Treatment of Cancer Related Low Back Pain with Spinal Cord Stimulation
AlexanderYakovlev, MD, Comprehensive Pain Management of the Fox Valley, Appleton,Wis.
Beth E. Resch, APNP, Comprehensive Pain Management of the Fox Valley, Appleton,Wis.
INTRODUCTION
At least one-third of patients with cancer have pain at the time of their diagnosis. Nearly 75% of the patients experience moderate-severe pain in the advanced and terminal stages of their disease (1). Unfortunately, 10-15% of patients with cancer-related pain do not achieve acceptable levels of pain relief with opiates alone or in combination with conventional adjuvant analgesics (2). In an attempt to provide increased pain relief for patients with intractable cancer pain, unconventional agents and interventional management approaches have received considerable attention. Spinal cord stimulation (SCS) has been used with increased frequency for the treatment of intractable cancer pain. It has been estimated that approximately 15-40% of chronic cancer pain has a neuropathic component (3), and this type of pain often responds poorly to opioids. Moreover, the side effect profile of opioids and other analgesics warrant consideration of other interventional pain management approaches in the treatment of cancer pain. SCS is a treatment option for cancer pain (4-5).
METHODS
Between April 2006 and March 2008, 14 patients suffering from intractable cancer related low back pain underwent spinal cord stimulator placement. These patients underwent surgical resections and radiation therapy because the metastatic disease related to colon, anal cancer or angiosarcoma of the sacrum. All of the patients had no evidence of local recurrences or metastases. Eight of them were males and six were females, aged from 43 to 62.The patients failed conservative therapy and had short lasting pain relief after epidural steroid blocks. They underwent successful trial of percutaneous placement of two 8-electrode epidural leads (Medtronic Inc, Minneapolis, MN). Epidural access was gained at theT12/L1 or L1/L2 interspace with final leads positioned atT8-T9 T10(Figure 1). During the 2 day SCS trial the patients reported greater than 50% improvement in pain.Two later the patients underwent implantation with permanent leads and RestorePRIME non-rechargeable or RestoreULTRA (Medtronic Inc., Minneapolis, MN) rechargeable generators.
RESULTS
After final implantation all patients reported significant pain relief (>70% reduction in VAS) with permanent stimulator. All patients were able to decrease or discontinue use of pain medications. Patients also reported other positive outcomes including the ability to return to social and educational activities and improved family relationships. At 12 months post-implant, the patients continued to report good pain control (VAS scores 1-3 out of 10) and improved functional status.
CONCLUSION
SCS may be a therapeutic alternative for patients with cancer related low back pain who in the past exhausted all available treatments. SCS is also an excellent option for patients with co-morbidities which make them less ideal candidates for more invasive interventions.This technique is a relatively easy to perform, effective, and safe procedure.The therapy is reversible should patients lose its pain-alleviating effect or if abdominal pain resolves. Reversal of SCS therapy does not require the patient to endure the uncomfortable weaning process associated with intrathecal or epidural pain medication. SCS is an important adjuvant treatment in patients with intractable neuropathic cancer pain which may make its own niche in the therapy algorithm for this group of patients.
FIGURES
Figure 1.Thoracic epidural placement of two eight-electrode epidural leads showing the electrodes in a staggered position with tips atT8-T9-T10.
Figure 2. Low back after sacral resection and radiation therapy.
REFERENCES
1. Gralow I. Cancer pain: an update of pharmacological approaches in pain therapy. Current Opinion in Anaesthesiology 2002; 15(5):555-561.
2. Sloan PA, Melzack R. Long-term patterns of morphine dosage and pain intensity among cancer patients. Hosp J 1999; 14:35-47.
3. Berger A, Dukes E, Mercadante S, Oster G. Use of antiepileptics and tricyclic antidepressants in cancer patients with neuropathic pain. Eur J Cancer Care 2005;15:138-145.
4. Cata JP, Cordella JV, Burton AW, Hassenbusch SJ,Weng H, Dougherty PM. Spinal cord stimulation relieves chemotherapy-induced pain: a clinical case report. J Pain and Symptom Manage 2004;27:72-78.
5. Hamid B, Haider N. Spinal cord stimulator relieves neuropathic pain in a patient with radiation-induced transverse myelitis. Pain Pract 2007;7:345-347.
© 2018 Клиника «МЕДЭЛЕКТ»
г. Москва, Спартаковский пер, д.2 стр. 5.
Телефон: (499) 281-61-47