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cancer pain - dr. lelyanov

us414
April 28, 2020

cancer pain - dr. lelyanov

cancer pain - dr. lelyanov

us414

April 28, 2020
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  1. PAIN MANAGEMENT IN PATIENTS WITH CANCER OLEKSIY LELYANOV, DO AND

    WILLIAM GRUBB MD PAIN MEDICINE RUTGERS /ROBERT WOOD JOHNSON MEDICAL SCHOOL APRIL 27, 2020
  2. OBJECTIVES • DISCUSS EPIDEMIOLOGY OF CANCER PAIN • REVIEW PATHOPHYSIOLOGY

    OF CANCER PAIN • DISCUSS PHARMACOLOGIC TREATMENT OPTIONS, INCLUDING ANTI-INFLAMMATORIES, ANTICONVULSANTS, ANTIDEPRESSANTS • DISCUSS NEURO-AUGMENTATION • DISCUSS INTRATHECAL DELIVERY SYSTEM • DISCUSS NEUROLYSIS FOR CANCER PAIN, INCLUDING ALCOHOL AND PHENOL • DISCUSS NEUROSURGICAL OPTIONS FOR CANCER PAIN
  3. EPIDEMIOLOGY OF CANCER PAIN • AVERAGE AGE AT CANCER DX

    IS 65 • 60-90% OF PTS WILL HAVE PAIN • PAIN FROM DISEASE OR TREATMENT? IN PEDS, TENDS TO BE FROM TX • PAIN AS FIRST SX OF CANCER TENDS TO INDICATE ADVANCED DISEASE AND IS AN INDEPENDENT PREDICTOR OF POOR PROGNOSIS
  4. SPECIAL POPULATIONS • IN PEDS, PAIN IS MORE COMMONLY FROM

    TX • IN GERIATRIC POPULATION, COMORBIDITIES AND DRUG-DRUG INTERACTIONS NEED TO BE TAKEN INTO EFFECT • PRESENT PAIN IS MOST RELIABLE IN SETTING OF COGNITIVE IMPAIRMENT • IN PATIENTS WITH SUBSTANCE ABUSE HX, THERE IS GREATER RELIANCE ON DIAGNOSTIC IMAGING • INMATES HAVE HIGHER RATES OF CANCER, INCREASED MORTALITY, AND UNDERTREATED SYMPTOMS
  5. SOURCES OF PAIN • DIRECT TUMOR INVASION --- TO BONE

    --- EPIDURAL , SPINAL SPACE, INTRATHECAL --- TO LIVER, LUNG ---OSTEOBLASTIC VS OSTEOCLASTIC • SECONDARY TO THERAPY -VARICELLA ZOSTER RESULTING FROM LOW WBC -RADIATION PLEXOPATHY – BRACHIAL PLEXOPATHY (R/O TUMOR REINVASION) -NEUROPATHY SECONDARY TO ONCOLOGY THERAPY • OBSTRUCTION BOWEL OR BILIARY SYSTEM • VERTEBRAL SYNDROMES FROM COMPRESSION BY TUMOR • HEADACHE - INTRACEREBRAL TUMOR • PARANEOPLASTIC SYNDROMES
  6. INFLAMMATORY PAIN • PERIPHERAL AND CENTRALLY MEDIATED • BRADYKININS, NERVE

    GROWTH FACTOR, CYTOKINES, ATP, PROTONS FROM DYING CELLS • THESE SUBSTANCES ACTIVATE PRIMARY AFFERENT AND AWAKEN SILENT NOCICEPTORS (FEED FORWARD LOOP) • PRIMARY AFFERENT DISCHARGE LEADS TO DORSAL HORN HYPEREXCITATION AND THE ACTIVATION OF MICROGLIA. • PERIPHERAL INHIBITION VIA ACTIVATION OF PERIPHERAL AND CENTRAL OPIOID RECEPTORS, COX PATHWAYS AND DESCENDING MODULATION.
  7. NEUROPATHIC PAIN • DAMAGE TO NEURONS EITHER PERIPHERAL OR CENTRAL

