Interventional Pain Management Interventional Pain Management In CancerIn Cancer
P N Jain, MD MNAMSP N Jain, MD MNAMSProfessor, Department Of Anaesthesia, Critical Care & Pain Professor, Department Of Anaesthesia, Critical Care & Pain
President, Indian Society for the study of painPresident, Indian Society for the study of [email protected] [email protected]
Tata Memorial HospitalMumbai, India
Role Of Invasive Therapy In Cancer PainRole Of Invasive Therapy In Cancer Pain
Drug therapy remains the foundation of cancer pain Drug therapy remains the foundation of cancer pain management. (management. (IASP Update Vol VI,ISS 1998)IASP Update Vol VI,ISS 1998)
WHO ladder is effective in 70-90% patients. WHO ladder is effective in 70-90% patients. ((WHO validation WHO validation study for cancer pain relief 1987, study for cancer pain relief 1987, de Conno , Ann Oncol 1993)de Conno , Ann Oncol 1993)
10-30% patients (unresponsive or SAE with opioids)10-30% patients (unresponsive or SAE with opioids)No clear-cut consensus, when to use invasive therapy in No clear-cut consensus, when to use invasive therapy in cancer paincancer painRule of thumbRule of thumb: start with conservative, progress to low : start with conservative, progress to low risk to more invasive high risk procedure: justified in severe risk to more invasive high risk procedure: justified in severe refractory pain refractory pain
Indications For Invasive ProceduresIndications For Invasive Procedures
Unrelieved pain by WHO 3-step ladderUnrelieved pain by WHO 3-step ladderUnacceptable side effects with systemic therapiesUnacceptable side effects with systemic therapiesPain crisisPain crisisPatient’s desire to avoid systemic therapyPatient’s desire to avoid systemic therapy
Short life expectancyShort life expectancy
……Effect may persist only for several months. Effect may persist only for several months. But for someone with a terminal illness, this But for someone with a terminal illness, this can be a lifetimecan be a lifetime
Lancet 2001:358(9276(:139-143 J Pain Symptom Manage 2002;24:152-159
What Is Neurolysis ?What Is Neurolysis ?
A treatment to destroy the nerve A treatment to destroy the nerve
Cancer pain often stems from growing Cancer pain often stems from growing
tumors and injured tissue, so an effective tumors and injured tissue, so an effective
block for it may be a neurolytic procedureblock for it may be a neurolytic procedure
Chemicals – Alcohol and PhenolChemicals – Alcohol and Phenol
Radio-Frequency Ablation –focused amounts Radio-Frequency Ablation –focused amounts
of heatof heat
Tata Memorial Hospital Pain Clinic: 2006-2007Tata Memorial Hospital Pain Clinic: 2006-2007Neurolytic BlocksNeurolytic Blocks
20062006 20072007 ComplicationsComplications
CPBCPB 4343 3434 ARF ARF
Intercostal + ParavertebralIntercostal + Paravertebral 2020 1818 Transient LL weaknessTransient LL weakness
Subarachnoid phenolSubarachnoid phenol 7 7 0606 Incontinence Incontinence
Stellate ganglionStellate ganglion 44 1212 Hoarseness Hoarseness
GlossopharyngealGlossopharyngeal 44 0606 Facial palsy Facial palsy
Maxillary + MandibularMaxillary + Mandibular 33 0606 Hematoma Hematoma
Local steroid Inj.Local steroid Inj. 33 0303
Superior hypogastricSuperior hypogastric 22 0606 Acute abdomen Acute abdomen
Lumbar sympatheticLumbar sympathetic 22 0404
88/713 (12%) 88/713 (12%) 95/890 (10.7%)95/890 (10.7%)
““Experience gives the pain practitioner good Experience gives the pain practitioner good judgment… judgment…
bad judgment provides a wealth of bad judgment provides a wealth of experience”.experience”.
