Randomized Prospective Trial of Epidural Analgesia after Open Hepatectomy.

OBJECTIVE: To evaluate whether patient-controlled epidural analgesia (PCEA) improves postoperative pain during ambulation following elective open hepatectomy. BACKGROUND: Strategies to alleviate postoperative pain are a critical element of recovery after surgery. However, the optimal postoperative pain management strategy following open hepatectomy remains unclear. METHODS: We conducted a prospective, nonblinded, randomized comparison of PCEA (intervention) versus intravenous patient-controlled analgesia (IV PCA; control) for postoperative pain following elective open hepatectomy. The primary end point was pain during ambulation on postoperative day (POD) 2. The study was powered to detect a clinically significant 2-point difference on the pain numeric rating scale (NRS). Secondary end points included pain at rest, morbidity, time to return of bowel function, and length of stay. RESULTS: From 2015 to 2020, 231 patients were randomized (116 patients in the PCEA arm and 115 in the IV PCA arm). The incidence of epidural failure was 3% (n=4/116), with no epidural-related complications. Patients in the PCEA arm had a <2-point difference in NRS pain scores during ambulation on POD 2 vs. IV PCA (median 4.0 vs. 5.0, P <0.001). There was no difference in overall complications between the PCEA and IV PCA arms (33% vs. 40%, P =0.276). Secondary outcomes, including pain scores at rest, were similar between the study arms. CONCLUSIONS: PCEA was safe following open hepatectomy and was associated with a small difference in pain with activity on POD 2 that did not reach our pre-specified definition of clinical significance.

Patient outcomes following implementation of an enhanced recovery after surgery pathway for patients with metastatic spine tumors.

BACKGROUND: Metastatic spine tumor surgery consists of palliative operations performed on frail patients with multiple medical comorbidities. Enhanced recovery after surgery (ERAS) programs involve an evidence-based, multidisciplinary approach to improve perioperative outcomes. This study presents clinical outcomes of a metastatic spine tumor ERAS pathway implemented at a tertiary cancer center. METHODS: The metastatic spine tumor ERAS program launched in April 2019, and data from January 2018 to May 2020 were reviewed. Measured outcomes included the following: hospital length of stay (LOS), time to ambulation, urinary catheter duration, time to resumption of diet, intraoperative fluid intake, estimated blood loss (EBL), and intraoperative and postoperative day 0-5 cumulative opioid use (morphine milligram equivalent [MME]). RESULTS: A total of 390 patients were included in the final analysis: 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program and 213 consecutive pre-ERAS patients. Although the mean case durations were similar in the ERAS and pre-ERAS cohorts (265 vs. 274 min; p = .22), the ERAS cohort had decreased EBL (157 vs. 215 ml; p = .003), decreased postoperative day 0-5 cumulative mean opioid use (178 vs. 396 MME; p < .0001), earlier ambulation (mean, 34 vs. 57 h; p = .0001), earlier discontinuation of urinary catheters (mean, 36 vs. 56 h; p < .001), and shorter LOS (5.4 vs. 7.5 days; p < .0001). CONCLUSIONS: The implementation of a multidisciplinary ERAS program designed for metastatic spine tumor surgery led to improved clinical quality metrics, including shorter hospitalizations and significant reductions in opioid consumption.

An Interventional Pain Algorithm for the Treatment of Postmastectomy Pain Syndrome: A Single-Center Retrospective Review.