    (VIA COMPRESSION OR ISCHEMIA/ HEMORRHAGE, CHEMICAL OR TRANSECTION). • PERIPHERAL DAMAGE  ACCUMULATION OF ABNORMAL SODIUM AND CALCIUM CHANNELS AT THE SITE OF INJURY • ALTERATIONS TO GENE EXPRESSION OF RECEPTORS • DAMAGED NEURONS DISCHARGE SPONTANEOUSLY AND THERE IS CROSS-TALK TO NORMAL FIBERS AND RECRUITMENT OF SILENT NOCICEPTORS • EXCESSIVE OR ABSENT DISCHARGE FROM PRIMARY AFFERENTS WITHIN THE DORSAL HORN RESULTS IN OVERALL EXCITATION AN ALTERATION IN EXPRESSION OF NMDA RECEPTORS AND FUNCTIONAL LOSS OF OPIOID AND GABAMINERGIC SYSTEMS • THERE IS RESULTANT HYPEREXCITATION WITH INCREASED RECEPTIVE FIELDS  PRIMARY AND SECONDARY HYPERALGESIA, AND ALLODYNIA • DORSAL COLUMNS RELAY PREDOMINATELY TO THALAMUS, GIVING RISE TO STRONG AUTONOMIC RESPONSES AND EFFERENT RESPONSES
  8. PHARMACOLOGIC TREATMENT • ANTIPYRETIC ANALGESIC- ACETAMINOPHEN • NSAIDS - OTC

    IBUPROFEN - NON SPECIFIC - SULINDAC -CYCLOOXYGENASE II SPECIFIC CELECOXIB AND MELOXICAM • ANTICONVULSANT AGENTS • ANTIDEPRESSANTS • MIXED MU AGONISTS • MU AGONISTS • ALPHA 2 AGONISTS
  9. ANTICONVULSANTS • MECHANISMS • CALCIUM CHANNEL ANTAGONISTS: VOLTAGE GATED CALCIUM

    CHANNEL IS AFFECTED BY BINDING THE ALPHA 2 DELTA UNIT OF VSCC • SODIUM CHANNEL BLOCKERS • GABA –A RECEPTOR BLOCKERS • UNDETERMINED MECHANISM
  10. CALCIUM CHANNEL BLOCKERS (GABAPENTIN AND PREGABALIN) • ANTI-HYPERALGESIC EFFECTS IN

    ANIMAL MODELS OF INFLAMMATION AND NERVE PAIN (LITTLE TO NO EFFECT ON ACUTE PAIN) • B L OCK THE AL PHA 2 DE LTA S UB UNIT OF THE L TYPE CAL CIUM CHANNE L • ACT IN THE OUTER LAYERS OF THE DORSAL HORN • DECREASE THE RELEASE OF GLUTAMATE NOREPINEPHRINE SUBSTANCE P
  11. GABAPENTIN (NEURONTIN) • DEVELOPED TO MIMIC GABA BUT DOES NOT

    BIND THE GABA RECEPTOR, BLOCKS ALPHA 2 DELTA SUBUNIT OF L CALCIUM CHANNEL IN CNS • MOLECULAR STRUCTURE SIMILAR TO GABA • PROVIDES ADDITIONAL RELIEF IN PATIENTS ONCOLOGY PATIENTS (IMPROVES ANALGESIC EFFICIENCY) MULTIPLE SCLEROSIS SPINAL STENOSIS • INITIATE AT 100MG -300MG DAILY • FATIGUE, SOMNOLENCE, DIZZINESS, CAUTION WITH RENAL DX
  12. PREGABALIN (LYRICA) • MORE RAPID ONSET THAN GABAPENTIN, WITH MAX

    EFFICACY AT 2 WEEKS VS 2 MONTHS • FEWER SIDE EFFECTS, BUT STILL CAUTION IN RENAL DX. • DOSED : 25 - 75 QHS IN ELDERLY TO MAX OF 150 PO/DAY • IN DIABETIC NEUROPATHY: NNT =6.3
  13. SODIUM CHANNEL BLOCKERS  THESE ARE PROVEN THERAPY FOR TRIGEMINAL

    NEURALGIA, PHN, DN, CRPS  INHIBIT DEVELOPMENT OF ECTOPIC DISCHARGES • ANTI-EPILEPTIFORM/ANTICONVULSANTS • LOCAL ANESTHETICS • TRICYCLIC ANTIDEPRESSANTS • ANTI-ARRHITHMICS
  14. CARBAMAZEPINE (TEGRETOL) • MECH: NA CHANNEL BLOCKADE, SELECTIVELY BLOCKS ACTIVE

