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Summary

Pain management: interventional procedures for cancer-related pain and non-cancer pain include sympathetic blocks, neurolysis, intrathecal pumps, externalized epidurals, spinal cord stimulators, nerve stimulators for tibial augmentation (eg, vertebroplasty, kyphoplasty), and vertebral body radiofrequency ablation; non-specific treatments include steroid injections into joints or epidural spaces and botulinum toxin injections

Sympathetic nerve block: useful for nociceptive pain and visceral related pain; targets include the celiac plexus, hypogastric plexus, and ganglion impair plexus, which relay pain signals through visceral afferent fibers; sympathetic nerve blocks interrupt visceral pain signaling and may be used for cancers of the gastrointestinal tract, liver, adrenal gland, vagina, bladder, and prostate

Presentation: patients typically report nondescript, achy pain which is unrelated to food consumption or a particular time of day; the pain may be described as gnawing; pain related to pancreatic cancer typically occurs in the epigastric region but may be felt in other areas

Neurolysis: not recommended for patients without terminal illness with metastasis because it causes destruction of the nervous system which may result in deafferentation pain; regrowth of the damaged nerves produces pain signals of greater intensity; patients with a life expectancy prognosis of 6 mo to 1 yr are candidates for neurolysis; repeated neurolysis is not advised; patients with widely metastatic disease (carcinomatosis) are not candidates for neurolysis because nerves other than visceral afferent fibers may be sending pain signals; McGreevy et al (2013) found reduced efficacy with repetition of sympathetic chain neurolysis because of involvement of other nerves as the cancer spreads

Contraindications: neurolysis is contraindicated in patients with bowel obstruction; a flush in the form of diarrhea occurs after neurolysis; patients with bowel obstruction may develop perforation following flush against a fixed space; patients with intra-abdominal infection and coagulopathy or thrombocytopenia that cannot be corrected are not recommended for neurolysis; neurolysis may cause a sudden drop in blood pressure and reflex tachycardia, which may be fatal in patients with existing poorly controlled coronary artery disease or congestive heart failure; other contraindications include patients on disulfiram and clinically unstable individuals

Intrathecal pumps: useful for management of nociceptive or neuropathic pain in patients with response to opioids who are dose limited by adverse effects (eg, constipation, dizziness, lethargy); opioids are delivered to a specific area of the spinal cord; the tip of the catheter is placed at the site where pain signals are processed; systemic absorption is avoided to prevent adverse effects (as with oral opioids); adjuncts, eg, local anesthetic, are added to opioids as part of the multimodal approach to pain; patients are admitted for intrathecal trials to identify the correct location for injection; the primary goal is to transition the patient from oral or systemic opioids to intrathecal injections, and obtain complete pain control; the intrathecal pump may be programmed for acute pain or as a continuous infusion of small amounts of opioids (long acting); patients with generalized pain or pain at multiple distant locations are not ideal for intrathecal pump therapy; patients are taken for implantation of the pump after the trial is successful; the pump is refilled every 3 mo; one fill is given before hospice care begins

Medications: morphine, ziconotide, and baclofen are approved by the Food and Drug Administration for intrathecal pumps; use of other opioids is considered off-label use

Risks: include bleeding, infection, nerve damage, increased pain, and medication reaction; increased concentration of opioid in the intrathecal pump may result in the development of an inflammatory mass (granuloma) at the catheter tip which compresses the underlying spinal cord; patients present with loss of efficacy of the intrathecal pumps, and neurologic signs; patients with neutropenia and thrombocytopenia are at increased risk for developing complications from intrathecal pumps; the internal system of the intrathecal pump is battery operated; reports exist of device failure when it is placed directly in the field of radiation; epidural and spinal metastases increase the risk for bleeding and other complications; conditional parameters have to be followed if the patient is slated to undergo magnetic resonance imaging (MRI)

Externalized epidural catheters: indicated in patients with a life expectancy prognosis of <3 mo; the spinal cord is numbed; reliance on opioids is reduced and patients may gain more quality time with family at end of life; the epidural catheter is placed before hospice care begins; the port of the catheter is connected to an infusion pump; nurses change the infusion bags regularly for epidural infusion; patients may remain lucid in their final moments; the concentration of medications used is similar to that in an intrathecal pump

Spinal cord stimulation: recommended for patients with neuropathic (nerve related) pain; tumors may invade nerves and cause pain; useful for chemotherapy-induced peripheral neuropathy and extremity pain after surgery; evidence is limited for the use of spinal cord stimulation in cancer patients; patients may undergo MRI but 30 min breaks in between the imaging processes are required; spinal cord stimulation has similar neuraxial considerations as intrathecal pumps

Peripheral nerve stimulation: useful for neuropathic pain; peripheral nerve stimulation targets a single superficial nerve; less invasive than spinal cord stimulation; useful for patients with nerve damage-related pain because of direct tumor invasion or postsurgical injury; the catheter is placed with ultrasonography guidance; systems are available with catheters that may be left in place indefinitely, or must be removed after 60 days

Structural rebuilding: patients with pathologic compression fractures from tumor metastases or multiple myeloma may present with axial back pain; vertebral body height is re-established with surgery; structural rebuilding produces immediate relief

Radiofrequency ablation: useful for management of nociceptive pain, eg, in patients with vertebral body metastasis presenting with axial back pain; trocars are inserted which are identical to kyphoplasty trocars; the metastatic lesion is ablated; signaling from periosteal nociceptors is prevented

Pain unrelated to cancer: patients with cancer may have trigger points which are palpable, discrete knots in, eg, the trapezius muscle; trigger point injections are beneficial; patients may have an exacerbation of their fibromyalgia central sensitization, which results a lower threshold for feeling pain from other causes; facet arthropathy refers to wear on the spine related to ageing; patients with cancer may have osteoarthritis, migraines (pre-existing or related to cancer treatment); approaches — medial branch block, radiofrequency ablation, epidural steroid injections, botulinum toxin injections, and steroid injections to the joints; palliative care — includes symptom management with medications for pain, nausea, and other symptoms related to cancer