SPINAL CORD STIMULATION IN NEUROPATHIC CANCER PAIN

PATIENTS – PRESENT LITERATURE SUPPORT

Dr Manish RajMD,DA,FMISS(US),FISP

Interventional spine & pain consultantMax smart superspeciality hospital,Delhi

Jaypee hospital,Noida

SPINAL CORD STIMULATION IN TREATMENT OF CANCER RELATED PAIN :

“ BACK TO ORIGINS”

Artemus Flagg II & Kai McGreevy & Kayode WilliamsCurr Pain Headache Rep ;6-2012-0276-9

CANCER PAIN MANAGEMENT ACCORDING TO WHO ANALGESIC GUIDELINES

MD Stephan A. Schug , MD Detlev Zech, Ulrike DörrJournal of Pain and Symptom Management

Volume 5, Issue 1, February 1990, Pages 27-32

11% of the patients required other methods of pain management.

Do we need SCS ?

VALIDATION OF WORLD HEALTH ORGANIZATION GUIDELINES FOR CANCER PAIN RELIEF: A 10-YEAR PROSPECTIVE STUDY

Zech DF, Grond S, Volume 63, Issue 1, October 1995, Pages 65-76

Marked efficacy and low rate of complications associated with oral and parenteral analgesic therapy as the mainstay of pain treatment in the palliative care of patients with advanced cancer

ASSESSMENT AND TREATMENT OF NEUROPATHIC CANCER PAIN : WHO GUIDELINES

Neuropathic cancer pain is not intractable and can

be relieved in the majority of patients by treatment following the WHO guidelines.

Stefan Grond, Lukas Radbruch,Volume 79, Issue 1, 1 January 1999, Pages 15–20

•SCS may be a therapeutic alternative for patients who have exhausted all available treatments or who have an increased risk for or prefer not to have more invasive interventions.

•No risks for potential neurologic dysfunctions which can complicate ablative procedures.

•Satisfactory symptom relief, an increase in QOL and discontinuation of pain medications.

SCS RELIEVES NEUROPATHIC PAIN IN A PATIENT WITH RADIATION-INDUCED TRANSVERSE MYELITIS.

Spinal cord stimulation may offer a therapeutic option for patients with neuropathic pain resulting from transverse myelitis and should be considered when other treatments fail.

Hamid B, Haider N. Pain Pract. 2007 Dec;7(4):345-7

CATA ET AL

Case report of two patients at MD Anderson:

Pt A: 61M w/ R elbow melanoma, tx’d w/ IL-2 Developed neuropathic pain refractory

to opioids, gabapentin Dual lead SCS placement at L1

Pt B: 46M w/ Ewing’s Sarcoma of R infraclavicular region, tx’d w/ Vincristine Developed neuropathic pain refractory

to opioids, gabapentin, amitriptyline Dual lead SCS placement at T11

Spinal Cord Stimulation Relieves Chemotherapy-Induced Pain: A Clinical Case Report. Journal of Pain and Symptom Management. 2004. 27(1): 72-78.

SCS RELIEVES CHEMOTHERAPY-INDUCED PAIN: A CLINICAL CASE REPORT

SCS offers a therapeutic option for patients with chemotherapy-induced peripheral neuropathy who have poor pain relief with standard medical treatment.

Juan P Cata, MD,Joseph V Cordella, BS

SCS : CURRENT PERSPECTIVES

•SCS is an effective treatment option for neuropathic pain.

• Technical advancement of SCS has led to improvement in stimulation patterns adapted to the patients’ needs.

• SCS for neuropathic pain is still underused.

• Careful preoperative diagnosis and proper patient selection is most important for the success of the methods

• Level 2 evidence from 2 studies of high quality supports the effectiveness of SCS to reduce pain in some neuropathic pain conditions.•There is supportive evidence from secondary outcomes from level 3a evidence that treatment with SCS improves functional status and QOL.• The need for SCS services is estimated at 300 to 660 people per year. Current services provide SCS to 30 to50 people per year

Ontario Health Technology Assessment Series 2005; Vol. 5, No. 4

At 24 months of SCS treatment, selected failed back surgery syndrome patients reported sustained pain relief, clinically important improvements in functional capacity and health-related quality of life, and satisfaction with treatment

Neurosurgery. 2008 Oct;63(4):762-70;

TREATMENT OF CANCER PAIN

The advances of recent decades suggest a future that includes increased evidence-based targeting of specific analgesic interventions within an individualised plan of care that is

appropriate throughout the course of illness.

