Background: Advanced tumors of the thoracic spine, while rare, may be difficult to treat and lead to complex pain syndromes. Following radiation and surgical options, pharmacologic therapy may be insufficient to manage a patient’s pain. Systemic corticosteroids are commonly used for quality of life and symptom control improvement in a palliative setting. However, limited data exists describing the effects for interventional options including focal particulate steroid injections. Furthermore, should local control of pain with injections be insufficient, neuroaxial procedures such as intrathecal drug delivery or dorsal column stimulation may improve a patient’s pain syndrome.
Objective: We describe 10 cases in which thoracic epidural steroid injections were successfully and safely utilized as adjunct treatment for pain related to tumor, and further describe 2 cases utilizing intervetional neuroaxial procedures including implantation of neuroaxial pain treatment devices.
Study Design: Retrospective case series analysis.
Setting: Anesthesia and critical care department at a major academic cancer center.
Methods: Ten cases were identified in which patients presented with poorly controlled thoracic axial and/or radicular pain secondary to metastatic disease, either treated with radiation, surgery and/or combination with chemotherapy. We discuss the diagnosis, location of disease, presenting symptoms, prior treatments, and Practitioner’s choice of intervention.
Results: There were no complications during the procedure or at subsequent follow up (Table 1). All cases resulted in some level of improvement in pain. Three patients had 100% improvement in pain on a NRS pain scale (between 1 and 8 months) with thoracic epidural injections. Six patients reported partial pain relief (greater than 1 point reduction on NRS or subjective functional improvement) with either paravertebral or thoracic epidural injection, however the duration of effect was less than one month. Two patients were found to have short term (less than one month) relief from repeated thoracic epidurals. One patient received spinal cord stimulator (Figure 1) with 88% pain relief at 1month followup, and 33% reduction in opiate use. The other patient ultimately received intrathecal pump with bupivacaine and morphine, with a VAS scale reduction from 8 to 2, and reduction of opioid usage by 80%.
Conclusion: We propose a treatment paradigm to manage oncologic patients with thoracic spinal tumor related pain. Thoracic epidurals and paravertebral blocks may be a safe and efficacious treatment option in the oncologic population with thoracic spinal tumor related pain. The use of advanced neuroaxial procedures such as intrathecal drug delivery or dorsal column stimulation may be a secondary option for optimal pain control.
Figure 1. Spinal Cord Stimulator
Table 1.