Neurolytic DrugsNeurolytic DrugsALCHOHOLALCHOHOL PHENOLPHENOL
Colourless Colourless water solublewater soluble
Very Viscous Very Viscous Insoluble in waterInsoluble in water
Absolute to 50%Absolute to 50% 6-10% 6-10% in saline, Hin saline, H22O, glycerine, O, glycerine, radiological dyesradiological dyes
Hypobaric Hypobaric (0.85 with respect to CSF)(0.85 with respect to CSF)
Hyperbaric Hyperbaric (1.1 with respect to CSF)(1.1 with respect to CSF)
Action:Action:Dehydration & sclerosis of nerve Dehydration & sclerosis of nerve fibres & demyelinationfibres & demyelination
Action:Action: protein denaturation (in vascular protein denaturation (in vascular structures Sp cord infarction)structures Sp cord infarction)IV phenol: arrhythmia,cardiac arrestIV phenol: arrhythmia,cardiac arrest
Longer Shelf LifeLonger Shelf Life Shelf Life -1 yearShelf Life -1 year
Longer duration of reliefLonger duration of reliefInexpensive drugsInexpensive drugsFrequent visits not requiredFrequent visits not requiredPatient can remain at homePatient can remain at homePain free or reduced Pain free or reduced medicationsmedications
Effect is unpredictableMay need hospitalization for Assessment / complications Skilled practitioner Imaging equipment Need to be repeated
Advantages Disadvantages
Neurolytic BlocksNeurolytic Blocks
Prerequisites for Neurolytic Block …Prerequisites for Neurolytic Block …
Technically demanding: Imaging modalities never pick up nerves, Technically demanding: Imaging modalities never pick up nerves,
Growth of the tumour, radiation fibrosis, Sx may distort the Growth of the tumour, radiation fibrosis, Sx may distort the
anatomy.anatomy.
Experience and Skill. Experience and Skill.
Careful selection of patients.Careful selection of patients.
Diagnostic block with LA is essential.Diagnostic block with LA is essential.
Anticipate and tackle complications ( Multidisciplinary Set up)Anticipate and tackle complications ( Multidisciplinary Set up)
Action unpredictable/ May be repeated/ Need follow up Action unpredictable/ May be repeated/ Need follow up
Weigh the risk versus the benefitWeigh the risk versus the benefit
Risk versus BenefitRisk versus Benefit
Benefit
Subarachnoid Block
Epidural Block
Coeliac Plexus Block
Risk
LR, HBLR, LB
HR, HBHR, LB
Stellate ganglion BlockPeripheral nerveblock
Types of Neurolytic BlocksTypes of Neurolytic Blocks
Autonomic Nerve BlocksAutonomic Nerve Blocks
Peripheral Nerve BlocksPeripheral Nerve Blocks
Neuraxial BlocksNeuraxial Blocks
Sympathetic BlocksSympathetic Blocks
TYPE OF BLOCK TYPE OF BLOCK SITE /CONDITION TREATEDSITE /CONDITION TREATED
Stellate ganglion Stellate ganglion Head or arm pain Head or arm pain
Celiac plexus (splanchnic Celiac plexus (splanchnic nerves) nerves)
upper abdominal pain (visceral origin) upper abdominal pain (visceral origin)
Lumbar sympathetic Lumbar sympathetic Lower limb pain Lower limb pain
Sup.Hypogastric plexus Sup.Hypogastric plexus Perineal, pelvic, and lower limb pain Perineal, pelvic, and lower limb pain
Ganglion Impar ( Walther) Ganglion Impar ( Walther) Perineal or Rectal pain Perineal or Rectal pain
Stellate Ganglion Stellate Ganglion BlockBlock
Neurolytic Coeliac Plexus Block (NCPB)Neurolytic Coeliac Plexus Block (NCPB)
