Lumbar Mets pain

[specepic]

Pt with advanced metastatic prostate cancer. I saw him several years ago and we did RFA's with mixed results. His primary sent him back to me recently seeing if there is anything else we could offer

Patient is already taking Percocet with primary care which was recently switched from hydrocodone. Percocet is working much better. No tolerance issues yet but it is early.

Looking at his recent CT and MRIs of the lumbar spine he has significant metastatic involvement in the lumbar spine. No pathologic fractures yet although there is a lot of enhancement on his STIR sequencing best seen on the sagittals in the location of these metastatic lesions

We are going to do medial branch blocks to reassess for candidacy for RFA but I am not convinced this is what he primarily needs

Questions for the group:

1) I do not treat a lot of cancer pain, in particular metastatic pain. Any other certain medications or classes of medications you find more helpful than others?

2) any other procedural thoughts for this gentleman? His central canal is wide open. There is some scattered neuroforaminal narrowing but nothing severe and he has no radicular pain whatsoever. This is all axial pain enhanced with activity/movement.

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[callmeanesthesia]

If you have somewhere to send him for vertebral RFA and augmentation, that might help. Rad onc if he’s a candidate. ITP, also if you have somewhere to refer him.

 

[RoloTomassi]

Yes tumor ablation, Optablate/Osteocool/STAR. IR does this in my area

 

[Ducttape]

NSAID - overlooked class in cancer pain as cancer docs rush to opioids

duloxetine

bisphosphonates.



kypho as noted above.


no role for ITP in my opinion on this patient, particularly given dose of meds currently involved and the fact he seems to be tolerating opioids.

i wonder why $ome pain doc$ want to implant IT pump$ $o $oon...

 

[Agast]

Methadone is the best opioid for metastatic bone pain IMHO

 

[Laryngospasm]

Osteocool/Kypho

 

[Espn123]

IT pump after tumor ablation if needed

 

[GlowInTheDark]

I’m in a similar situation but more advanced. Patient is wheel chair bound at this point.

Anyone doing intrathecal neurolysis anymore?

 

[Ducttape]

not in the past 6 or so years.

prob should be academic center work.