Cancer pain management
Dr. Ahmed Helmy Abouel SoudBoard member of WSPC
Professor of Pain Relief, N.C.I., Cairo University, Egypt
Sustained release opioids
• Oral weak opioids e.g. tramundine, D.H.C.
• Oral strong opioids e.g. MST, oxycontin and MXL
• Transdermal e.g. Fentanyl patch (Durogesic)
Newer Fentanyl (Durogesic) patch
• Simpler, thinner• Better adhesion• Fentanyl in dissolved
state with no ethanol as permeation enhancer
• Can be divided • Guarantee stable
blood fentanyl level for 72 h
Pain interventions
minimally invasive procedures
• Delivery of opioids to the C.N.S.
• Destruction of pain pathway
Delivery of opioids to the C.N.S.
• Frequent delivery by special device• Generalized pain, initial good response to
the systemic drug with appearance of tolerance or side effects, adequate test response
• Better response with lower dose and lesser side effects
Ideal procedure
• Life long• High success rate with selective destruction • Complete or satisfactory pain relief• Percutaneous by R.F. or neurolytics • Under local anesthesia • No or minimal morbidity
Common targets
• Celiac plexus• Superior hypogastric
plexus• Ganglion impar • Posterior root• Spinothalamic tract• Trigeminal tract &
nucleus
Celiac plexus destruction
Upper abdominal visceral pain
Pancreas, hepatobiliary, stomach, intestine
85% success
Superior hypogastric plexus destruction
• Pelvic visceral pain• Bladder, prostate,
cervix, uterus, ovary, colon& rectum
• 75% success
Ganglion impar
• Junction of the two paravertebral sympathetic chains
• Sacroccygeal junction• SMP at the perineal region • Ca rectum, anal canal, vagina& vulva• 50-60% success
Posterior (sensory) root
• Localized somatic• Rib metastases, ca
rectum & anal canal• 70% success• Sensory loss
Percutaneous RF procedures
• Cordotomy
• Tractotomy-nucleotomy
• Spinothalamic tract
• Trigeminal tract & nucleus
Spinothalamic tract
• Crossed fibers• Anterolateral
quadrant • Pain & temperature• Somatotopic
organization• Important relations
Cordotomy
• Unilateral cancer pain below the clavicle
• Lung, pleura, pelvic bones & muscles, upper & lower limb
• 95% success• Loss of pinprick &
temp
Descending trigeminal tract & subnucleus caudalis
• Posterolateral part• Joined by VII, IX and X• Somatotopic organization• Important relations• Pain & temperature
Trigeminal Tractotomy-Nucleotomy
• Percutaneous • under L.A. & sedation• C-T guided• R.F. • Occiput / C1 level • 75 % success