Russell K Portenoy, Volume 377, Issue 9784, 25 June–1 July 2011, Pages 2236–2247

Pain

Step 1±Nonopioid± Adjuvant

Pain persisting or increasing

Step 2Opioid for mild to moderate pain

±Nonopioid ± Adjuvant

Pain persisting or increasing

Pain persisting or increasing

Step 3Opioid for moderate to severe pain

±Nonopioid ±Adjuvant

Invasive treatments Opioid Delivery

Quality of Life

MODIFIED WHO ANALGESIC LADDER

Proposed 4th Step

The WHOLadder

MODIFIED WHO ANALGESIC LADDER

TIMING FOR SCS

SCS & FUNCTIONAL MAGNETIC RESONANCE IMAGING :

MODULATION OF CORTICAL CONNECTIVITY WITH THERAPEUTIC

SCS

SCS reduces the affective component of pain resulting in

optimal pain relief. Study shows a decreased connectivity between somatosensory and limbic areas

associated with optimal pain relief due to SCS

Deogaonkar M1, Sharma M1.Neuromodulation. 2016 Feb;19(2):142-53

SCS modulates cerebral function: an fMRI study.

Neuroradiology. 2012 Dec;54(12):1399-407

key role of the medial thalamus as a mediator and the involvement of a corticocerebellar network implicating the modulation and regulation of averse and negative affect related to pain. The observation of a deactivation of the ipsilateral antero-medial thalamus might be used as a region of interest for further response SCS studies.

CHANGES AT CORD & NEURONAL LEVEL

P Honore,S.D Rogers .Neuroscience;Volume 98, Issue 3, June 2000, Pages 585–598

Murine models of inflammatory, neuropathic and cancer pain each generates a unique set of neurochemical changes in the spinal cord and sensory neurons

FUTURE IN NEUROMODULATION

Burst stimulation High frequency stimulation Peripheral nerve field stimulation DRG stimulation

A SYSTEMATIC EVALUATION OF BURST SPINAL

CORD STIMULATION FOR CHRONIC BACK AND LIMB PAIN

New approach that possibly causes more pain reduction for short-term duration than tonic SCS without eliciting paresthesia.

This is an AAN recommendation level U. Further research is needed with a larger sample size and a standardized study design.

Hou S, Kemp K, Grabois M, Neuromodulation. 2016 Jun;19(4):398-405

ONE-YEAR OUTCOMES OF SPINAL CORD STIMULATION OF THE DORSAL ROOT GANGLION IN THE TREATMENT

OF CHRONIC NEUROPATHIC PAIN.• Comparable to traditional SCS in terms of

pain relief and associated benefits in mood and quality of life.

• Ability to achieve precise pain-paresthesia concordance, including in regions that are typically difficult to target with SCS

• Consistently maintain that coverage over time

Liem L, Russo M, Huygen FJ,Neuromodulation. 2015 Jan;18(1):41-8

HIGH FREQUENCY SCS

First randomized double-blind study on SCS. HFSCS was equivalent to sham for the primary outcome (improvement of PGIC) as well as for both the secondary outcomes (VAS and EQ-5D index).

Christophe Perruchoud MD,Neuromodulation, Volume 16, Issue 4,July/August 2013 ,Pages 363–369

SPINAL CORD STIMULATION IN NEUROPATHIC CANCER PAIN

The incidence of neuropathic component in cancer pain is estimated to be around 15% to 40%.

Spinal cord stimulators have been reported as a safe and effective management of neuropathic cancer pain.

Cata et al showed benefit in chemotherapy –induced pain in two patients.

Hamid and Haider showed improved pain relief in radiatherapy-induced transverse myelitis.

Yakovlev et al presented two case reports of cancer patients, with uncontrolled neuropathic pain using conventional medications, who benefitted from the implantation of spinal cord stimulator.

In sum multiple case series, no RCT’s.

THANK YOU