Perhaps the most rewarding block Perhaps the most rewarding block CPB may improve bowel motility and may convert CPB may improve bowel motility and may convert bedridden patient into an ambulatory one (1)bedridden patient into an ambulatory one (1)CPB abolishes pain until death in 10-24% when employed CPB abolishes pain until death in 10-24% when employed alone. 80%-90% when used with other treatment options alone. 80%-90% when used with other treatment options (2)(2)Significant pain relief at 2 ,4,6 months and survival benefit Significant pain relief at 2 ,4,6 months and survival benefit in 137 unresectable pancreas cancer patients (3)in 137 unresectable pancreas cancer patients (3)Significant reduction in morphine consumption and VAS Significant reduction in morphine consumption and VAS score in the first month (4,5)score in the first month (4,5)
1. Br J Surg 1998;85:199-2011. Br J Surg 1998;85:199-201 2. Anesthesiology 1992:76:394 – 4102. Anesthesiology 1992:76:394 – 410
3. Ann Surg 1993;217:447-4573. Ann Surg 1993;217:447-457 4. Pain 1993;52:534-5404. Pain 1993;52:534-540 5. Pain 1996;64:597-6025. Pain 1996;64:597-602
Indications:Severe upper Abdominal pain (PS >7.0)Poor control on NSAID + opioidsLife expectancy > 3 months
Contraindications:Ascitis++, encased CP(CT scan)Multiple painscoagulation?Deny consent
Anterocrural Vs Retrocrural spread
Fluoroscopic imaging in CPBFluoroscopic imaging in CPB
De Cicco et al, Single-needle celiac plexus block,Anesthesiology:87;1997
Cephalad to celiac trunk
Caudad
NCPB reduced pain intensity and morphine consumption, NCPB reduced pain intensity and morphine consumption, improved performance status at one month improved performance status at one month
Journal of Pain and Palliative Care Pharmacotherapy.2005;19(3);15-20
Demographic DataDemographic DataAge (yrs)Age (yrs) CPB CPB
(n=48)(n=48)Morphine Morphine (n=50)(n=50)
Mean Mean SD SD 48.62 48.62 10.5010.50 50.90 50.90 10.0210.02
RangeRange 23-7323-73 32-7832-78
Sex RatioSex Ratio CPB CPB (n=48)(n=48)
MorphineMorphine (n=50)(n=50)
MaleMale 24 (50%)24 (50%) 30(60%)30(60%)FemaleFemale 24 (50%)24 (50%) 20(40%)20(40%)
4848 5050 PN Jain et al, Journal of Pain and Pall Care Pharmacotherapy Vol 19,N0 3 2005
CPBCPBn=48n=48
MorphineMorphine n=50n=50
PancreasPancreas 18 (37.5%)18 (37.5%) 18(36%)18(36%)Gall BladderGall Bladder 17 (34.5%)17 (34.5%) 21(42%)21(42%)
StomachStomach 8 (16.7%)8 (16.7%) 8(16%)8(16%)L 1/3 oesophagusL 1/3 oesophagus 3 (6.3%)3 (6.3%) 00Transverse ColonTransverse Colon 1 (2.1%)1 (2.1%) 00
Liver metastasisLiver metastasis 1 (2.1%)1 (2.1%) 3(6%)3(6%)
TotalTotal 4848 5050
DiseaseDisease
PN Jain et al, Journal of Pain and Pall Care Pharmacotherapy Vol:19,No 3 2005
What is the evidence on CPB?What is the evidence on CPB?
Author and yearAuthor and year(reference)(reference)
Type of Type of paperpaper
No. ofNo. ofpatientspatients
Type of Type of CancerCancer
GuidanceGuidance
Ischia (1992) Ischia (1992) RCTRCT 6161 PancreasPancreas FluoroscopyFluoroscopy
Lillemoe (1993) Lillemoe (1993) RCTRCT 137137 PancreasPancreas Intra-operative Intra-operative Neurolysis Neurolysis
Polati (1998) Polati (1998) RCTRCT 2424 PancreasPancreas FluoroscopyFluoroscopy
Gunaratnam(2001) Gunaratnam(2001) NRCTNRCT 5858 PancreasPancreas Endoscopic USGEndoscopic USG
Mercadante (2003) Mercadante (2003) RCTRCT 2222 PancreasPancreas FluoroscopyFluoroscopy
Wong (2004) Wong (2004) RCTRCT 100100 PancreasPancreas FluoroscopyFluoroscopy
Stefaniak (2005) Stefaniak (2005) NRCTNRCT 5959 PancreasPancreas ThoracoscopyThoracoscopy
Neurolytic celiac plexus block for pain control in unresectable pancreatic cancer (A systematic review)
RESULTS: Five RCTs involving 302 patients (NCPB, N = 147; control, N = 155)
CONCLUSIONS: In patients with unresectable pancreatic cancer, NCPB is associated with improved pain control, and reduced narcotic usage and constipation compared with standard treatment, albeit with minimal clinical significance. PMID: 17100960 [PubMed - indexed for MEDLINE]
Yan BM, Am J Gastroenterol. 2007 Feb;102(2):430-8.
Recent modalities of CPBRecent modalities of CPBUSG USG (Montero,1989)(Montero,1989) / CT guided / CT guided ((Herpels 1988Herpels 1988))EUS guided EUS guided ((Levy MJ 2003Levy MJ 2003))Trans-discal splanchicectomy Trans-discal splanchicectomy (Plancarte 2003)(Plancarte 2003)
Thoracoscopic splanchicectomy Thoracoscopic splanchicectomy (Worsey (Worsey 1993,Stefaniak 2005)1993,Stefaniak 2005)
Laparoscopic ablation Laparoscopic ablation (Strong 2006)(Strong 2006)
Radiofrequency ablation (Radiofrequency ablation (P Raj,2001P Raj,2001))
Peripheral Nerve BlocksPeripheral Nerve Blocks
Blockade has to be proximal to the source of IrritationBlockade has to be proximal to the source of Irritation
Sensory distribution overlap :blockade of the neighboring Sensory distribution overlap :blockade of the neighboring
segment recommendedsegment recommended
Many peripheral nerves are of mixed typesMany peripheral nerves are of mixed types
Diagnostic block with LA is essential: impact of concomitant Diagnostic block with LA is essential: impact of concomitant
motor deficitmotor deficit
Accuracy essential for good effect and to avoid damage of Accuracy essential for good effect and to avoid damage of
non targeted structuresnon targeted structures
Paravertebral Nerve BlockParavertebral Nerve Block
Subarachnoid and Epidural NeurolysisSubarachnoid and Epidural Neurolysis
Advantages:Advantages:Good resultsGood results
Ease of injection & repetitionEase of injection & repetition
No hospitalisationNo hospitalisation
Good duration of analgesiaGood duration of analgesia
Used in aged & debilitated Used in aged & debilitated
Low complication rateLow complication rate
Complications: Complications: Paresis Paresis
Bladder-bowel dysfunctionBladder-bowel dysfunction
Subarachnoid Versus Epidural NeurolysisSubarachnoid Versus Epidural Neurolysis
Verification of placement more specific (CSF Verification of placement more specific (CSF return) return)
More profound AnalgesiaMore profound Analgesia
Can be performed on an outpatient basisCan be performed on an outpatient basis
Precise control, proper positioning , minimum Precise control, proper positioning , minimum dose is possible with subarachnoid blockdose is possible with subarachnoid block
RRodriguez et al Surg Gynecol Obstet 1991:173(1):41 44)odriguez et al Surg Gynecol Obstet 1991:173(1):41 44)
Subarachnoid Phenol in GlycerineSubarachnoid Phenol in Glycerine(Dorsal Rhizotomy)(Dorsal Rhizotomy)
Subarachnoid Subarachnoid Absolute alcoholAbsolute alcohol
Superior Hypogastric Block
Plancarte R, Anesthesiology 1990 & Reg Anesth,1997
Ganglion ImparGanglion Impar
Plancarte R, Anesthesiology 1990
ConclusionsConclusions
Pain Physicians should consider nerve blocks when Pain Physicians should consider nerve blocks when
systemic analgesics are failing. systemic analgesics are failing. (Adjuvant therapy)(Adjuvant therapy)
Careful selection of patients Careful selection of patients
Benefits should outweigh the risksBenefits should outweigh the risks
Thorough knowledge of the limitations and side effectsThorough knowledge of the limitations and side effects
Need for randomized controlled clinical trialsNeed for randomized controlled clinical trials
Thanks
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