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Interventional techniques for managing complex cancer‐related pain

Effective management of pain can be achieved in approximately 90% of patients using pharmacological analgesia such as opioids, non‐opioids and adjuvants (Jain [111]). However, for some patients, despite thorough assessment and treatment, it is difficult to attain and maintain adequate pain control and these patients may benefit from interventional techniques (EONS [65]).
Examples of complex pain where interventional techniques may be considered include (Bennett [14], Peat and Hester [170]):
  • nerve plexus invasion (brachial plexopathy or lumbosacral plexopathy)
  • visceral upper abdominal pain (liver, pancreas or stomach cancers)
  • fractures (rib, pelvic, spinal or limb fractures)
  • chest wall pain (infiltration of chest wall and mesothelioma)
  • rectal pain (tumour or persistent following surgery)
  • perioperative management of patients dependent on high‐dose opioids
  • opioid toxicity preventing titration of analgesia.
Effective control can be achieved by a variety of different types of blocks which can reduce intractable cancer pain caused by tumour invasion of soft tissues, nerves or organs. The interventions aim to interrupt the neural pathways of pain transmission. They can be given as:
  • single nerve blocks and injections (such as trigger point and joint injections)
  • regional peripheral and plexus blocks that target individual nerves, plexuses or ganglia (such as intercostal blocks, lumbar plexus blocks)
  • neuraxial (spinal) blocks (such as epidural and intrathecal).
These interventions can be useful but careful consideration and assessment must take place to ensure that any potential side‐effects are discussed with the patient (interventional techniques may severely limit the patient's activities) and that future planning is addressed with the patient and family as some interventions may limit discharge options for the patient who is dying.
Simpson ([205]) describes the following general principles to follow when considering a nerve block:
  • Pain must be carefully assessed and investigated.
  • Careful explanation and informed consent.
  • Patients and carers must be given time to consider interventions.
  • Those involved in the patient's care must understand the procedure, what it can achieve, aftercare, and beneficial and adverse effects.
  • Nerve blocks must not cause functional defects.
  • Neuro‐destructive procedures must be selective of sensory or autonomic nerves and leave motor paths and sphincters intact.
  • Nerve blocks should not be regarded as a treatment in isolation but must form part of a strategy for analgesia.
  • Nerve blocks must not be left as a last resort when the patient may be too ill to tolerate the technique or to come to a hospital for complex procedures.
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