Term 2 Week 8 (w/c 05/03/12)
This week’s case was submitted by one of our followers and hopefully offers something a little bit different. It is however stil very relevant to training in anaesthesia. We change out of our scrubs and head off into the pain clinic.
You see a 39 year old lady who has a diagnosis of Renal Cell Carcinoma. The palliative care consultant is on leave and she has been refferred to the pain clinic. She complains of recurrent back ache which is central and she characterises it as a dull ache. She scores the pain at 5/10 severity but this increases to 7/10 severity on movement.
What would be the most appropriate initial management steps for this lady?
You refer the patient for imaging of her spine. CT scan shows a metastatic lesion in the lumbar spine as illustrated by the CT below. The additional image shows other potential locations for spinal metastasis.
You prescribe simple analgaesics (WHO step ladder) to try and treat her nocioceptive pain.
Are there any adjunctive treatments you would consider? What other treatment options are available for her at this point?
So far we have discussed management of this lady’s cancer / nocioceptive pain. Imagine now that she is re-referred to the clinic some weeks later. The GP is concerned that there maybe ‘nerve involvement’.
What signs and symptoms would suggest to you that there was a neuropathic component? How would you approach it’s management?
Some months after your initial diagnosis of nerve root involvement and neuropathic pain, the lady returns. She now has profund weakness in the leg suggesting that the nerve has been fully infiltrated by the tumour ;
What options are there now to help alleviate this Lady’s symptoms? Does her life expectation have any bearing on your choices?
This weeks case was a complex one involving an area that many of us are no longer familiar with. Training in both acute and chronic pain management are still core topics on the Anaesthesia syllabus.
Initially we were looking at non-specific back pain which is a common problem in both general practice and pain clinic settings. Specific guidelines exist for the management of non-specific lower back pain.
These guidelines are not applicable in the context of malignancy however. Quite rightly contributors pointed out that in this context we must search for red flag symptoms (neurology, pathological facture, infection, rapid progression of symptoms) and conduct relative investigations (imaging, biochemistry etc) to determine the presence of a specific spinal lesion or alternative cause.
Suggestions for management of her nocioceptive pain included a WHO step ladder approach. Other measures include radiotherapy, bisphosphonates and oral opiates. NSAIDS are effective for nocioceptive pain providing there is no contraindication.
Another suggested modality was the gabapentinoids which have found an increasing role in the management of non-neuropathic pain. Metareview
Following re-presentation with disease progression the following were universally agreed
- Optimum symptom management may require palliative care input
- Continuation of medical therapy including the use of steroid and gabapentinoids
- Oral ketamine
- The use of epidural block or intrathecal opiate (with port access)
- Neurolytic blocks
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