OBJECTIVE: Breast cancer is the most common female malignancy worldwide. Breast surgery and adjuvant oncological therapies are often required to increase survival. Treatment-related pain may persist and evolve into postmastectomy pain syndrome (PMPS) in a significant subset of breast cancer survivors. In this retrospective investigation, we will present our experience in applying an interventional algorithmic approach to treat PMPS. DESIGN: A retrospective study. SETTING: An academic cancer hospital. SUBJECTS: Adult females with PMPS diagnosis. METHODS: We reviewed 169 records with the diagnosis of PMPS from 2015 to 2019 within our health system. Pre- and post-injection pain scores, relief duration, and medication usage changes were collected. The decision to perform each procedure was based on the anatomic location of the painful area with the corresponding peripheral sensory innervation. Decision-making flow diagrams were created to present our experience in managing PMPS beyond peripheral nerve blocks. RESULTS: Ultrasound-guided peripheral nerve block results (n=350) were analyzed. The mean baseline pain score was 7, compared with the post-treatment mean score of 3 (95% confidence interval: 3.58 to 3.98, P = 0.0001). Among the responders, the mean pain relief duration was 45 days, with a median of 84 days. Opioid medication consumption was reduced by 11% (t = 0.72, P = 0.47). CONCLUSIONS: Ultrasound-guided nerve blocks of this area could be performed safely and effectively after breast surgeries. We also present our proposed algorithm to provide a stepwise application for selecting the appropriate therapies in the management of more complex PMPS.

The Use of L2 and L3 Lumbar Sympathetic Blockade for Cancer-Related Pain, an Experience and Recommendation in the Oncologic Population.

OBJECTIVE: The sympathetic nervous system has a recognized role in transmission of pain, and the lumbar sympathetic blockade is intended to provide analgesia. We share our experiences of lumbar sympathetic blockade in the treatment of cancer-related pain. METHODS: We performed a retrospective analysis of patients with cancer-related pain in the back, abdomen, pelvis, or legs treated at Memorial Sloan Kettering Cancer Center between 2000 and 2018 undergoing lumbar sympathetic blockade at L2 or L3. Blocks were accomplished by injection of local anesthetic or local anesthetic with steroid under fluoroscopy. We measured numerical rating scale scores, percent relief, and relief time. The primary end point was defined as "effective" or "ineffective" pain relief. Effective pain relief was defined as ≥30% relief for at least one day. RESULTS: We identified 124 data points of lumbar sympathetic blockade at L2 or L3, of which 57 were with complete data and used for analysis. Peri-injection, 42 data points had active disease whereas 15 were in remission. Lumbar sympathetic blockade was 67% effective in the back pain cohort, 82% effective in the abdominopelvic pain cohort, and 75% effective in the leg pain cohort. Seventeen data points went on to neurolysis, two to neuromodulation, and eight to intrathecal pump implantation. CONCLUSIONS: Lumbar sympathetic blockade is effective for back, abdominopelvic, and leg pain related to cancer and its treatments. Future research should be aimed at refining its role within multimodal pain management.

Interventional Pain Management for Sacroiliac Tumors in the Oncologic Population: A Case Series and Paradigm Approach.

Introduction: Tumors invading the sacrum and/or ilium often represent incurable metastatic disease, and treatment is targeted toward palliation of symptoms and control of pain. As systemic opioid therapy is frequently inadequate and limited by side effects, a variety of interventional techniques are available to better optimize analgesia. Using six patients as a paradigm for interventional approaches to pain relief, we present a therapeutic algorithm for treating sacroiliac tumor-related pain in the oncologic population. Methods: We describe the use of ultrasound-guided proximal sacroiliac joint corticosteroid injection, sacroiliac lateral branch radiofrequency ablation, percutaneous sacroplasty, and implantable neuraxial drug delivery devices to treat malignant sacroiliac pain in six patients. Pre- and postprocedure numerical rating scale (NRS) pain scores, duration of pain relief, and postprocedure pain medication requirements were studied for each patient. Results: Each patient had marked improvement in their pain based on an average postprocedure NRS difference of six points. The average duration of pain relief was eight months. In all cases, opioid requirements decreased after the intervention. Discussion: Depending on tumor location, burden of disease, and patient preference, patients suffering from metastatic disease to the sacrum may find benefit from use of ultrasound-guided proximal sacroiliac joint corticosteroid injection, sacroiliac lateral branch radiofrequency ablation, percutaneous sacroplasty, dorsal column stimulator leads, and/or implantable neuraxial drug delivery devices. We provide a paradigm for treatment in this patient population.

