Cancer pain management: Interventional therapies
- Ronald Kaplan, MD
Ronald Kaplan, MD
- Attending Physician
- Beth Israel Medical Center
- Professor of Clinical Anesthesiology
- Albert Einstein College of Medicine
- Russell K Portenoy, MD
Russell K Portenoy, MD
- Chief Medical Officer
- MJHS Hospice and Palliative Care
- Professor of Neurology and Family and Social Medicine
- Albert Einstein College of Medicine
- Section Editor
- Janet Abrahm, MD
Janet Abrahm, MD
- Section Editor — Pain: Assessment and Management
- Professor of Medicine
- Harvard Medical School
- Deputy Editors
- Diane MF Savarese, MD
Diane MF Savarese, MD
- Senior Deputy Editor — UpToDate
- Deputy Editor — Oncology and Palliative Care
- Clinical Instructor of Medicine
- Harvard Medical School
- Marianna Crowley, MD
Marianna Crowley, MD
- Deputy Editor — Anesthesiology
- Assistant Professor of Anesthesiology
- Harvard Medical School
Chronic pain that is severe enough to warrant long-term opioid therapy is experienced by 30 to 50 percent of cancer patients undergoing active antineoplastic therapy and by 75 to 90 percent of those with advanced disease [1,2]. Treatment guidelines for cancer pain emphasize the primary role of systemic opioid therapy [3-5], which can yield adequate relief in 70 to 90 percent of patients . This favorable statistic underscores the need to provide patients with access to opioid-based systemic pharmacotherapy for moderate to severe cancer pain. (See "Cancer pain management: General principles and risk management for patients receiving opioids" and "Cancer pain management with opioids: Optimizing analgesia".)
However, despite optimization of opioid therapy and the use of analgesic adjuvants, a substantial number of patients with cancer pain do not obtain satisfactory relief with first-line analgesic therapy. (See "Cancer pain management: Adjuvant analgesics (coanalgesics)" and "Cancer pain management: Use of acetaminophen and nonsteroidal antiinflammatory drugs".)
When effective pain relief cannot be achieved through pharmacologic means, nonpharmacologic approaches offer an important alternative. The most important of these nonpharmacologic approaches are the so-called “interventional” pain management strategies. Interventional strategies comprise a very diverse group of invasive therapies, most of which are nondestructive and performed using needles (table 1). Interventional therapies include injections, non-neurolytic and neurolytic nerve blocks, and implanted neurostimulation and neuraxial drug infusion techniques. The evidence base for all of these approaches is limited and includes very few controlled trials. Nevertheless, there is acceptance of these approaches in cancer pain management.
With the exception of some simple injections (eg, trigger point injections), interventional therapies for pain management are implemented by professionals who have received specialized training. Ideally, all patients with cancer pain that does not respond promptly to systemic pharmacotherapy should have access to a specialist who can assess the appropriateness of interventional treatments.
This topic review will cover interventional therapies for cancer pain. General principles of cancer pain assessment and management; the use of pharmacologic therapies for cancer pain, including opioids, analgesic adjuvants, acetaminophen and NSAIDs; and psychologic, rehabilitative, and integrative therapies are discussed elsewhere. (See appropriate topic reviews).
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- INJECTION THERAPIES
- Soft tissue and joint injections
- Pathologic vertebral compression fractures
- - Vertebroplasty and kyphoplasty
- Pamidronate as an alternative
- NEURAL BLOCKADE
- Diagnostic nerve block
- Prognostic nerve block
- Therapeutic nerve block
- - Epidural blood patch
- - Epidural steroids for acute herniated disc pain
- Analgesic and anesthetic nerve blocks
- - Non-neurolytic blocks
- Sympathetic blocks
- Somatic nerve blocks
- - Neurolytic blocks
- IMPLANTED NEUROSTIMULATION AND NEURAXIAL INFUSION TECHNIQUES
- Implanted neurostimulation
- Neuraxial infusion
- - Intrathecal versus epidural catheter placement
- - Choice of agent
- - Outcomes
- - Complications
- Intraventricular opioid delivery
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS