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 Table of Contents  
LETTER TO THE EDITOR
Year : 2021  |  Volume : 35  |  Issue : 1  |  Page : 89-90

Intrathecal neurolysis is still an economical glorious art in terminal cancer patients in a developing country like India


1 Consultant Pain Management, Pain & Palliative Care Department, Rajiv Gandhi Cancer Institute & RC, Rohini, Delhi, India
2 Consultant Radiologist, Department of Radio-diagnosis, Rajiv Gandhi Cancer Institute & RC, Rohini, Delhi, India
3 Academic Senior Resident pursuing DM (Pain Medicine- Anaesthesia), AIIMS, Rishikesh, Uttarakhand, India

Date of Web Publication27-Apr-2021

Correspondence Address:
Dr. Bablesh Mahawar
AM-69, Shalimar Bagh, Delhi - 110 088
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_40_20

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How to cite this article:
Mahawar B, Mahawar V, Sharma RS. Intrathecal neurolysis is still an economical glorious art in terminal cancer patients in a developing country like India. Indian J Pain 2021;35:89-90

How to cite this URL:
Mahawar B, Mahawar V, Sharma RS. Intrathecal neurolysis is still an economical glorious art in terminal cancer patients in a developing country like India. Indian J Pain [serial online] 2021 [cited 2021 Jun 15];35:89-90. Available from: https://www.indianjpain.org/text.asp?2021/35/1/89/314697

Sir,

Cancer has become a huge global threat to human lives. It is the second most common disease in India responsible for the mortality of about 0.7 million deaths per year. According to reports, cancer will double every 20 years in India. Almost 75%–80% of patients have advanced disease (Stages 3–4) at the time of diagnosis. The most worried symptom of advance-stage cancer patients is pain, which is usually a sign of progression. Pain and palliative management reduces their suffering, myths and supports them to lead a good-quality life in the society. Thus, pain and palliative management is an essential part of oncology management.

A 68–year-old female patient, a case of metastatic breast carcinoma postmultiple lines of treatment with brain and spinal metastasis with malignant cells positive in cerebrospinal fluid, received intrathecal chemotherapy once, had seizures, and presented in severe pain with progressive weakness of the lower limb with bladder and bowel involvement. She was bedridden for more than 15 days. She was started on injection dexamethasone 8 mg intravenously (IV) three times a day, levetiracetam 500 mg IV two times a day, paracetamol 1 g IV three times a day, tramadol 100 mg three times a day, and tablet clonazepam 1 mg in night. Expert opinion from a radiotherapy specialist was taken for palliative radiotherapy for symptomatic relief but was not feasible in view of diffuse leptomeningeal disease and poor performance status. She was referred to the pain and palliative care team due to her worsening pain. History and examination revealed her worse pain toward her left leg. She was bed bound, used to scream in pain 24 h a day, and not slept at night since weeks. Her pain score was 8/10 on a numerical rating scale. She was started on tablet morphine 5 mg 4 h and gabapentin 300 mg once in the night, the dosage of which was gradually increased to 15 mg four times over 6 days with poor pain control. The case was discussed in tumor board and considering that the patient had a lifespan of 2–3 months and had intense pain nonamenable to opioids,[1] she was planned for intrathecal chemical neurolysis (ICN) after explained written consent. ICN is a useful technique in terminal cancer pain patients refractory to opioids. ICN leads to the temporary denervation of a targeted nerve or nerve plexus by directed infiltration of chemicals, for example, phenol or alcohol. ICN[2] was performed at the lumbar L2–L3 level using 5% phenol 0.4 mL with glycerin in the left lateral decubitus position; within an hour, pain score reduced to 1/10 and she slept that night with serenity. Her quality of life improved as she stopped screaming in pain day and night and started accepting little more feed and massage therapy of her lower limbs. No worsening symptoms of her bladder and bowel were noted post-ICN. She was kept under observation for 2 days, and the caregivers were educated about the need of hospice care during this transition phase of disease. Later, the patient was shifted to Shanti Avedna Sadan Cancer hospice. The patient survived with dignity for 28 days and died a peaceful, pain-free death.

India has low socioeconomic indices. Twenty to 25% of the population lives below the national poverty line. Pain and palliative care services are accessible to <3% of the Indian population. Many interventional pain procedures and intrathecal drug delivery pumps have supplanted ICN. However, sophisticated gadgets such as spinal cord stimulator and various intrathecal drug delivery systems are not cost-effective for a majority of the needy cancer patients. To conclude, ICN is a beneficial, important, and glorious alternative technique for cancer patients with shorter life spans and intractable refractory pain. We believe that all younger pain and palliative care physicians should acquire the knowledge of ICN with wiser selection of patients, especially in a developing country like ours where major population are not insurance protected and modern costly methods are not accessible to all.

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.
Rehman SU, Khan MZ, Ahmed YI. Intrathecal chemical neurolysis for intractable cancer pain. Anaesth Pain Intensive Care 2015;19:287-91.  Back to cited text no. 1
    
2.
Wareen JS, Bhaskar A. Cancer pain management: Interventional techniques. Anaesth Crit Care Pain 2015;15:68-72.   Back to cited text no. 2
    




 

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