS/SUBJECTS All patients were suffering from severe, refractory unilateral pain secondary to malignancy with poor pain relief or intolerable side effects of conventional analgesics including opioids and adjuvants. MEASUREMENTS Variables recorded preprocedure, at 2 days, and at 28 days postprocedure were numerical rating scale for maximum and average pain, oral morphine equivalent dose, and global impression of change. Adverse events and survival postprocedure were recorded. RESULTS Prospective data was obtained in 45 patients. Survival postprocedure ranged from 7 days to 33 months. There was a significant reduction from baseline in pain scores at 2 days and at 28 days postprocedure. Thirty-two patients experienced significant pain relief--average numerical rating scale (NRS) of zero--on day 2. Improvement in pain scores was sustained at 28 days. There were no serious adverse events observed such as respiratory failure. CONCLUSIONS PCC is a safe and highly effective procedure to treat intractable unilateral cancer pain. It offers significant advantages over other pain control methods. Patient selection and attention to detail is paramount for a successful outcome.
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Affiliation(s)
- Emma Bain
- Department of Pain Medicine, The Walton Centre NHS Foundation Trust, Liverpool, United Kingdom
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Ripamonti CI, Santini D, Maranzano E, Berti M, Roila F. Management of cancer pain: ESMO Clinical Practice Guidelines. Ann Oncol 2013; 23 Suppl 7:vii139-54. [PMID: 22997447 DOI: 10.1093/annonc/mds233] [Citation(s) in RCA: 297] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- C I Ripamonti
- Supportive Care in Cancer Unit, Fondazione IRCCS, Istituto Nazionale Tumori, Milan, Italy
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Kim JH, Jung JY, Cho MS. Continuous intrathecal morphine administration for cancer pain management using an intrathecal catheter connected to a subcutaneous injection port: a retrospective analysis of 22 terminal cancer patients in korean population. Korean J Pain 2013; 26:32-8. [PMID: 23342205 PMCID: PMC3546208 DOI: 10.3344/kjp.2013.26.1.32] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 10/13/2012] [Accepted: 10/31/2012] [Indexed: 11/23/2022] Open
Abstract
Background Intrathecal opioid administration has been used widely in patients suffering from severe cancer pain that is not managed with conventional modalities. However, the potential serious neurological complications from the procedure and the side effects of intrathecal opioids have made many clinicians reluctant to employ continuous intrathecal analgesia as a first-line therapeutic option despite its dramatic effect on intractable pain. We retrospectively investigated the efficacy, side effects, and complications of intrathecal morphine administration through intrathecal catheters connected to a subcutaneous injection port (ICSP) in 22 Korean terminal cancer patients with successful intrathecal morphine trials. Methods Patient demographic data, the duration of intrathecal opioid administration, preoperative numerical pain rating scales (NRS) and doses of systemic opioids, side effects and complications related to intrathecal opioids and the procedure, and the numerical pain rating scales and doses of intrathecal and systemic opioids on the 1st, 3rd, 7th and 30th postoperative days were determined from medical records. Results Intrathecal morphine administration for 46.0 ± 61.3 days significantly reduced NRS from baseline on all the postoperative days. A significant increase in intrathecal opioids with a nonsignificant decrease in systemic opioids was observed on the 7th and 30th postoperative days compared to the 1st postoperative day. The most common side effects of intrathecal opioids were nausea/vomiting (31.8%) and urinary retention (38.9%), which were managed with conservative therapies. Conclusions Intrathecal morphine administration using ICSP provided immediate and beneficial effects on pain scores with tolerable side effects in terminal cancer patients.