    FIBERS WITH NO EFFECT ON NORMAL FUNCTIONING A- DELTA AND C-FIBERS • DOSE INITIAL 100MG PO BID TO TID • SIDE EFFECTS: PANCYTOPE NIA - AGRANULOCYTOSIS AND APLASTIC ANEMIA; CBC NECESSARY EVERY THREE WEEKS (BLOOD TESTS 2-4 MONTHS) STEVEN JOHNSON SYNDROME TOXIC EPIDERMAL NECROSIS DIZZINESS AND GAIT DISTURBANCE • TREATMENT MODELS TG NEURALGIA- NNT<2, NNH 24 POST CVA PAIN
  15. OXYCARBAMAZEPINE (TRILEPTAL) • MECH- NA CHANNEL BLOCKADE • TITRATE TO

    600 MG/DAY • SIDE EFFECTS: HYPONATREMIA (<125) DIZZINESS, SOMNOLENCE, N/V CAN ALSO SUPPRESS BONE MARROW • TREATMENT MODELS: DIABETIC NEUROPATHY, TRIGEMINAL NEURALGIA
  16. PHENYTOIN (DILANTIN) • MECH: NA CHANNEL BLOCKADE, PREVENTS GLUTAMATE RELEASE

    • DOSE: 100MG BID • SIDE EFFECTS: CHANGE IN FACIAL FEATURES (COARSENING) GINGIVAL HYPERPLASIA SEDATION CHANGES IN MOTION STABILITY • TREATMENT MODELS: STILL USED IN RECALCITRANT ONCOLOGY RELATED PAIN • INCREASES ACTIVITY OF CP450, DECREASING EFFICACY OF METHADONE, FENTANYL, TRAMADOL, MEXILETINE, LAMOTRIGINE, CARBAMAZEPINE • WHEN CO-ADMINISTERED WITH ANTIDEPRESSANTS, AND VALPROIC ACID, THE DECREASED ACTIVITY OF P450 WILL PRODUCE INCREASED CONCENTRATION OF PHENYTOIN
  17. LAMOTRIGINE (LAMICTAL) • MECH: STABILIZES THE SLOW NA CHANNEL >

    SUPPRESS GLUTAMATE RELEASE • DOSE 25MG BID • SIDE EFFECTS: • SKIN RASH • RARE STEVEN JOHNSONS SYNDROME, (NOTED WHEN COMBINED WITH VALPROIC ACID IN CHILDREN) • TREATMENT MODELS: TN, DIABETIC NEUROPATHY, DISTAL SENSORY POLYNEUROPATHY OF HIV DISEASE
  18. TOPIRAMATE (TOPAMAX) • MECH: NA CHANNEL BLOCKER INCREASES GABA ACTIVITY

    INHIBITS AMPA-TYPE EXCITATORY GLUTAMATE RECEPTOR • DOSE START 25MG QHS • SIDE EFFECTS: SEDATION KIDNE Y S TONE S (TOPIRAMATE INHIB ITS CARB ONIC ANYHYDRAS E ) GLAUCOMA
  19. LEVETIRACETAM (KEPPRA) • MECH: UNDETERMINED • DOSE 250MG-500MG BID •

    NOT METABOLIZED BY P450 • SIDE EFFECTS ASTHENIA, DIZZINESS, SOMNOLENCE, HEADACHE
  20. MEXILETINE • DOSE 150 BID • MECH: NA CHANNEL BLOCKER

    • SIDE EFFECTS: NAUSEA BLURRED VISION IRRITABILITY • CLASS 1B ANTIARRHYTHMIC (STABILIZES MEMBRANES)
  21. VALPROATE (DEPAKOTE) • DOSE NEEDS TO BE TITRATED WITH BLOOD

    LEVELS APPROXIMATING 50-100 MCG/ML BUT THESE DOSES ARE NEVER USED WHEN TREATING CHRONIC PAIN • MECH: GABA–A RECEPTOR AGONIST • SIDE EFFECTS: CNS DEPRESSION • TARGET TREATMENT GROUPS: CHANGE IN MIGRAINE THERAPY, SUPPRESS CNS COMPRESSION BY TUMOR
  22. LIDOCAINE PATCH (LIDODERM) • MECHANISM LOCAL ANESTHETIC, NA CHANNEL BLOCK

