Neuraxial Neuraxial Techniques in Techniques in Palliative CarePalliative Care

Karen H SimpsonKaren H Simpson

Consultant in Pain Consultant in Pain MedicineMedicine

Leeds Teaching Hospital Leeds Teaching Hospital TrustTrust

Cancer Pain Management

• Pain management part of a broader therapeutic endeavor • Palliative care is the active, total care of the patient with active, progressive, life‑threatening disease

• Both involve a variety of health care professionals

• Continuing management includes

control of pain and symptomsmaintenance of function

psychosocial and spiritual support

comprehensive end of life care

Cancer pain

• Pain common in cancer

• WHO estimate 4 million people worldwide have cancer pain

• Many patients have more than one site of pain

• >50% of patients in hospitals and hospices have pain

• Advanced cancer more likely to be painful

• Breakthrough and incident pain common

• Adequate pain relief achieved by 75% patients using simple techniques e.g. WHO analgesic ladder

Why Pain Control Can Be a Problem

• Survey of physicians actively involved in cancer care 1/3 wait until the prognosis <6 months before giving maximal analgesia (Von Roenn et al. 1993) • Study of 81 doctors only 5% could convert a parenteral dose of morphine to an equivalent of MST and were unfamiliar palliative radiation (Mortimer and Bartlett 1997)  • Study of 318 nurses’ knowledge about pain assessment and management showed lack of understanding about opioids (Hamilton and Edgar 1992)

Basic Pain Management Principles Meticulous assessment of pain and appropriate investigation

Decrease pain & improve quality of lifeDo no further harm

Allow patient and carers choices Use resources as effectively as possible

Basic Pain Management in Cancer

• Modify the disease process if the cause cannot be removed

• Remove exacerbating factors

• Explore meaning of pain for the patient and carers

• Modify social/physical environment

• Treat associated mood disorders

• Regular oral analgesics and co-analgesics

• Nerve block or neuromodulation

• Neurosurgery

Nerve Blockade or Neuromodulation • May help about 10% patients

• If pain persists despite optimal oral analgesia • If effective oral analgesia gives intolerable side effects  • Rapid, effective analgesia is required with limited time available for titration of oral analgesics or co-analgesics • Conditions that readily respond to nerve blocks e.g. joint pain, ischaemic pain

Neuraxial blocks • Local anaesthetic/steroid • Somatic and/or sympathetic blocks • Neurolytic blocks• Spinal drug delivery• Neuro-destructive surgical procedures  Ideally combined approach aimed at several different levels within nervous system provides optimum relief with least adverse effects

Simple Nerve Blocks

ComplexNerve Blocks

AutonomicNerveBlocks

Spinal Drug Delivery • Much smaller drug doses needed

• 1-2% patients with cancer pain

• If simpler and more economic methods fail • Indications failure of systemic treatment intolerable drug side effects

Choice of Patient for Spinal Drugs  Contraindications • Local or systemic infection• Head pain• Non-correctable co-aggulopathy • Patient refusal • Lack of resources• Lack of aftercare and community support  Indications• Segmental pain or spasticity • Positive response to test doses

Investigations

• Cord compression

• Good CSF flow

• Infection screen

• Coagulation

• Life expectancy

• Aftercare

Epidural or Intrathecal Drug Delivery

Intrathecal or Epidural Delivery?• Intrathecal drugs need not pass dura

• IT used in lower doses and volumes

(10-20% epidural dose)

• Large volumes epidurally - spinal cord compression

• Change in epidural fat influences drug delivery

• Epidural catheters blocked by fibrosis

• Infection not more likely with intrathecal

External or Internal Systems

Implantable or External System?•Pain problem•Patient’s condition and expected survival•Experience of the team•Support available

Spinal Drugs OpioidsClonidineKetamineOctreotideMidazolamNeostigmineBaclofen Local anaestheticsZiconotide

Conclusions

• Patients should be referred early for consideration of interventions

• The pain must be carefully assessed and investigated • Careful explanation to ensure the full understanding and consent of the patient is essential

• Patients and carers must be given adequate time to think about interventions and ask questions

Conclusions

• Those involved in patient’s care after block must understand the nature of the procedure

what block can and cannot achievehow to look after the patient what the likely effects and side effects

• Nerve blocks must not cause functional defects

• Neuro-destructive procedures must be selective of sensory or autonomic nerves leaving motor paths and sphincters intact • Neuraxial techniques should not be a treatment given in isolation but must form part of an overall strategy for analgesia

Conclusions

• Nerve blocks often forgotten or left as a last resort

• Patient may become too ill to tolerate technique

or come to hospital for more complex procedures

• Need careful selection of patients and timing of interventions

• Early discussion between colleagues essential

Conclusions

• Anaesthetists should make themselves easily available for consultation about patients with difficult cancer pain

• Pain services should offer prompt treatment

• The choice of techniques offered depends on the skills and resources of the local pain management service