Cancer Pain

Intraspinal Analgesia: 

Epidural

• Is the most common option for spinal or radicular pain caused by primary or metastatic lesions
• Causes lesions that may affect intervertebral disks, nerve roots, or spinal canal size
• Provides highly selective pain relief, while producing analgesia over a large area
• Targets cervical, thoracic, lumbar, or caudal levels
• Allows single injections of a steroid, sometimes with a local anesthetic (e.g., lidocaine or bupivacaine)
• Allows continuous infusions of an opioid with a temporary catheter

Intrathecal

• Provides highly selective pain relief of spinal origin
• Allows for minimal side effects typically associated with higher dosages of oral medications of the sametype due to significantly reduced concentration and dosages
• May be tested with single injections of opioid and bupivacaine, clonidine, or ziconotide prior to catheterimplantation
• May involve a permanent intraspinal catheter and implanted subcutaneous pump if the patient’s survivalexpectancy is more than 3 months
• Options include (single agents or multi-agent combinations):
  • Morphine
  • Hydromorphone
  • Fentanyl
  • Sufentanil
  • Bupivacaine
  • Clonidine
  • Ziconotide
  • Baclofen
  • Meperidine (pethidine)

Nerve Blocks

• Target regional symptoms in the distribution of single or multiple peripheral nerves
• Allow single or multiple injections of a steroid, sometimes with a local anesthetic
• Provide short-term and potentially long-term benefits, but not permanent relief
• Options include:
  • Trigger point injection for myofascial pain
  • Local anesthetic injection administered in sympathetic ganglia for CRPS
  • Stellate ganglion block for head and neck pain
  • Lumbar sympathetic chain block for nociceptive or neuropathic cancer pain affecting the lowerextremity

Neurolytic Procedures

• Are useful in neuropathic or visceral pain in the distribution of specific peripheral or autonomic nerves
• Typically follow a diagnostic nerve block performed with local anesthetic
• Use chemical neurolysis to destroy peripheral or autonomic nerves
• Use ethyl alcohol or phenol as neurolytic agents
• Options include:
  • Hyperbaric phenol saddle block for midline perineal pain in patients with rectal and pelvicmalignancies
  • Celiac plexus block for visceral pain of gastrointestinal origin, particularly pancreatic cancer
  • Intrapleural phenol block for visceral pain associated with esophageal cancer
  • Superior hypogastric plexus block for tumor extension into the pelvis
  • Ganglion impar block for visceral pain of the perineum

Spinal Cord Stimulation

• Is useful in chronic neuropathic pain in the setting of chronic regional pain syndrome, postherpeticneuralgia, chemotherapy-induced peripheral neuropathy, and postradiation nerve injury

 Peripheral Nerve Stimulation

• Has the same indications as above, but its utility is limited to neuropathic pain involving specificnondermatomal peripheral nerves
• Allows suboccipital placement for migraines
• Provides an alternative to regional nerve block