    • 12ON/12OFF, ROTATE PATCH • GREAT NEAR DRAIN SITES, CHEST TUBES, RECENT LARGE INCISIONS • SIDE EFFECTS INCLUDE DIZZINESS AND BLURRED VISION AND AT CONCENTRATIONS OF 10MCG/ML, SEIZURE AND 25 MCG/ML CARDIAC DEPRESSION, BUT THE S E PL AS MA L E VE L S HAVE NE VE R RE S ULTE D FROM THE PATCHE S
  23. ANTIDEPRESSANTS • ANTI DEPRESSANTS HAVE BEEN USED TO TREAT DEPRESSION

    ASSOCIATED WITH CHRONIC PAIN OR RESULTING FROM THE CHRONIC PAINFUL CONDITION • THERE ARE THREE BASIC CATEGORIES: • TCA - EXAMPLE ELAVIL • SSRI - EXAMPLE PROZAC (RARELY USED IN ONCOLOGY PATIENTS WHY DUE TO SEROTONIN SYNDROME) • SNRI – EXAMPLE CYMBALTA
  24. TCA • OLDER FORMS INHIBIT REUPTAKE OF SEROTONIN AND NOREPI,

    INCREASING SYNAPTIC LEVELS OF THESE MEDS • THEY HAVE INDEPENDENT ANALGESIC PROPERTIES AT LOWER DOSES • DIFFER IN TERMS OF SIDE EFFECTS: • ANTICHOLINERGIC, (DRY MOUTH, CONSTIPATION, BLURRED VISION, URINARY RETENTION) • ANTIHISTAMINE EFFECTS (SEDATION)
  25. TCA PHARMACOLOGY • QUINIDINE LIKE PROPERTIES MAKE THEM PROARRHYTHMIC •

    TCA PROLONG THE QT INTERVAL, GET AN EKG • TCA DECREASE SEIZURE THRESHOLD • SOME TCA HAVE DOCUMENTED ANALGESIC PROPERTIES • ALL TCA CAUSE URINARY RETENTION, DRY MOUTH, POSTURAL HYPOTENSION, WEIGHT GAIN • HEPATIC CLEARANCE INVOLVES THE P450 SYSTEM MEDS WHICH COMPETE FOR THE ENZYME WILL INCREASE LEVELS WHEN CO-ADMINISTERED (SSRI, CIMETIDINE, METHYLPHENIDATE) • P450 ENZYME INDUCERS WILL DECREASE SERUM TCA LEVELS (PHENOBARBITAL, CARBAMAZEPINE, CIGARETTE SMOKING)
  26. SSRI • LOWER SIDE EFFECT PROFILE THAN TCA, BUT DECREASE

    SEIZURE THRESHOLD • ASSOCIATED WITH EASY BRUISING AND OSTEOPOROSIS • SIDE EFFECTS INCLUDE DECREASED LIBIDO, IMPOTENCE, DYSTONIA, AKATHISIA, RARE SIADH • FEW INDEPENDENT PAIN PROPERTIES • NEVER PROVEN TO BE OPIOID SPARING WHEN COMPARED TO TCA • TAPER OFF SLOWLY
  27. SEROTONIN SYNDROME • SEEN WHEN SSRI ARE COMBINED WITH: •

    MIXED MU AGONISTS (TRAMADOL, TAPENTADOL) • ANTI-EMETICS: (ZOFRAN, REGLAN) • NARCOTICS: MEPERIDINE, FENTANYL, PENTATOZINE • PRESENTS AS: • CLONUS, TACHYCARDIA, MENTAL STATUS CHANGE
  28. SNRI • INHIBIT REABSORPTION OF SEROTONIN AND NOREPINEPHRINE • DULOXETINE

    (CYMBALTA) INDICATED FOR TX OF DIABETIC NEUROPATHY AND FIBROMYALGIA • STARTING DOSE: 30MG PO • SIDE-EFFECTS: DRY MOUTH, DIZZINESS, CONSTIPATION, 2D6 INHIBITOR
  29. VISCERAL PAIN • DIFFUSE, POORLY ORGANIZED - PATIENT MAY OFTEN