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Affiliation(s)
- Jong Hae Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
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Vertebroplasty in Patients with Tumour-Related Vertebral Fractures: Is Rehabilitation Needed? Asian Spine J 2013; 7:248-52. [PMID: 24066224 PMCID: PMC3779780 DOI: 10.4184/asj.2013.7.3.248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 08/22/2012] [Accepted: 08/23/2012] [Indexed: 11/08/2022] Open
Abstract
For about 20 years, vertebroplasty has been used to achieve relief from pain and improve function in eligible patients affected by vertebral fractures. The procedure is also performed in patients with tumours of the vertebral body. The aim of this study was to investigate, by means of a literature review, correlations between vertebroplasty and the need for rehabilitation after patients with tumour-related vertebral fractures were operated on. This review was based on literature from the US National Library of Medicine, National Institutes of Health (PubMed), using the following Medical Subject Headings (MeSH) terms: "vertebroplasty," "surgical procedures minimally invasive," "bone neoplasm," "spine," "postoperative care," "rehabilitation," and "exercise." In total, 14 citations were retrieved: potentially relevant studies were identified by searching titles and abstracts, and then the full text of the selected articles was reviewed. From this review, the postoperative course of vertebroplasty today does not strictly indicate the need for rehabilitation.
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Peretti-Watel P, Bendiane MK, Spica L, Rey D. Pain narratives in breast cancer survivors. PAIN RESEARCH AND TREATMENT 2012; 2012:153060. [PMID: 23150819 PMCID: PMC3488421 DOI: 10.1155/2012/153060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/17/2012] [Accepted: 07/30/2012] [Indexed: 11/17/2022]
Abstract
In-depth interviews were conducted with French breast cancer survivors 24 month after cancer diagnosis (N = 21 women). We documented their experience of chronic pain, compared their pain narratives with their answers to the WHOQOL-BREF questionnaire, and studied both the meaning they gave to their pain and how they dealt with it in their daily lives. Half of participants reported are suffering from iatrogenic chronic pain. Most of the time, this pain was not captured by the WHOQOL questionnaire and was not medically treated. Patients "normalized" their pain in various ways: they considered it either as a necessary step on the road to recovery, as the proof of treatment efficacy, or as a permanent condition one must learn to live with. They learned to deal with pain by taking precautions, giving up certain activities, and changing the way they performed others. Participants were also prone to compare themselves with other patients suffering worse pain. Breast cancer survivors should be better informed about chronic pain and how to alleviate it. Physicians should contribute to fighting pain-related beliefs which lead patients to conceal their pain. Techniques used by patients to cope with chronic pain in their daily lives should also be promoted.
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Affiliation(s)
- Patrick Peretti-Watel
- INSERM, UMR912 (SESSTIM), 13006 Marseille, France
- Aix Marseille Université, UMR_S912, IRD, 13006 Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, 13006 Marseille, France
| | - Marc-Karim Bendiane
- INSERM, UMR912 (SESSTIM), 13006 Marseille, France
- Aix Marseille Université, UMR_S912, IRD, 13006 Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, 13006 Marseille, France
| | - Laura Spica
- INSERM, UMR912 (SESSTIM), 13006 Marseille, France
- Aix Marseille Université, UMR_S912, IRD, 13006 Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, 13006 Marseille, France
| | - Dominique Rey
- INSERM, UMR912 (SESSTIM), 13006 Marseille, France
- Aix Marseille Université, UMR_S912, IRD, 13006 Marseille, France
- ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d'Azur, 13006 Marseille, France
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Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract 2012; 2012:560879. [PMID: 22761615 PMCID: PMC3385590 DOI: 10.1155/2012/560879] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 04/10/2012] [Accepted: 04/17/2012] [Indexed: 12/29/2022] Open
Abstract
A continuous peripheral nerve block (cPNB) is provided in the hospital and ambulatory setting. The most common use of CPNBs is in the peri- and postoperative period but different indications have been described like the treatment of chronic pain such as cancer-induced pain, complex regional pain syndrome or phantom limb pain. The documented benefits strongly depend on the analgesia quality and include decreasing baseline/dynamic pain, reducing additional analgesic requirements, decrease of postoperative joint inflammation and inflammatory markers, sleep disturbances and opioid-related side effects, increase of patient satisfaction and ambulation/functioning improvement, an accelerated resumption of passive joint range-of-motion, reducing time until discharge readiness, decrease in blood loss/blood transfusions, potential reduction of the incidence of postsurgical chronic pain and reduction of costs. Evidence deriving from randomized controlled trials suggests that in some situations there are also prolonged benefits of regional anesthesia after catheter removal in addition to the immediate postoperative effects. Unfortunately, there are only few data demonstrating benefits after catheter removal and the evidence of medium- or long-term improvements in health-related quality of life measures is still lacking. This review will give an overview of the advantages and adverse effects of cPNBs.