The Tri-Institutional Pain Registry-Analysis of Outpatient Pain Management at a Specialized Cancer Center.

Objectives: The Outpatient Pain Clinics at Memorial Sloan Kettering Cancer Center participated in developing a pain registry to gain insight on the referral and management of cancer pain as related to demographic information, cancer history, prescription records, and interventional pain procedures stored in the institutional database. Methods: Five cohorts (subsets of one another) were defined and compared to describe demographics and differences in management and outcomes by age, race, sex, and cancer type. Clinic patients were compared with the entire institution to determine factors associated with better pain relief and reduced side effects. Results: A small percentage were referred to a pain specialist. A total of 1,043 patients completed 3,544 surveys. Compared with the institution, there were higher proportions of patients age 51 to 60 years, nonwhites, and patients with thoracic, abdominal, and head and neck cancers. Medical management controlled pain with three drug categories in 40% of visits. Short-acting opioids were the only category that statistically provided good pain relief with fewer side effects. Pain scores were improved with increasing opioid dose. Management differed by sex, age, and race; women consistently had lower doses of opioids, poorer pain control, more side effects, and were prescribed a greater variety of medications. Conclusions: A limited set of medications was required to manage most patients in the clinic, supporting the continued place of opioids and the World Health Organization analgesic ladder in managing cancer pain. Women may need a more nuanced approach for obtaining the best balance of pain relief and side effects.

Ultrasound-Guided Serratus Plane Block for Treatment of Postmastectomy Pain Syndromes in Breast Cancer Patients: A Case Series.

Postmastectomy pain syndrome is common after surgical treatment for breast cancer and may be challenging to manage. Currently, there are a wide variety of approaches to treat this type of pain, including medications, physical therapy, and interventional procedures. However, because of the complexity of innervation of the breast, the serratus plane block may better target the web of nerves innervating the anterior chest wall including the breast. We present a case series of 8 patients who were successfully treated with serratus plane block for pain after treatment for breast cancer. We feel that this particular application for the serratus plane block deserves further investigation, as it is relatively easy to perform and has good clinical utility for this type of pain.

A retrospective review and treatment paradigm of interventional therapies for patients suffering from intractable thoracic chest wall pain in the oncologic population.

INTRODUCTION: Tumors invading the chest wall and pleura are often incurable, and treatment is targeted toward palliation of symptoms and control of pain. When patients develop tolerance or side effects to systemic opioid therapy, interventional techniques can better optimize a patient's pain. We performed a retrospective review of 146 patients from April 2004 to January 2014 who underwent diagnostic and therapeutic procedures for pain relief. Using four patients as a paradigm for neurolytic approaches to pain relief, we present a therapeutic algorithm for treating patients with intractable thoracic chest wall pain in the oncologic population. MATERIAL AND METHODS: For each patient, we describe the use of intercostal/paravertebral nerve blocks and neurolysis, pulsed radiofrequency ablation (PRFA) of the thoracic nerve roots, or intrathecal pump placement to successfully treat the patient's chest wall pain. Analysis of 146 patient charts is also performed to assess effectiveness of therapy. RESULTS: Seventy-nine percent of patients undergoing an intercostal nerve diagnostic blockade (with local anesthetic and steroid) stated that they had improved pain relief with 22% having prolonged pain relief (average of 21.5 days). Only 32% of successful diagnostic blockade patients elected to proceed to neurolysis, with a 62% success rate. Seven patients elected to proceed to intrathecal drug delivery. DISCUSSION: Intercostal nerve diagnostic blockade with local anesthetic and steroid may lead to prolonged pain relief in this population. Furthermore, depending on tumor location, we have developed a paradigm for the treatment of thoracic chest wall pain in the oncologic population.

Considerations for evaluating the use of intrathecal drug delivery in the oncologic patient.

