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 Table of Contents  
Year : 2021  |  Volume : 35  |  Issue : 1  |  Page : 11-15

Interventional management for cancer pain

Department of Anesthesiology, Critical Care and Pain, Division of Pain, Tata Memorial Centre, Mumbai, Maharashtra, India

Date of Submission01-Mar-2021
Date of Decision15-Mar-2021
Date of Acceptance05-Apr-2021
Date of Web Publication27-Apr-2021

Correspondence Address:
Prof. Parmanand N Jain
Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_17_21

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The WHO analgesic ladder (1986) has recommended certain oral analgesics vis-a-vis intensity of cancer pain for optimum relief as a practical doctrine, easy to implement, and taught extensively to healthcare professionals globally. However, the WHO approach despite been implemented appropriately and aggressively in the last three decades, 10%–20% of patients may not achieve acceptable pain relief. There is a refractory group of patients which is considered for interventional pain management; however, reserving this modality as a last resort is questioned by interventional protagonists. It is anticipated that the general understanding of interventional approach on cancer pain relief may not only expedite pain relief but should also consider all potential therapeutic options. Interventional physicians, mainly anesthesiologists, have a well-defined and beneficial role in the treatment of cancer pain, if patients are appropriately selected with various cancer pain syndromes. Pain physicians should successfully optimize outcomes depends on timely referral with adequate assessment and patient selection. Pain physicians have a complex role. Managing expectations of referring physicians, of patients, and family members, assuring adequacy of interventional care is not an easy task. An experienced, skilled interventionist who is well versed in not only techniques of procedure but side effects management, if any, will assume full responsibility for pre- and postintervention evaluation and follow-up care as indicated by the circumstances of each patient to be managed.

Keywords: Cancer pain, cancer pain syndromes, interventional pain management

How to cite this article:
Jain PN. Interventional management for cancer pain. Indian J Pain 2021;35:11-5

How to cite this URL:
Jain PN. Interventional management for cancer pain. Indian J Pain [serial online] 2021 [cited 2021 Sep 24];35:11-5. Available from: https://www.indianjpain.org/text.asp?2021/35/1/11/314694

  Introduction Top

The WHO recommended oral analgesics as the main stay of cancer pain management.[1] Pain treatment using the WHO guidelines provides pain relief in majority of patients, though an effective pain relief may take a long time in one-third of the all patients. The National Cancer Care Network USA (2019) cancer pain guidelines recommend a flexible approach to control pain including employing multiple therapies simultaneously. Patients may suffer from pain due to various mechanisms caused by tissue damage. A pain physician should adopt a multidisciplinary approach and evaluate the “total pain” including physical, psychological, social, spiritual, and financial components. He dissects each element including the adequacy of ongoing or completed cancer therapy and response of previous prescribed analgesics before prescribing any new pain therapy. Approximately 12% of patients with inadequately managed pain on oral analgesics may have the option to proceed for interventional techniques for optimal pain relief.[2] The Indian Society for the Study of Pain (ISSP) has come out with ISSP interventional cancer pain guidelines in adults in 2019–2020.[3]

In true sense, any analgesic prescribed to the patient should also be considered an intervention but Dr. S Waldman conducted a meeting in Nice (France) in 1993 where 300 pain physicians participated and after a thorough discussion the term “intervention” was coined for all invasive procedure used for pain medicine.

A comprehensive patient assessment and counseling before any intervention is paramount. An informed consent shall be taken after full explanation about the cause of pain and the exact role of intervention with possible side effects. Interventional techniques have been shown, in some cases, to eliminate or significantly reduce the level of pain. Invasive procedures may allow a significant decrease in the dose of systemic analgesics. Various interventional therapies for relief of cancer pain include nerve blocks, vertebral augmentation, and regional infusion of analgesics, radiofrequency (RF) ablation, and many other interventional radiological techniques.

  Patient Selection Top

A detailed history and physical examination are required to decide upon the exact need of any intervention in cancer pain management.

Any possible cardiac and any pulmonary complications due to the procedure should be the essential part of evaluation. The thorough history of analgesics taken and their response including their allergy status should be ascertained. As many of our procedures are performed in prone position, airway, congenital, or physical deformities should be noted before any procedure.

  Selection Criteria of Interventional Techniques Top
  1. The most important reason for offering an intervention is <50% pain relief on oral analgesics. When ongoing systemic drug therapy (oral, transdermal, subcutaneous, etc.,) fail to provide adequate pain relief or causes unacceptable side effects
  2. Adequate counseling of the patient and caregivers is an integral part of selecting a patient suitable for a procedure. They should be apprised of the benefits, risks, expenses, complications, and also the potential of failure of nerve block or intervention
  3. Written informed consent in the language best understood by the patient and family in a customized text made for the patient and not the common standard printed consent form
  4. Rule out any other causes of pain apart from his primary cancer
  5. Interventionalist should be fully trained and having expertize in performing the procedure
  6. There should no contraindications to the planned procedure due to his comorbid conditions or any ongoing thromboprophylaxis drugs. He should have a stable health status on prescribed drugs for his various coexisting diseases
  7. Screening for any psychological disorder should also be done before any intervention
  8. All neuroloytic block should precede a successful diagnostic block to demonstrate a temporary pain relief state and fully understand the etiology of pain better.

