Neuraxial
Techniques in
Palliative Care
Karen H Simpson
Consultant in Pain
Medicine
Leeds Teaching Hospital
Trust
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 symptoms
maintenance 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 life
Do 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
Complex
Nerve
Blocks
Autonomic
Nerve
Blocks
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
Opioids
Clonidine
Ketamine
Octreotide
Midazolam
Neostigmine
Baclofen
Local anaesthetics
Ziconotide
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 achieve
how 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