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 Table of Contents  
CASE SERIES
Year : 2019  |  Volume : 33  |  Issue : 2  |  Page : 100-102

Role of pulsed radiofrequency neuromodulation adjacent to lumbar dorsal root ganglion in bone metastatic cancer pain


1 Rajiv Gandhi Cancer Institute and RC, Delhi, India
2 Department of Anesthesiology and Critical Care, Aiims, Jodhpur, India

Date of Submission14-Feb-2019
Date of Decision16-Mar-2019
Date of Acceptance14-Apr-2019
Date of Web Publication7-Aug-2019

Correspondence Address:
Dr. Bablesh Mahawar
Rajiv Gandhi Cancer Institute and RC, Rohini, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_10_19

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  Abstract 

Metastatic bone pain is among the most commonly reported pain conditions in cancer patients. Conventional therapy for metastatic bone pain is multidisciplinary, for example, radiotherapy, systemic treatment, and supportive care, which sometimes does not give adequate pain relief. Pulsed radiofrequency (PRF) neuromodulation of dorsal root ganglion (DRG) is a minimally invasive and an effective alternative procedure in treating symptomatic bone metastases in regard to pain reduction, safety, and quality of life. Although cervical DRG PRF has some evidence in pain relief, there is paucity in the literature evaluating the efficacy of lumbar DRG PRF for metastatic bone pain.

Keywords: Dorsal root ganglion, Eastern Cooperative Oncology Group, pulsed radiofrequency


How to cite this article:
Mahawar B, Mahawar V, Sharma RS. Role of pulsed radiofrequency neuromodulation adjacent to lumbar dorsal root ganglion in bone metastatic cancer pain. Indian J Pain 2019;33:100-2

How to cite this URL:
Mahawar B, Mahawar V, Sharma RS. Role of pulsed radiofrequency neuromodulation adjacent to lumbar dorsal root ganglion in bone metastatic cancer pain. Indian J Pain [serial online] 2019 [cited 2019 Aug 17];33:100-2. Available from: http://www.indianjpain.org/text.asp?2019/33/2/100/264070


  Introduction Top


Many solid cancers, for example, breast, prostate, and lung are associated with bone involvement which increases morbidity and suffering in patients with metastatic cancers. Conventional treatment for bone metastatic pain is multidisciplinary, for example, radiation therapy is the preferred treatment in this setting, but other modalities such as chemotherapy, hormonal therapy, and surgery alone or in combination with nonsteroid anti-inflammatory drugs, opioids, and adjuvant drug are used for pain palliation. Thirty percent of patients do not get any relief with the conventional therapy. Pulsed radiofrequency (PRF) neuromodulation is a relatively new method for the treatment of painful bone metastases and has shown anecdotal benefits in chronic metastatic bone pain. PRF of dorsal root ganglion (DRG) is a minimally invasive and an effective alternative procedure in treating symptomatic bone metastases in regard to pain reduction, safety, and good quality of life. PRF is fast, safe, effective, and tolerable for patients.

In our case series, we determine the efficacy of PRF of lumbar DRG in bone metastatic pain. Three patients presented to the pain outpatient department (OPD) with metastatic bone pain. The intensity of pain varies 7-10 on Numerical Rating Scale (NRS). Diagnostic transforaminal intervention gave >70% pain relief. Informed written consent was obtained. PRF of selective nerve root was done under fluoroscopic guidance. Pain was measured 1 day before PRF, postintervention, and at the follow-up periods of 1, 3, and 6 weeks. In addition, quality of life was self-assessed through the Eastern Cooperative Oncology Group scale at each follow-up. No complications or adverse events were noted from this minimally invasive procedure. PRF may be considered a potential intervention in treating certain nociceptive and neuropathic cancer pain conditions.


  case Reports Top


Case 1

A 42-year-old male was diagnosed with metastatic non-small cell carcinoma lung, Stage IV with osteolytic lesion over the right neck of the femur with no impending fracture, on palliative chemotherapy, which failed to halt disease progression. Magnetic resonance imaging revealed altered marrow signal intensity lesion with anterior soft-tissue component. He had severe right hip pain for which he received palliative radiotherapy. He was on tablet tramadol 100 mg three times a day, tablet gabapentin 400 two times a day, tablet etoricoxib 60 mg two times per day, and bisphosphonates monthly. Despite all medications he had severe pain which was gradually increasing. He was later referred to Pain clinic. Pain was more on sitting, standing, and walking and radiates to the anterior aspect of the thigh till the knee. After written informed consent diagnostic L2, L3 transforaminal intervention under fluoroscopic guidance was done which reduced pain >-70% followed by PRF L2, L3 DRG on next day [Table 1].
Table 1: Pre- and postpain (Numerical Rating Scale) score and Eastern Cooperative Oncology Group

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Case 2

A 38-year-old female patient normotensive, nondiabetic, a case of metastatic adenocarcinoma right lung presented with L4 vertebral metastasis with retropulsion and compression of left L4, L5 nerve root causing symptoms of intractable back, hip, and left leg pain for 2 months. NRS score was 9/10. Pain from the lower back radiates to the lateral aspect of the thigh, knee, and leg till the sole. She was on tablet tramadol and paracetamol combination three times a day and tablet pregabalin 75 mg two times a day. Diagnostic intervention of L4, L5 was done followed which PRF of L4, L5 DRG was performed [Figure 1] and [Figure 2].
Figure 1: Anteroposterior view of L4, L5 dorsal root ganglion

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Figure 2: Lateral view of L4 dorsal root ganglion

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Case 3

A 68 year old male patient, case of carcinoma lung developed pathological fracture femur for which he underwent interlocking. Patient presented to pain OPD in view of persistent pain post surgery. He complained of pain in groin which was radiating to anteromedial aspect of thigh. In view of patient suffering and to improve his quality of life, PRF of L2, L3 was done. After PRF therapy, the patients reported markedly improvement in his back and leg pain. No complications or adverse events were noted from this minimally invasive procedure.

Methodology

We performed PRF under fluoroscopic guidance using a Cosman radiofrequency generator. In the surgical suite, the patient was placed in a prone position, and the lumbar region was aseptically draped. The skin was anesthetized with 2% lidocaine administered subcutaneously. A 22-gauge, 10-cm radiofrequency cannula with a 5-mm active tip was inserted percutaneously at the lumbar spine. The introducer needle was withdrawn, and the RF electrode was advanced. Selective sensory nerve stimulation (50 Hz) showed concordant pain <0.5 V, which confirmed the PRF electrode location. Motor nerve stimulation was tested at 2 Hz. After stimulation and fluoroscopic confirmation, PRF was administered at 60 V and 42°C for 6 min at the specific DRG.


  Discussion Top


Bone pain is very often the first symptom in some cancer that spread to the bones. Singh et al.[1] quoted in their study that breast and lung cancers were the most common primary cancers in metastatic bone disease. Mantyh[2] explained the science behind metastatic bone pain that bone metastases are the most common cause of cancer pain and up to two-thirds of patients with bone metastases will suffer severe pain.

Pain becomes worse at night initially and later becomes worse on movements. Trivial trauma can lead to fracture in weakened bones, thus increasing pain further. It increases morbidity and impaired quality of life resulting from pain, fractures, and other skeletal-related events. Pain can originate directly from the bone caused by direct invasion, microfractures, increased pressure on the endosteum, and periosteum distortion or may also arise from nerve root compression or muscle spasm at the lesion. Bone pain is frequently caused by the release of chemical mediators that facilitate nociceptive conduction to the central nervous system. Metastatic bone pain is considered to have both somatic and neuropathic components of pain. Effective treatments for metastatic bone pain are, therefore, an essential part of cancer care. Conventional therapy for metastatic bone pain is multidisciplinary. Approximately 20%–30% of patients do not get effective pain relief. Thus, minimally invasive or noninvasive techniques may play an important role under these circumstances.

In a study by Lin et al.[3] a case of multiple bone metastases from the L1-L4 vertebrae, when conventional treatment with vertebroplasty using bone cement, radiotherapy and analgesics became ineffective, a percutaneous PRF at the L1-L4 DRG was performed which not only relieved his back pain but his chronic pain medications were also reduced. PRF provides nerve-sparing therapy and is increasingly employed to treat chronic pain conditions using selective neuromodulation.

Arai et al.[4] quoted DRG PRF procedure providing sound pain relief for patients with intractable vertebral metastatic pain.

Brandon et al.[5] studied clinically relevant information on PRF neuromodulation. They collected a variety of publications reviewing the safety and efficacy of PRF for various conditions commonly encountered in the field of pain management “Pulsed Radiofrequency Neuromodulation in Interventional Pain Management—A Growing Technology.” After PRF, a minimally invasive procedure, the patients reported satisfactory pain relief and improved daily life quality during the residual periods. Due to its safety and effectiveness, PRF may be an alternative strategy in treating neuropathic cancer pain. Similarly, in our cases, after failure of conservative therapy, when diagnostic transforaminal block of selective lumbar nerve root gave a patient >75% pain relief, then we thought of proceeding further with PRF of lumbar DRG.


  Conclusion Top


We used marginal homogeneity model to test whether our treatment has a significant effect in the pain reduction of the patients or not. P value was coming out to be <0.05 (0.0497), so we can reject the null hypothesis and conclude that there was a statistically significant reduction in pain after PRF.

To conclude, PRF of selective lumbar dorsal root ganglia is an effective option for treating bone metastatic cancer pain. In addition, it will reduce opioids and other analgesic consumption as well.

Limitations

There are several limitations to the present report. Since it is a small case series, it will require a randomized controlled trial with longer sample size.

PRF addresses only pain management, but bone lytic lesions continue to be a risk for fracture, particularly in weight-bearing bones.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Singh VA, Haseeb A, Alkubaisi AA. Incidence and outcome of bone metastatic disease at university Malaya medical centre. Singapore Med J 2014;55:539-46.  Back to cited text no. 1
    
2.
Mantyh P. The science behind metastatic bone pain. Eur J Cancer 2006;4:4-8.  Back to cited text no. 2
    
3.
Lin WL, Lin BF, Cherng CH, Huh BK, Ma HI, Lin SL, et al. Pulsed radiofrequency therapy for relieving neuropathic bone pain in cancer patients published in J Med Sci J 2014;34:84-7.  Back to cited text no. 3
    
4.
Arai YC, Nishihara M, Yamamoto Y, Arakawa M, Kondo M, Suzuki C, et al. Dorsal root ganglion pulsed radiofrequency for the management of intractable vertebral metastatic pain: A case series. Pain Med 2015;16:1007-12.  Back to cited text no. 4
    
5.
Brandon CR, Edward ST. Pulsed radiofrequency neuromodulation in interventional pain management – A growing technology. J Radiol Nurs 2018;37:181-7.  Back to cited text no. 5
    


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