While the majority of cancer pain patients are successfully managed with conservative medical management, some patients may suffer from intractable pain or intolerable side effects. The implantation of an intrathecal drug delivery system offers many advantages to improve both analgesia and side effect profile. Practitioners may decide to proceed toward implantation after appropriate patient selection, and, when applicable, a suitable trial for the device. Once implantation is completed, multiple medication combinations may be used to optimize the therapeutic benefit of the device. We describe a stepwise paradigm to implement an intrathecal drug delivery program in the cancer pain population.

Paravertebral and erector spinae plane blocks decrease length of stay compared with local infiltration analgesia in autologous breast reconstruction.

BACKGROUND: Autologous breast reconstruction is associated with significant pain impeding early recovery. Our objective was to evaluate the impact of replacing surgeon-administered local infiltration with preoperative paravertebral (PVB) and erector spinae plane (ESP) blocks for latissimus dorsi myocutaneous flap reconstruction. METHODS: Patients who underwent mastectomy with latissimus flap reconstruction from 2018 to 2022 were included in three groups: local infiltration, PVB, and ESP blocks. Block effect on postoperative length of stay (LOS) and the association between block status and pain, opioid consumption, time to first analgesic, and postoperative antiemetic administration were assessed. RESULTS: 122 patients met the inclusion criteria for this retrospective cohort study: no block (n=72), PVB (n=26), and ESP (n=24). On adjusted analysis, those who received a PVB block had a 20-hour shorter postoperative stay (95% CI 11 to 30; p<0.001); those who received ESP had a 24-hour (95% CI 15 to 34; p<0.001) shorter postoperative stay compared with the no block group, respectively. Using either block was associated with a reduction in intraoperative opioids (23 morphine milligram equivalents (MME)), 95% CI 14 to 31, p<0.001; ESP versus no block: 23 MME, 95% CI 14 to 32, p<0.001). CONCLUSIONS: Replacing surgical infiltration with PVB and ESP blocks for autologous breast reconstruction reduces LOS. The comparable reduction in LOS suggests that ESP may be a viable alternative to PVB in patients undergoing latissimus flap breast reconstruction following mastectomy. Further research should investigate whether ESP or PVB have better patient outcomes in complex breast reconstruction.

Intrathecal pain pump infusions for intractable cancer pain: an algorithm for dosing without a neuraxial trial.

BACKGROUND: Patients with pain from advanced cancer often have limited life expectancy. Undergoing an epidural trial for placement of an intrathecal pump in these selected patients can exhaust limited days of life. We sought to analyze historical data at our cancer center to develop an algorithm to predict initial intrathecal pump dosing based on the starting preimplant systemic opioid regimen, thus averting an epidural trial and minimizing hospital stay. METHODS: We used data pre- and postpump from 46 cancer patients receiving systemic opioids undergoing intrathecal pump placement in the last 6 years, all of whom had undergone an epidural trial before pump placement. RESULTS: By analyzing intrathecal opioid dosage on discharge (in IV morphine equivalents) to age, type of pain, cancer type, preimplant opioid dose, and preimplant pain score using multiple regression, we created an algorithm that predicts, for cancer patients, an appropriate initial dose for an intrathecal pump based on the prepump systemic opioid dose, thus avoiding an epidural trial. The predicted value does have a broad 95% prediction interval (-122.7% to 147.6%) pointing to the value of a trial when feasible. CONCLUSIONS: When an epidural trial is not feasible and an intrathecal pump is required in a cancer patient, it is possible to predict an initial dose for the intrathecal pump based on the systemic opioid usage. This minimizes delays in achieving satisfactory analgesia and discharge to home.

Treatment of knee osteoarthritic pain with platelet-rich plasma: a systematic review of clinical studies.

