Case: A patient with metastatic spinal tumors
With Professor Dae-Hyun Kim | 18 Jul 2014 | Print
Submitted by Professor Dae-Hyun Kim, Director of the Pain Clinic, Department of Anesthesiology and Pain Medicine, Research Institute and Hospital, National Cancer Center, Goyang, Korea.
Noninvasive treatments for cancer-related pain include analgesics, adjuvant agents, radiation therapy, chemotherapy and hormone therapy. In this case study, Professor Kim reports on a patient with metastatic spinal tumors at T12 and L1 of the vertebral body, requiring a pain management plan involving oral medication and percutaneous radiofrequency ablation.
Jung-Ho* is a 58-year-old male with history of colon cancer with metastases to the liver, lung and the T12 and L1 vertebral body. He presented to our clinic complaining of persistent left flank pain and left upper quadrant pain of severe intensity (numeric rating scale [NRS] 7/10 at rest) 2 months after receiving palliative radiation therapy to the spine. The physical examination was compatible with T12 and L1 vertebral body involvement, presenting as pain and tingling sensations in the corresponding dermatomes. Bone scan and magnetic resonance imaging (MRI) scans of the spine showed metastatic lesions at the T12 and L1 vertebral bodies with mild compression fractures of the T12 and L1 vertebrae (Figure 1).
Figure 1. MRI scans of the spine showing metastatic lesions at the T12 and L1 vertebral bodies with mild compression fractures of the T12 and L1 vertebrae
The patient received medical treatment with opioids (oral extended-release [ER] oxycodone 20 mg/d and immediate-release [IR] oxycodone 5 mg prn) and adjuvant medications, ie, gabapentin 300 mg/d and amitriptyline 10 mg/d. The lack of response to palliative radiation therapy and medical treatment, combined with the progression of symptoms, led us to try interventional procedures to manage Jung-Ho’s pain.
After supplying informed consent, Jung-Ho underwent left T12 and left L1 selective transforaminal epidural steroid injections. The procedure was performed without difficulty. On his first visit after the procedure, ie, 2 days post-procedure, Jung-Ho reported pain relief of more than 50% (NRS 4/10), indicating a positive response. Thereafter, his pain was stable on oxycodone 30 mg/d.
However, after 4 weeks, Jung-Ho fell in the bathroom and his back pain increased. We increased the doses of his oral medications: oral ER oxycodone to 60 mg/d, IR oxycodone to 10 mg prn, gabapentin to 600 mg/d and amitriptyline to 20 mg/d. Two days later, we changed the dose of oral ER oxycodone to 120 mg/d because Jung-Ho reported persistent pain (NRS 6/10) with the original dose increment.
Another 4 weeks later, Jung-Ho visited the clinic reporting severe pain (NRS 10/10), nausea, vomiting and loss of appetite. He had been barely able to eat or drink anything for a week because of the nausea and vomiting. To adequately treat his pain and to reduce the potential for adverse effects with opioids, dose titration using an intravenous patient-controlled analgesia (IV PCA) device was selected and the patient was admitted immediately. The dose of ER oxycodone was decreased to 90 mg/d and IV PCA was applied (IV morphine hydrochloride 2 mg/cc, basal infusion rate 1.4 mL/h, patient-controlled dose 1.4 mL, lockout time 10 min). Symptomatic treatments included peripheral venous cannulation for hydration, IV injection of an antiemetic agent and an NPO order. The following day, pain intensity had decreased to NRS 2/10 at rest and 4/10 with motion (ie, standing, bending and walking). Pain was severe at the T12 dermatome and slightly less at the L1 dermatome.
Hence, we scheduled percutaneous radiofrequency ablation (RFA) of the left T12 lesion and selective transforaminal epidural steroid injection of the left L1 under fluoroscopic guidance. The patient was placed in the prone position on the procedure table with an abdominal pillow to decrease lumbar lordosis. After preparing and draping his back in sterile fashion, the T12 and L1 levels were identified using fluoroscopic guidance. Local anesthesia was achieved with skin infiltration of 1% lidocaine, after which an RFA needle (15 cm, curved, blunt tip) was placed in the T12 foramen via a transforaminal approach. We assessed the tip location by examining anteroposterior and lateral views and injecting contrast dye (Figure 2). After confirming the location of the needle tip, sensory stimulation (50 Hz) was applied, revealing paresthesia in the T12 area at 0.4 V. For motor stimulation, we performed a 2-Hz stimulation, and obtained a motor response at 1.0 V in T12. At this location, after injecting 2 mL of a mixture of 2% lidocaine and 5 mg triamcinolone, T12 lesioning was performed during 90 seconds at a temperature of 81°C.
Figure 2. RFA needle tip inserted in the T12 foramen via a transforaminal approach, visualized in anteroposterior and lateral radiograph views with contrast dye
Jung-Ho was discharged on the following pain management regimen: ER oxycodone 90 mg/d, IR oxycodone 10 mg/d prn, gabapentin 600 mg/d and haloperidol 1.5 mg/d. As he reported pain relief to NRS 1/10 immediately after the procedure, we decided to maintain the ER oxycodone dose at 90 mg/d and add haloperidol as prophylaxis for nausea and vomiting. There was no procedure-related acute complication at the time of discharge. Seven days later, Jung-Ho reported pain relief of more than 90% (NRS 1/10) and no adverse effects.
*The patient’s name has been changed to maintain confidentiality
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