    COMPLAIN OF CRAMPING AND SPASMS, SILENT NOCICEPTORS BECOME ACTIVATED BY INFLAMMATION • ALSO STIMULATED BY: ISCHEMIA, DISTENTION/CONTRACTION, AND COMPRESSION • KEY TRANSMITTERS: SEROTONIN (PERIPHERAL AND CENTRAL) CALCITONIN-GENE-RELATED PEPTIDE, VASOACTIVE INTESTINAL, PEPTIDE, KININS. • DORSAL HORN MODULATION IS TRANSMITTED CENTRALLY VIA SPINOTHALAMIC TO VISCERO- SENSORY CORTEX
  30. FREQUENTLY USED BLOCKS FOR ABDOMINAL PAIN • PANCREATITIS, ACUTE AND

    CHRONIC • DIAGNOSTIC • TREATMENT OF ABDOMINAL ISCHEMIA • TREATMENT OF ACUTE PAIN AFTER ARTERIAL EMBOLIZATION FOR CANCER PAIN • TREATMENT OF PAIN SECONDARY TO UPPER ABDOMINAL MALIGNANCY
  31. CELIAC PLEXUS BLOCK • LARGEST PRE-VERTEBRAL PLEXUS, PARA-AORTIC • RETROPERITONEAL,

    BUT ANTERIOR TO THE CRUS OF THE DIAPHRAGM • THIS IS IMPORTANT : AS AN ANTEROCRURAL BLOCK, THE NEEDLE IS APPRX 1 CM ANTERIOR TO THE LOWER BORDER OF L1; WILL GO THROUGH THE AORTA ON THE LEFT SIDE, DEPOSITING DYE ANTERIOR TO THE AORTA ON THAT SIDE • CONTRIBUTING GANGLIA INCLUDE AORTICO-RENAL AND MESENTERIC • COVERS ENTIRE ASCENDING AND TRANSVERSE COLON, THE DESCENDING COLON AND RECTUM ARE NOT COVERED. • CURRENT LITERATURE REVIEW SUGGESTS THAT THE ADRENAL AND POSSIBLY THE NERVE SUPPLY TO THE OVARY IS COVERED BY THE CPB
  32. NERVE SUPPLY TO CELIAC PLEXUS • SYMPATHETIC EFFERENT FIBERS FROM

    BECOMING THE SPLANCHNIC NERVES • AFFERENT SENSORY FIBERS - C TYPE SILENT NOCICEPTORS WHICH RUN WITH THE ABOVE FIBERS • PARASYMPATHETIC FIBERS FROM THE VAGUS NERVE • SYMPATHETIC AFFERENTS
  33. PERFORMING CELIAC PLEXUS BLOCK • PATIENT PRONE ON PILLOW, IV

    SEDATION, MONITORING INCLUDING EKG, PULSE OX, ABP • S/PREP BETADINE X3 WITH STERILE DRAPE • LOWER BORDER SPINES OF T12 AND L1 • DISTAL END OF RIB 12, 45° TOWARD MIDLINE • NEEDLE ADVANCED 15° CEPHALAD, SLOWLY UNDER THE LATERAL ASPECT OF THE L1 VERTEBRAL TRANSVERSE PROCESS TO ANTERIOR BODY L1
  34. CELIAC PLEXUS VS SPLANCHNIC N BLOCK • GREATER SPLANCHNIC T5-T10

    LESSER SPLANCHNIC T10-T11 LEAST SPLANCHNIC T11-T12 • THE NEXT SLIDE DEMONSTRATES A TRUE SPLANCHNIC N. BLOCK-DIAGNOSTIC • THERE IS OBVIOUSLY AN INCREASED RISK OF PNEUMOTHORAX AT THE T12 LEVEL
  35. INJECTION AGENTS • DIAGNOSTIC NERVE BLOCK- 30ML OF DILUTE LOCAL

    ANESTHETIC + STEROID • NEUROLYTIC- SAME VOLUME OF PHENOL OR ALCOHOL AFTER SUCCESSFUL BLOCK FOLLOWED BY CONTRAST DYE STUDY • PHENOL 6%-12% ANESTHETIC HYPERBARIC DELAYED EFFECTS • ALCOHOL PAINFUL ON INJECTION HYPOBARIC IMMEDIATE EFFECTS • ALCOHOL HAS BEEN ASSOCIATED WITH SPASM OF THE MAJOR SPINAL ARTERIES CAUSING TRANSIENT PARALYSIS
  36. COMPLICATIONS • HYPOTENSION FROM SYMPATHETIC BLOCK • PUNCTURE OF ABD