Introduction: Knee osteoarthritis is a degenerative joint disease that is secondary to degradation of articular cartilage, reformation of subchondral bone through degradation and proliferation as well as presence of synovitis. Materials & methods: This systematic review was conducted and reported as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Results: A total of 30 of the 48 comparators showed statistically significant superiority with platelet-rich plasma (PRP) compared with a control, while the other 16 comparators showed no significant difference between PRP and the comparator. Conclusion: We can only recommend PRP for patients with early-stage osteoarthritis (I or II) and who are aged below 65, based on our findings. Based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) recommendations, while studies reviewed were randomized controlled studies, and therefore, high grade, due to variance in imprecision, risk of bias and inconsistency among the 37 studies, it would be reasonable to rate this paper as subjectively moderate.

Patient-Reported Outcomes and Opioid Use by Outpatient Cancer Patients.

The Memorial Sloan Kettering Pain Registry contains patient characteristics, treatments, and outcomes for a prospective cohort of 1,534 chronic pain cancer patients who were seen at outpatient pain service clinics. Average pain intensity (Brief Pain Inventory) was reported as mild by 24.6% of patients, moderate by 41.5%, and severe by 33.9%. The patient's report of average percent pain relief and health state (EuroQOL 5 dimensions) was inversely related to average pain intensity category, whereas measures of pain interference, number of worst pain locations, and physical and psychological distress were directly related to pain intensity category. Eighty-six percent of patients received an opioid at 1 or more clinic encounters. Regression analysis revealed that male sex or being younger (65 years of age or younger) was associated with a greater likelihood of an opioid ordered. Male sex nearly doubled the likelihood of a higher dose being ordered than female sex. Bivariate analysis found that patients receiving opioids reported significantly more pain relief than no-opioid patients. However, patients receiving opioids had higher pain interference scores, lower index of health state, and more physical distress than no-opioid patients Our results identify the need to consider opioid use and dosage when attempting to understand patient-reported outcomes (PROs) and factors affecting pain management. PERSPECTIVE: This report describes the results of the analyses of PROs and patient-related electronic health record data collected under standard of care from cancer patients at outpatient pain management clinics of Anesthesiology and Palliative Care at the Memorial Sloan Kettering Cancer Center. Consideration of sex and age as predictors of opioid use is critical in attempting to understand PROs and their relationship to pain management.

"A Tale of Two Planes": Deep Versus Superficial Serratus Plane Block for Postmastectomy Pain Syndrome.

INTRODUCTION: Postmastectomy pain syndrome (PMPS) is a significant burden for breast cancer survivors. Although multiple therapies have been described, an evolving field of serratus anterior plane blocks has been described in this population. We describe the addition of the deep serratus anterior plane block (DSPB) for PMPS. METHODS: Four patients with history of PMPS underwent DSPB for anterior chest wall pain. A retrospective review of these patients' outcomes was obtained through postprocedure interviews. RESULTS: Three of the patients previously had a superficial serratus anterior plane block, which was not as efficacious as the DSPB. The fourth patient had a superficial serratus anterior plane that was difficult to separate with hydrodissection but had improved pain control with a DSPB. CONCLUSIONS: We illustrate 4 patients who have benefitted from a DSPB and describe indications that this block may be more efficacious than a superficial serratus plane block. Further study is recommended to understand the intercostal nerve branches within the lateral and anterior muscular chest wall planes.

Comparison of perioperative outcomes for epidural versus intravenous patient-controlled analgesia after radical cystectomy.