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Affiliation(s)
- José Aguirre
- Division of Anesthesiology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Alicia Del Moral
- Department of Anesthesiology, General University Hospital of Valencia, 46014 Valencia, Spain
| | - Irina Cobo
- Department of Anesthesiology, General University Hospital of Valencia, 46014 Valencia, Spain
| | - Alain Borgeat
- Division of Anesthesiology, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Stephan Blumenthal
- Department of Anesthesiology, Triemli Hospital, 8063 Zurich, Switzerland
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Laufenberg-Feldmann R, Schwab R, Rolke R, Weber M. [Cancer pain in palliative medicine]. Anaesthesist 2012; 61:457-67; quiz 468-9. [PMID: 22665134 DOI: 10.1007/s00101-012-2022-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
During the course of cancer progression up to 90% of the patients suffer from pain of nociceptive, neuropathic or mixed nociceptive/neuropathic origin. Psychological, social or existential factors may additionally affect the intensity of pain (concept of "total pain"). The WHO "analgesic ladder" provides a large variety of effective drugs that can be used according to the specific pain type. Parenteral or peridural opioid therapy as well as neurodestructive methods can effectively support the analgesic treatment in selected cases.
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Affiliation(s)
- R Laufenberg-Feldmann
- Klinik für Anästhesiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstrasse 1, 55131 Mainz, Deutschland.
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Abstract
PURPOSE OF REVIEW Interventional techniques were the mainstay for cancer pain management before the WHO ladder and opioids were freely available. The three-step WHO ladder has its limitations, and cancer pain is often under treated. Advances in treatment options mean that cancer patients are living longer and pain interventions may have a role to play even early in the cancer diagnosis for better quality of analgesia. The role of high doses of opioids in pain management is also currently under scrutiny. RECENT FINDINGS Recent advances in intrathecal analgesia, radiofrequency techniques, both in tumour ablation and neurotomies, are being widely used for palliation. Vertebroplasty techniques have been used not only for pain relief, but also for stabilization. Improved imaging and thoracoscopic techniques have made coeliac plexus and splanchnic blockade safer and more efficacious. There has been recent interest in percutaneous cordotomy with newer techniques using computed tomography/MRI and endoscopy guidance. Percutaneous electrical nerve stimulation and 8% capsaicin patches have been successfully used for managing neuropathic pain in cancer. SUMMARY Interventions form an integral part in providing pain relief in complex cancer pains. Oncologists and palliative care physicians are to be educated on the usefulness and timing of interventions in the management of complex cancer pain.
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Taheri A, Abolahrar N, Farbod A. Comment on: Malignant Pheochromocytoma Presenting as Incapacitating Bony Pain. Pain Pract 2012; 12:415; author reply 415. [DOI: 10.1111/j.1533-2500.2012.00550_1.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Laufenberg-Feldmann R, Schwab R, Rolke R, Weber M. [Cancer pain in palliative medicine]. Internist (Berl) 2012; 53:177-90. [PMID: 22231695 DOI: 10.1007/s00108-011-2902-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
During the course of cancer progression up to 90% of the patients suffer from pain of nociceptive, neuropathic or mixed nociceptive/neuropathic origin. Psychological, social or existential factors may additionally affect the intensity of pain (concept of "total pain"). The WHO "analgesic ladder" provides a large variety of effective drugs that can be used according to the specific pain type. Parenteral or peridural opioid therapy as well as neurodestructive methods can effectively support the analgesic treatment in selected cases.
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Affiliation(s)
- R Laufenberg-Feldmann
- Klinik für Anästhesiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, Mainz, Germany.
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