Cancer Pain

If you or a loved one have been diagnosed with cancer, there are thankfully many options to treat your pain. Most cancer pain is due to tissue injury caused by the growing tumor. The frequency and amount of pain that patients experience varies depending on the stage of disease, type of neoplasm, previous treatment, and co-existing disease. Uncontrolled pain can negatively affect one's ability to cope with the disease and perform daily activities so it is important that you speak up and inform your physicians if your pain is inadequately controlled.

Pain management in patients with cancer should include a multi-disciplinary approach. In our practice, patients are often comanaged in conjunction with their oncologist, radiation oncologist, surgeon and primary care physician. In some cases, medications may be utilized to aid in the management of pain. Although opioids are used to treat patients with moderate to severe cancer pain, there are some downsides to opioids including possible sedation, gastrointestinal issues such as constipation, and fatigue which may prevent patients from fully enjoying the relief they may provide. In our practice, we often look beyond medications only, and explore procedural and interventional options for pain control, based on the location of the pain. For example, trigger point injections can provide relief to cancer patients with focal musculoskeletal pain. This is a fairly low risk type of procedure that can provide a significant amount of relief in those with muscle pain. Providing care to cancer patients with chronic pain may also entail treating their comorbidities, including osteoarthritis, that may also cause pain. A joint injection is another type of procedure that can be done to provide relief in patients with painful joints. This type of procedure involves injecting steroid into a particular joint.

Among patients with cancer, neck pain or low back pain may signify the presence of co-existing diseases, which may or may not be related to the malignancy itself. Radiofrequency nerve ablations, facet injections, epidural steroid injections, and sacroiliac injections are commonly used to alleviate low back and neck pain and are procedures for which patients with cancer may be candidates.

Other examples of patients who may benefit from Interventional therapies for cancer pain include patients with lung cancer. If you have rib pain or nerve pain around the rib, an intercostal nerve block or epidural steroid injection may be beneficial. If you have nerve pain in your shoulder or arm due to tumor involvement, a stellate ganglion block, brachial plexus block (supraclavicular or infraclavicular block), axillary block, or suprascapular block may be beneficial, based on the location of the pain and structures involved. For pain in the spine itself due to tumor involvement, epidural steroid injections, or medial branch blocks which block the mechanical portion of the pain, followed by radiofrequency ablation may be beneficial for long-term relief. For hip involvement, intraarticular hip injections, sacroiliac joint injections, or radiofrequency ablation of the hip joint may be beneficial. For nerve pain in the lower limbs, lumbar sympathetic blocks, femoral or sciatic nerve blocks, popliteal blocks, peroneal nerve or tibial nerve blocks are often helpful.

For patients who have tumor involvement in the pancreas, stomach, small intestine, or large intestine, or other hollow organs, blocks such as Celiac plexus or Splanchnic nerve block may be very helpful. These blocks are performed under x-ray guidance with or without sedation, and a radiofrequency ablation or neurolysis of the celiac plexus with alcohol or phenol may be used to give you 6 months or more of relief. It is one of the more gratifying procedures in medicine when a pancreatic cancer patient receives excellent relief from the neurolytic celiac plexus block and is able to take much less medication and enjoy time with family.

A common symptom in patients with cancer metastasis is bone pain. Treatment plans for these patients are typically formulated with the main goal of reducing the amount of pain, decreasing the risk of adverse outcomes, and preserving function. Bone metastases or osteoporosis may lead to a compression fracture of the spine / vertebra resulting in pain. Patients with a type of bone cancer called Multiple Myeloma often experience these painful vertebral compression fractures. Fortunately, these compression fractures can be treated with a procedure known as a kyphoplasty to restore bone and vertebral body height, stabilize the bone, and prevent further height loss and bone movement and inflammation associated with pain. Kyphoplasty entails introducing bone tamps that are inflatable into the vertebral body at the location of the fracture. Next, the bone tamps are then inflated securing the height of the bone while producing a space that is then filled with bone cement. More than fifty percent of people had improvement in pain with vertebral augmentation, such as kyphoplasty, based on systematic reviews of studies conducted in patients with cancer. In one analysis, kyphoplasty led to less patients requiring assistive devices, such as a cane or walker; bracing; bed rest; and medications.

Spinal cord stimulation is an implantable type of neurostimulatory treatment that may be an option for cancer patients who have neuropathy as a result of the malignancy or its treatment, or a comorbidity. This is usually considered if other measures have failed. The ideal candidate for SCS would be someone with intractable nerve-related pain who has not responded to traditional therapy such as medication and nerve blocks.

Intrathecal pain pumps / Spinal pain pumps are sometimes used for patients who have severe widespread intractable cancer pain which has not responded to traditional measures. With this modality, the patient’s pain medication is delivered straight to the spinal cord and nerves in the spine with a pain pump which is implanted under the skin. The medications used may include morphine, bupivacaine, hydromorphone, fentanyl, ziconotide, or a combination of these medications. The advantages to an intrathecal morphine pain pump include: less sedation, improved pain control, less side effects such as constipation, and improved survival by 3-5 months. Disadvantages including required pain pump refills, chance for infection, and retained device which requires minor surgery to place.

Additionally, other pain management measures we implement in our plans of care frequently among patients with cancer are the use of braces, TENS units, aquatic therapy and/or physical therapy for strengthening and conditioning, and opioid and non-opioid medications.

At Cahaba Pain and Spine Care we are pleased to be a part of your cancer treatment team. We do our best to get you the relief you need so you can get back to achieving your treatment goals. We take into account all of your medical issues, current treatments, and goals and formulate a cancer pain treatment plan which engages you as an educated advocate and places your needs first.