    BLOOD VESSELS • PNEUMOTHORAX • DIARRHEA • PERSISTENT HYPOTENSION (AFTER LYSIS) • SILENT ABDOMEN • ALCOHOL MIGRATION ACROSS DIAPHRAGM • INTRAVASCULAR ALCOHOL UPTAKE • INFECTION • BLEEDING
  37. SUPERIOR HYPOGASTRIC PLEXUS BLOCK • THIS BLOCK IS INDICATED FOR

    THE DIAGNOSIS AND POSSIBLY TREATMENT OF PAINFUL CONDITIONS OF THE PELVIS • THE BLOCK IS PERFORMED USING FLUOROSCOPY FROM THE POSTERIOR APPROACH
  38. NON-PHARMACOLOGIC TX • ANTINEOPLASTIC THERAPIES • RADIATION THERAPY • SURGICAL

    DECOMPRESSION FOR SPINAL TUMORS • NON SURGICAL DECOMPRESSION- CRYOTHERAPY, RFA • CHEMICAL DENERVATION OF TUMOR INVOLVED AREAS • AUGMENTATION OF TUMOR INVOLVED AREAS • SCS • INTRATHECAL NARCOTIC INFUSIONS
  39. INTERVENTIONAL TECHNIQUES • PALLIATIVE BLOCK ; +/- STEROIDS • CRYOTHERAPY

    • RFA LESIONING • NEUROLYTIC BLOCK, PERIPHERAL • NEUROLYTIC BLOCK, CENTRAL • SCS • IT DRUG DELIVERY
  40. SPINAL CORD STIMULATION FOR ONCOLOGY PATIENTS • WITH THE APPLICATION

    OF MORE DISCRETE AND LOCALIZED STIMULATION PLACEMENT, A ONCOLOGY PAIN GENERATOR CAN BE TREATED BY OVERRIDING THE PAIN SIGNAL WITH A STIM PATTERN • DRG • MRI COMPATIBLE
  41. DRG

  42. INTRATHECAL DELIVERY • FDA APPROVED SINCE 1980S • IMPORTANT BECAUSE

    IT IS ESTIMATED THAT UP TO 20% OF PATIENTS HAVE SUBOPTIMAL PAIN CONTROL DESPITE APPROPRIATE WHO ANALGESIC LADDER. • PARADIGM SHIFT: INTERVENTIONAL PAIN MANAGEMENT NO LONGER LAST RESORT • MORPHINE: INTRATHECAL DAILY DOSE COULD BE REDUCED BY A FACTOR 12 TO 300, COMPARED WITH THE ORAL DAILY DOSE
  43. • B E NE FITS : • FIXED CONTINUOUS RATE

    OF INFUSION WITH BOLUS OPTION FOR BREAKTHROUGH PAIN • LOWER DOSES OF DRUG GENERALLY PRODUCE FEWER ADVERSE EFFECTS (SEDATION, COGNITIVE DEFICITS, FATIGUE, AND CONSTIPATION) • INTRATHECAL DRUG ADMINISTRATION CAN PROVIDE MORE EFFECTIVE ANALGESIA THAN SYSTEMICALLY ADMINISTERED • EARLY IMPLEMENTATION MAY LEAD TO IMPROVED SURVIVIAL (SMITH, T.J. ET AL. 2002. JOURNAL OF CLINICAL ONCOLOGY) • MINIMIZE DIVERGENCE OF MEDICATIONS
  44. FDA APPROVED • ZICONOTIDE (PRIALT) • NONOPIOD INTRATHECAL PEPTIDE THAT

    ACTS AT THE SUBSTANTIA GELATINOSA OF THE SPINAL CORD • ANTAGONIZES PRESYNAPTIC N TYPE CALCIUM CHANNELS WITHIN THE DORSAL ROOT GANGLION AND THE REXED LAMINA I AND II • MORPHINE • CENTRAL MU AGONIST
  45. SURGICAL PROCEDURES • DO EVERYTHING ELSE FIRST • MOST OF

