Cancer pain management: Interventional therapies
- 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
- David J Copenhaver, MD
David J Copenhaver, MD
- Director of Cancer Pain Management and Supportive Care, Anesthesiology and Pain Medicine Department
- University of California at Davis
- Section Editors
- Janet Abrahm, MD
Janet Abrahm, MD
- Section Editor — Pain: Assessment and Management
- Professor of Medicine
- Harvard Medical School
- Scott Fishman, MD
Scott Fishman, MD
- Section Editor — Acute and Chronic Pain
- Professor of Anesthesiology and Pain Medicine
- University of California, Davis School of Medicine
- 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
A substantial number of patients with cancer pain do not obtain satisfactory relief with conventional first-line approaches, including treatment of underlying causes, if possible, opioid-based pharmacotherapy, and noninvasive second-line therapies. For some of these patients, the so called “interventional” pain management strategies may offer safe and effective pain relief. The term “interventional” usually is applied to a group of invasive analgesic therapies, including injection-based treatments, catheter-based infusion therapies, implanted devices, and some surgical approaches.
In the present era, most interventional strategies are nondestructive and are performed using needles (table 1). Some are neurolytic, however, and some involve sophisticated technology, such as implanted neurostimulation and neuraxial drug infusion devices. The evidence base for all of these approaches is limited, particularly in the population with cancer pain, and there are very few controlled trials. Nevertheless, experience in the management of acute and chronic pain suggests that a carefully selected subset of patients with cancer pain may benefit from these procedures.
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. All clinicians involved in the management of cancer pain should have an appreciation for the indications, risks, and benefits associated with the various interventional approaches. If pharmacotherapy is unsuccessful or the benefits versus risks of an intervention outweigh those of other options including pharmacotherapy, an interventional procedure may be a viable alternative, and the patient should have access to a specialist who can confirm the appropriateness of interventional treatments and safely implement them as needed.
This topic will discuss interventional therapies for cancer pain. General principles of cancer pain assessment and management, the use of pharmacologic therapies for cancer pain, and psychological, rehabilitative, and integrative therapies are discussed separately. (See "Assessment of cancer pain" and "Overview of cancer pain syndromes" and "Cancer pain management with opioids: Optimizing analgesia" and "Cancer pain management: Adjuvant analgesics (coanalgesics)" and "Cancer pain management: Use of acetaminophen and nonsteroidal antiinflammatory drugs" and "Psychological, rehabilitative, and integrative therapies for cancer pain".)
Soft tissue and joint injections — Injections into soft tissue and joints are often performed in the management of common chronic non-cancer pain syndromes, such as myofascial pain or painful arthropathy. A patient with cancer who develops one of these painful conditions should be considered a candidate for the appropriate intervention, as long as they do not have a contraindication (eg, coagulopathy or leukopenia, pneumothorax), and the decision to proceed or not should be based on a careful assessment of benefits, risks, alternative treatments, and the overall goals of care. (See "Overview of cancer pain syndromes".)
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- INJECTION THERAPIES
- Soft tissue and joint injections
- Spine-related injections for back or neck pain
- Vertebral compression fracture
- - Vertebral augmentation procedures
- - Alternative therapies
- NEURAL BLOCKADE
- Diagnostic nerve block
- Prognostic nerve block
- Therapeutic block
- - Nonneurolytic blocks
- Sympathetic blocks
- Somatic nerve blocks
- - Neurolytic blocks
- Dorsal punctate midline myelotomy
- ADVANCED NEURAXIAL TECHNIQUES
- Spinal cord stimulation
- Neuraxial infusion
- - Intrathecal versus epidural catheter placement
- - Choice of agent
- - Outcomes
- - Complications
- - Intraventricular opioid delivery
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS