Pain in cancer is one of the most common symptoms, especially in late stages. It is important to provide adequate pain relief so that these patients can live the rest of their life pain-free. It is important to treat total pain i.e. physical, psychological, social & spiritual.
WHO has given guidelines to treat cancer patients, as 3 step ladder. Now WHO added 4th step into it as Interventional therapy. Initial 3 steps are pharmacological which includes Non-opioids, opioids & adjuvants like an antidepressant, anticonvulsant, NMDA antagonists, Corticosteroids, Bisphosphonates, Baclofen & calcitonin.
In interventional therapies, it includes various nerve block techniques. In cases with intractable pain is not responding to a simple nerve block, pain can be controlled by neurolytic blocks or advanced modalities like implanting a highly specialized intraspinal drug delivery pump.
Various other non-pharmacological therapies & Psychosocial therapies are used as an adjuvant.
| A. Systemic Analgesic Therapy (WHO Ladder) | B. Anti Neoplastic Therapy | C. Interventional Therapy | D. Non Pharmacological Therapy | E. Psycho-social Therapy |
|---|---|---|---|---|
| Non-opioid | Surgery | Anesthetic blocks | Heat/cold application | Cognitive therapy |
| Opioid | Radiotherapy | Spinal/ Epidural – Setroid | Exercise | Relaxation/ Imagery |
| Adjuvants- Antidepresants Anticonvulsant NMDA antagonists Corticosteroids Diphosphonats Baclofen Calcitonin | Chemotherapy | Spinal/ Epidural – Opioid | TENS | Distraction/ reframing |
| Neurolytic procedures | Occupational therapy | Hypnosis | ||
| Neurostimulatory Procedures | Physical therapy | |||
| Advanced procedures |
Techniques Of Neurolysis:
- Radiofrequency Ablation
- Neurolysis with glycerol, alcohol
Specific Nerve/plexus neurolysis indications:
- Gasserian Ganglion Neurolysis: Indicated in Secondary neuralgic pain due to facial pain resulting from terminal cancer
- Sphenopalatine Ganglion Block: Pain from cancer of tongue and floor of the month.
- Stellate ganglion (C5 to T1 ± T2-3) block: Cancer pain of the Head, Neck & Upper extremities, CRPS I & II
- Coeliac plexus block: Indications are-
- Intra abdominal visceral analgesia
- Upper abdominal surgery combining intercostal block and celiac block
- Intra-abdominal malignancy
- Cancer of stomach
- Pancreatic cancer
- Gall bladder cancer
- Adrenal mass
- Common bile duct cancer
- Lumbar symp block: Indications are- Pain in
- Lower limb due to bony metastsis
- Amputation stump pain
- Phantom pain
- CRPS I & II
- Sup hypogastric block: Indicated in Neoplasms of pelvic viscera (Bladder, uterus, vagina,
prostate, rectum, etc.) - Ganglion impar: indicated in Neoplasms of perineal region.
Treatment Options Or Interventions
- Stellate Ganglion Block for Head and Neck cancer pain
- Neurolytic Coeliac plexus block for Cancer of the pancreas or other abdominal Viscera (Stomach, Liver, Gall Bladder, etc.)
- Lumbar sympathetic chain block for Nociceptive or Neuropathic cancer pain affecting the lower extremity
- Neurolytic Superior Hypogastric plexus block for Cancer of Pelvic Viscera
- Hyperbaric phenol saddle block for midline perineal pain in patients with Rectal and Pelvic malignancies
- Intrapleural phenol block for visceral pain associated with esophageal cancer
- Ganglion Impar block for visceral pain of the perineum
- Multiple peripheral nerve blocks (Neurolytic/ Radiofrequency Ablation)
- Intraspinal Analgesia with epidural & intrathecal injections / Infusions/ Implantable pumps of local anaesthetics, opioids etc .
- Advanced Radiofrequency ablation procedures for benign and cancer pain.