    THESE PROCEDURES HAVE BEEN REPLACED BY: AUGMENTIVE DCS, PNS, DBS AND DRG STIM, IT THERAPY (PRIALT,NARCOTICS,CLONIDINE)
  46. SYMPATHECTOMY • INDICATION: VISCERAL PAIN OF CANCER • HOW: RF

    OR CHEMICAL ABLATION AT SYMPATHETIC CHAINS OR GANGLIA • HAS BEEN REPLACED BY SCS FOR TREATMENT OF CRPS
  47. DORSAL RHIZOTOMY • SENSORY INPUT CAN BE TARGETED BY SEVERING

    THE NERVE IN THE POSTERIOR (DORSAL ASPECT) • THIS IS NOT TOTALLY EFFECTIVE AS SOME OF THE AFFERENT NERVE FIBERS TRAVEL IN THE VENTRAL NERVE ROOTS
  48. DRG GANGLIONECTOMY • ABLATION OF THE CELL BODIES OF SENSORY

    SYSTEM OUTSIDE THE FORAMEN • PROCEDURES USED TO TREAT AXIAL PAIN • USED ONLY IF THE LIMB CAN BE FUNCTIONLESS AND ANESTHETIC AFTER THE PROCEDURE
  49. CRANIAL NERVE RHIZOTOMIES • RHIZOTOMIES STILL USEFUL FOR THE TREATMENT

    OF CRANIAL NERVE NEURALGIAS TRIGEMINAL GLOSSOPHARYNGEAL • RF LESIONING, GLYCEROL, BALLOON COMPRESSION • STERIOTACTIC RADIOSURGERY FOR TREATMENT OF TRIGEMINAL NEURALGIA IS ALSO POSSIBLE, BUT PAIN RELIEF CAN TAKE TWO WEEKS TO MATURE
  50. C2 GANGLIONECTOMY • OCCIPITAL NEURALGIA • PAIN RELIEF SIMILAR TO

    THAT ACHIEVED WITH OCCIPITAL NERVE STIMULATION
  51. DREZ LESIONING • 1972, FIRST DONE W/CRYO PROBE, NOW RFTC

    • INDICATION: -BRACHIAL PLEXUS INJURY/MALIGNANCY -TRIGEMINAL CEPHALIC NUCLEUS • TARGET IS LISSAUERS TRACT, INFEROLATERAL ASPECT, WHERE THE DORSAL SENSORY SYSTEM ENTERS THE DORSAL HORN OF SPINAL TRACT • DISRUPTS INFLOW AND OUTFLOW FROM THE SUPERFICIAL LAYERS OF SPINAL CORD DORSAL HORN • PRESERVES PROPRIOCEPTION
  52. ANTEROLATERAL CORDOTOMY • TARGET -LST LAT SPINOTHALAMIC TRACT, ASCENDING FIBERS

    • WHERE –SURG ACCESS UPPER POSTERIOR SPINE • WHY – TREAT PAIN OF MALIGNANCY, CUTS THE CENTRAL PROCESSES ON NOCICEPTORS AFTER THEY CROSS IN ANTERIOR COMMISSURE, THEN ASCEND, LANCINATING PAIN THERAPY • RESULTS: CONTRALATERAL DEFECT IN PAIN AND TEMPERATURE 2-5 LEVELS BELOW THE LESION • CONCERNS/COMPLICATIONS: THERE IS A HIGHER RISK OF PULMONARY COMPLICATIONS ON THE TREATED SIDE
  53. CINGULOTOMY • WHY- TARGET “AFFECTIVE” COMPONENTS OF PAIN, ESSENTIALLY A

    LOBOTOMY PROCEDURE THAT WAS PERFECTED BY FREEMAN AND WATTS • WHERE-RF LESIONS OF BILATERAL ANTERIOR CINGULATE GYRUS • INDICATED FOR INTRACTABLE PAIN OF MALIGNANT ORIGIN • ALL OTHER TREATMENT FAILED “PSYCOSURGERY”
  54. HYPOPHYSECTOMY • PAIN RELIEF MECHANISM UNKNOWN • BENEFIT FOR RELIEF

    OF PAIN FROM TUMORS KNOWN TO RESPOND TO HORMONES