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GUIDELINES FOR THE USE OF INTERVENTIONAL TECHNIQUES IN

24.1 GENERAL PRINCIPLES  Up to 90% of pain is successfully managed according to the WHO ladder. 1

 However 10% of cancer patients with pain do not achieve adequate analgesia e.g. due to incomplete response to or intolerable side effects. 1

 Up to 90% of non responding patients may benefit from advanced techniques. 1

 Careful patient selection is important for the success of advanced pain management techniques. 2, 3

 Joint assessment of patients by pain and palliative care specialists is beneficial for patients and healthcare professionals. It furthers mutual understanding, increases the number of appropriate referrals and improves patient care. 4, 5, 6

 Commonly used advanced pain management techniques are described in Table 24.1.

24.2 GUIDELINES  The Merseyside and Cheshire Cancer Network should have a named lead pain clinician. 7 [Level 4]

 Specialist palliative care MDTs should have local access to a named anaesthetist with expertise in blocking. Some patients may require referral to a regional centre for specialised intervention. 7 [Level 4]

 Patients with difficult pain considered for advanced pain management techniques should be reviewed jointly between pain and palliative care specialists. 4 [Level 4]

 Patients with difficult pain should be assessed for an intervention before poor performance status or significant drug toxicities make them ineligible. 8 [Level 3]

 Interventional pain techniques in patients with cancer should be considered if:

− Pain is not responding to standard treatments.

− The patient is fit enough for a procedure.

− The patient is able to give informed consent. 8 [Level 3]

 Careful selection of the type of procedure is important as patients may be only fit enough to undergo one procedure. The procedure with the greatest chance of success should be selected. 5 [Level 4]  If there is refractory bilateral pain, consider an epidural or intrathecal catheter. 9 [Level 3]

 Patients with refractory pain and a prognosis of at least three months may be suitable for an device. 10 [Level 1]

 Patients with unilateral pain below the shoulder and a prognosis of 3-12 months should be considered for referral for percutaneous . 11 [Level 4]

24.3 STANDARDS 7 1. The Merseyside and Cheshire Cancer Network should have a named lead pain clinician. [Grade D]

2. Specialist palliative care MDTs should have local access to a named anaesthetist with expertise in performing nerve blocks. 7 [Grade D]

3. All patients considered for interventions should have joint assessments by palliative care and pain specialists. 4, 5, 6 [Grade D]

4. All specialist palliative care services should have local guidelines available for patients who undergo interventional pain management procedures. 8 [Grade D]

Table 24.1 Advanced interventional pain management techniques Indication Procedure Comments 1. Neuraxial Infusions Pain at any level but mainly for pain in lower half of the Insertion of catheters into epidural or High concentration of receptors in and body. intrathecal space. therefore local application of opioids with fewer systemic side Use strong opioids and local anaesthetic. effects. Smaller dose of opioids required to achieve analgesia than with systemic opioids. 1.1 Epidural catheters 3, 9 Can remain in situ for months, but if prognosis likely to Catheter usually tunnelled into skin to decrease Centres involved in patients with epidural catheters should be more than three months consider referral risk of infection and disconnection. develop local guidelines for management. These guidelines for implantable intrathecal pump device. should address types of medication infused, doses of medication, safe administration of medication, monitoring of epidural catheters in situ and management of complications such as infection or disconnection. Can be cared for in the community, but will require care protocols to be agreed locally. 1.2 Intrathecal catheters 12 More reliable analgesia in the long-term compared to an Volume of infusion and dosage of opioid Smaller dose-toxicity range than with epidural catheters. epidural catheter (more defined space for drug required smaller than for epidural catheters. Will require care protocols to be agreed locally. distribution, no risk of catheter overgrowth). Needs to be placed in theatre. 1.3 Implantable drug For patients with life expectancy of more than three Requires operation to implant pump. Requires locally agreed protocols of care when patients are in delivery systems (IDDS) 10 months. Reservoir filled with analgesia. the community. 2. Peripheral Nerve Blocks 2 Pain in territory of one or more peripheral . Involves infusion/injection of local anaesthetic Includes femoral nerve block / paravertebral block / brachial and . plexus block / suprascapular block. Rarely sole or principal treatment 3. Autonomic blocks Coeliac Block inhibits autonomic supply to upper gastrointestinal Can be performed intraoperatively or under Patient needs to have good performance status. plexus bloc 13 tract. For pain from pancreatic and upper abdominal radiological guidance at specialist centres using Should be done early in disease course when anatomy not malignancies. phenol. too distorted. 4. Saddle block 14 Indicated for pain in perineal area. Injection of intrathecal phenol. Bladder and bowel function can be affected. 5. Epidural phenol 15 Indicated for severe pain not controlled by epidural Injection of 5ml-10ml 6-10% phenol via analgesia. epidural catheter. The epidural infusion is continued following injection of phenol until the full effect is achieved. 6. Percutaneous cordotomy11 For unilateral cancer-related pain e.g. caused by Procedure carried out under local anaesthetic. 80% chance of significant reduction in pain. mesothelioma. Patient needs to be able to lie flat for 45 Life expectancy should be 3-12 months. Suitable for pain below C4 dermatome (below shoulder). minutes. Side effects are usually temporary and include: occipital , mirror pain (pain on side opposite to initial pain), ipsilateral weakness, urinary incontinence or retention. 7. Open cordotomy 16 For unilateral cancer pain for patients who cannot tolerate Performed neurosurgically under general As for percutaneous cordotomy. percutaneous cordotomy. anaesthetic.

For pain below T6/7 dermatome.

24.4 REFERENCES

1. Schug SA, Zech D, Dorr U. Cancer pain management according to the WHO analgesic guidelines. J Pain Symptom Manage 1990; 5: 27-32.

2. Chambers WA. Nerve blocks in palliative care. Br J Anaesthesia 2008; 101(1): 95-100.

3. Day R. The use of epidural and intrathecal analgesia in palliative care. Int J Palliat Nurs 2001; 7(8): 369-374.

4. Kay S, Husbands E, Antrobus JH, Munday D. Provision for advanced pain management techniques in adult palliative care: a national survey of anaesthetic pain specialists. Palliat Med 2007; 21: 279-284.

5. Twomey F, Corcoran GD, Nash TP. Collaboration in difficult pain control in palliative medicine-it’s good to talk. J Pain Symptom Manage 2006; 31(6): 483-484.

6. Linklater GK. Leng MEF, Tiernan EJJ, Lee MA. Pain management services in palliative care: a national survey. Palliat Med 2002; 16: 435-439.

7. National Institute for Health and Clinical Excellence. NICE Guidance: Specialist Palliative Care Services. Improving Supportive and Palliative Care for Adults with Cancer. 2005. p.128 Available from http://www.nice.org.uk [Last accessed 25 June 2009]

8. Scottish Intercollegiate Guidelines Network. Guideline 44, section 12: International Techniques for the treatment of pain from cancer 2000; Cited 2008, Sept 25. Available from http://www.dh.gov.uk [Last accessed 25 June 2009]

9. Burton AW, Rajagopal A, Shah HN, Mendoza T, Cleeland C, Hassenbusch SJ et al. Epidural and intrathecal analgesia is effective in treating refractory cancer pain. Pain Med 2004; 5(3): 239-247.

10. Smith TJ, Coyne PJ, Staats PS, Deer T, Stearns LJ, Rauck RL et al. An implantable drug delivery system (IDDS) for refractory cancer pain provides sustained pain control, less drug- related toxicity, and possibly better survival compared with comprehensive medical management (CMM). Ann Oncol 2005; 16: 825-833.

11. Jackson MB, Pounder D, Price C, Matthews AW, Neville E. Percutaneous cervical cordotomy for the control of pain in patients with pleural mesothelioma. Thorax 1999; 54(3): 238-241.

12. Baker L, Lee M, Regnard C. Evolving spinal analgesia practice in palliative care. Palliat Med 2004; 18: 507-515.

13. Yan BM, Myers RP. Neurolytic celiac plexus block for pain control in unresectable . Am J Gastroenterol 2007; 102(2): 430-438.

14. Slatkin N, Rhiner M. Phenol saddle blocks for intractable pain at the end of life: Report of four cases and literature review. Am J Hosp Palliat Care 2003; 20(1): 62-66.

15. Salmon JB, Finch PM, Lovegrove FT, Warwick A. Mapping the spread of epidural phenol in cancer pain patients by radionuclide admixture and epidural scintigraphy. Clin J Pain 1992; 8: 18-22.

16. Jones B, Finlay I, Fay A, Simpson B. Is there still a role for open cordotomy in cancer pain management? J Pain Symptom Manage 2003; 25(2): 179-184.

24.5 CONTRIBUTORS

Lead Contributors External Reviewers

Dr J Bellieu Dr M Sharma Specialist Registrar in Palliative Medicine Consultant in Pain Management Marie Curie Hospice The Walton Centre for Neurology and Liverpool Neurosurgery NHS Trust Liverpool

Dr E McKenna Dr A Jones Specialist Registrar in Palliative Medicine Consultant Anaesthetist Willowbrook Hospice Royal Liverpool and Broadgreen University Prescot Teaching Hospitals NHS Trust

and Dr H Hugel Marie Curie Hospice Consultant in Palliative Medicine Liverpool Aintree University Hospitals NHS Foundation Trust Liverpool

Dr A Goebel Consultant Anaesthetist The Walton Centre for Neurology and Neurosurgery NHS Trust Liverpool