  Commonly used Interventional Procedures Top
  1. Neuro-destructive procedures for localized cancer pain syndromes
    1. Head-and-neck region: peripheral nerve block
    2. Upper limb: brachial plexus block or intrathecal neurolysis
    3. Chest wall: epidural/intrathecal/intercostal neurolysis
    4. Upper abdominal region (visceral): Celiac plexus neurolysis (CPN) or splanchnic neurolysis
    5. Pelvic pain: superior hypogastric plexus (SHP) block
    6. Rectal or perineal pain: Intrathecal neurolytic saddle block, midline SHP block, Ganglion Impar block
    7. Unilateral pain syndromes: cordotomy
  2. Interventional radiological procedures for pain relief: Percutaneous vertebroplasty/kyphoplasty, radiofrequency (RF) ablation for bone lesions
  3. Neuro-stimulation procedures for cancer pain (i.e., peripheral neuropathy)
  4. Regional analgesic infusions via catheter, pump and port (e.g., intrathecal drug delivery system) for infusions of opioids, local anesthetics, and clonidine.

  Neurolytic Procedures Top

Neurolytic procedures are slowly turning into a dying art and very sparingly used now for cancer pain control due to their potential of irreversible complications and lack of expertise and possible medico-legal implications. Many studies pertaining to neurolytic blocks were performed as observational studies, most of them from 1950s to 1970s during JJ Bonica's period, who was considered de facto the father of pain medicine. There are very few randomized controlled trials (RCT) on neurolytics and hence the evidence for various procedure is spread over a spectrum of credibility and firm conviction. Yet, nobody challenges the effectiveness of neurolytic procedures due to the lack of controlled trials. This treatment is firmly established because of the strong observational data. Neurolytic blockade is a therapeutic option when actual source of pain is untreatable.

The purpose is to relieve the pain by blocking the nerves that transmit pain from its noxious source. The primary indication for neurolytic blockade is complete relief of pain when the target is destroyed. Phenol, alcohol, and glycerol are locally neurotoxic substances used for blocking the nerves. These dehydrating agents cause a nonselective destruction of neuronal tissues followed by necrosis, nonsegmental demyelination, Wallerian degeneration, and complete conduction block, occurring within 10 min of application. Cryoneurotomy and thermal RF procedures are also done to break the link from noxious pain generator. Some common agents used for neurolysis are absolute alcohol or 50% alcohol, 6% aqueous phenol, and 6% phenol in glycerin. One retrospective study[4] comparing the effectiveness, duration of benefit, and complication profile of these two agents had shown no difference in pain outcomes, complications and duration of benefit. Thus, we recommend choice of neurolytic agent can be appropriately left to the good clinical judgment and availability of the expertize.

  Sympathetic Block Procedures Top
Celiac plexus neurolysis

There are many case series and uncontrolled, RCTs and meta-analysis been reported on its beneficial effects. CPN is used for the pain relief of upper abdominal structures, for example, pancreas, liver and biliary tract, kidney, ureter, spleen, bowel up to proximal third of transverse colon. Procedures were done using the landmark guided or fluoroscopy-guided technique since the last three decades, however, newer modalities such as endoscopic ultrasound, trans-abdominal ultra-sound or sometimes computed tomography (CT) guidance is employed to delineate the precise delivery of the neurolytic solution causing the block. CPN may provide good pain relief and lower the opioid requirement, reducing their side effects and improving the quality of life (QOL). There are four randomized controlled trials (RCT) comparing fluoroscopic-guided CPN with standard analgesics. One comparing CT-guided CPN with analgesics showed good and prolonged pain relief with reduced opioids and better QOL.[5],[6],[7],[8],[9] No RCT has compared endoscopic or trans-abdominal ultrasound-guided neurolysis as compared with standard analgesics. There are observational studies on the USG-guided CPN showing positive results.[10],[11],[12] Interestingly, one recently published trial showed endoscopic ultra sound (EUS) guided RF neurolysis resulted in good pain relief and QOL versus endoscopic neurolysis.[13] Two recent meta-analysis has shown EUS guided CPN is effective for pain relief in 80% and 72% of cancer patients, respectively.[14],[15] Furthermore, the Cochrane review had demonstrated that CPN may cause fewer adverse effects and should be considered for pain relief.[16]

Splanchnic nerve neurolysis

Splanchnic nerve neurolysis (SNN) was first described by Kappis in 1919 and thereafter multiple studies had shown its benefit. SNN may have gone out of vogue due to its higher complications owing to its proximity to the lower dorsal dermatomes with possible pulmonary, vascular and neurological complications. Although upper abdominal tumors cause little anatomical disturbance in the posteriorly located territory of retrocrural splanchnic nerves, hence, SNN may be employed in advanced disease too, however SNN has limited evidence having only one observational and three retrospective studies.[17],[18],[19]

The evidence on the RF CPN is limited with only one retrospective study.[20] Some clinicians may combine RF lesioning with CNN for better long-term effect.

Superior hypogastric plexus block

One RCT and three observational studies have shown good pain relief consequent to SHP block.[21],[22],[23],[24] The neurolysis can be done under fluoroscopy, CT or USG guidance; with the CT and USG approach may be attempted in supine position with lesser potential of a vascular injury.

Ganglion impar block

There are case series on the use of ganglion impar block[25],[26] for pain relief from perianal structures. The block can be performed with the aid of ultrasound, fluoroscopy, or CT guidance. It may be combined with SHP block for combined pelvic and perianal pain.

  Peripheral Nerve Blocks Top
Intercostal neurolysis

Although the intercostal neurolysis or radiofrequency ablation has been used for chest wall pain from cancer, the evidence is limited with observational studies and case series.[27],[28],[29],[30]

Brachial plexus neurolysis

The brachial plexus neurolysis has been useful for relieving intractable pain arising from tumor compressing upon it. It may lead to loss of motor function of the limb and should be best avoided due to better available modalities of pain management.[31],[32],[33] Use of continuous brachial plexus block with a catheter may be a good alternative and has been described in a few descriptive studies.[34],[35] Intrathecal selective sensory neurolysis should be attempted by positioning the patient in such a way that it does not compromise motor function.

  Neuraxial Blocks Top
Epidural neurolysis

Evidences on interlaminar or transforaminal epidural neurolysis have been tried in cancer cervix and colorectal disease.[36],[37],[38] However, these are not attempted nowadays due to the lack of expertize and also due to available safer options such as intrathecal delivery of opioids.

Intrathecal neurolysis

The literature on the intrathecal neurolysis is also scarce with a few old studies or some case reports.[39],[40],[41] Most commonly chemical agents such as alcohol with concentrations of 50%–100% and phenol 6%–12% are used for neurolysis. Alcohol is hypobaric and the affected side is positioned up at 45°. Phenol solution is hyperbaric and the affected side is positioned down at 45°. Their limitations include poor pain control due to disease progression, or shorter duration of effect due to imprecision, rarely motor weakness of leg, and bowel or bladder dysfunction.[42]

The procedure may be useful in patients with <1 year life expectancy with well localized intractable somatic pain rather than visceral pain.[43]

Epidural, intrathecal or intra-ventricular opioid infusions

This technique provides good benefit to select group of patients. There are only two randomized trials[44],[45] showing both improved analgesia and prolonged survival in patients receiving neuraxial opioids versus conventional medical management. Another high-quality review[46] has found similar efficacy of opioids.

Different types of pumps, connected to percutaneous catheters to fully implantable programmable pumps ones available. Furthermore, after 3 months, the cost of therapy of implantable pumps is less than nonimplantable ones.

If patient's life expectancy <3 months, an epidural route and if >3 months, intra-thecal route is preferred. The epidural catheter is usually placed percutaneously and fixed by tunneling and connected via a programmable pump or syringe driver. The programmable pumps need refilling after few weeks or months, and these patients needs to in close follow-up with the managing specialists.

Most commonly, opioids such as morphine is used for patients who respond partially to systemic morphine and/or are limited by side effects. For patients, who fail to respond to opioids, other medications such as local anesthetics, clonidine, and ziconitidine can also be used and have shown good results [Table 1].[47],[48],[49]

Table 1: Grades of recommendation

Click here to view

  Other Interventional Procedures Top

Cementoplasty types are: vertebroplasty, kyphoplasty, sacroplasty, acetabuloplasty, and osteoplasty. In cementoplasty, the injection of acrylic bone cement into the malignant bone cavities is done to either relieve the pain or stabiles the bone, or both. Vertebroplasty means injection of bone cement into the vertebral body. Cement into the sacrum, acetabulum and other weight bearing bones termed as sacroplasty, acetabuloplasty, and osteoplasty, respectively. Kyphoplasty restores of the original height of the vertebrae by inflating a balloon in the cavity of vertebra and then the space filled with bone cement. Cementoplasty may be considered after tumor ablation using RF.

A recent review of the studies has showed that cementoplasty has significantly reduced the pain, opioids needs, and functional disabilities.[50]

  Summary Top

Interventional pain management has brought out a revolution in the armamentarium of cancer pain helping patients, pain physicians, palliative care physicians, and others who are involved in cancer pain care for better pain control with a minimum side effects ensuring maintained QOL.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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