BACKGROUND AND OBJECTIVES: The use of patient-controlled epidural analgesia after various operations has been associated with an early return of bowel function, thus decreasing patients' length of stay (LOS). The primary aim of this study was to compare LOS after radical cystectomy between patients who received epidural analgesia versus those who received intravenous patient-controlled analgesia. Our secondary analysis included the assessment of other metrics such as total opioid requirements, pain scores, return of bowel function, and complication rates between the 2 groups. METHODS: We conducted a retrospective review using the electronic medical records of 308 patients who underwent radical cystectomies at Memorial Sloan Kettering between 2006 and 2011. We aimed to understand if epidural analgesia was associated with a reduced LOS compared with patient-controlled intravenous opioid analgesia. We also aimed to identify performance improvements as a function of epidural analgesia status using various metrics such as pain management, bowel function return, and complication rates. We used both univariate and multivariate analyses to identify if epidural analgesia was associated with meaningful differences in the aforementioned metrics. RESULTS: Median age at radical cystectomy, body mass index, sex, American Society of Anesthesiologists score, and T stage were similar for both groups. For our primary objective of LOS, we found no significant difference between the 2 cohorts (8 vs 7 days, P = 0.2). Analysis of our secondary outcome measures revealed that epidural analgesia use was associated with less total opioid requirement for the first 3 postoperative days (PODs) (P = 0.0001). In addition, epidural analgesia was found to be associated with improved postoperative pain scores compared with intravenous patient-controlled analgesia on PODs 1 (P = 0.0001) and 2 (P = 0.004), and there was a slight improvement on POD 3, but this was not significant (P = 0.77). In contrast, we found no difference between pain management types with regard to proportion of patients who experienced a delay in gastrointestinal recovery, fluid bolus requirements within the first 3 perioperative days, rates of infection, pulmonary complications, and grade 3 or greater complications. CONCLUSIONS: We have demonstrated that, despite significant improvements in initial pain control and less opioid requirement with patient-controlled epidural analgesia, there was no association between analgesic approach and LOS, return of bowel function, or complications.

Neurolytic transversus abdominal plane block with alcohol for long-term malignancy related pain control.

There have been several case reports in the literature of neurolytic transversus abdominis plane (TAP) blocks being used for malignant abdominal wall pain. However, most used phenol as a neurolytic agent. We found only a single case report by Sakamoto using alcohol for TAP neurolysis. Unfortunately this patient passed away only 5 days after performance of the block. We attempt to extend upon the existing literature by describing neurolytic TAP blockade outcomes using alcohol on 3 cancer patients with metastatic disease to the abdominal wall. Two of our 3 patients had colorectal cancer invading the abdominal musculature. The third patient had a metastatic neuroendocrine nodule in the left rectus muscle. In our case series, all 3 patients had sustained and significant (greater than 50%) relief of abdominal wall pain after performing TAP neurolysis using alcohol. Ultrasound guidance was used for all blocks. The concentration of alcohol used varied from 33% to 77% between patients. Duration of relief lasted between 17 days and 6 months. Opioid use either decreased or remained relatively stable for prolonged periods of time after neurolysis. Other than one patient with transient post-procedure pain related to alcohol injection, there were no significant complications. Addition of a depo steroid for diagnostic TAP blockade prior to neurolysis did not appear to extend or provide additional analgesia. Based on our observations, TAP neurolysis using alcohol also offers a feasible option for long-term control of malignant abdominal wall pain. Further investigation is needed to determine if alcohol offers any significant advantage compared with phenol.

The use of combined spinal-epidural technique to compare intrathecal ziconotide and epidural opioids for trialing intrathecal drug delivery.

SUMMARY Choosing the initial medications for intrathecal delivery is often confusing and not standardized. We describe a novel way for using a combined spinal-epidural technique to compare two first-line medications for intrathecal delivery; ziconotide and morphine (or hydromorphone). Five patients with intractable chronic or cancer pain were elected to have an intrathecal drug delivery system implanted for pain management. Each patient was given a 3-day inpatient trial with the combined spinal-epidural technique. The Visual Analog Scale, Numerical Rating Scale, short-term McGill questionnaire and opioid consumption were monitored daily. The results were used to develop a paradigm to describe how ziconotide can be used in practice.

The use of lumbar sympathetic blockade at L4 for management of malignancy-related bladder spasms.

BACKGROUND: Cancer-related bladder spasms may be a rare but severe symptom of bladder or metastatic cancer or its related treatments. Various treatments described in the literature include systemic medications, intravesical or epidural medications, or even sacral neurolectomies. OBJECTIVE: We present 3 patients who have suffered from bladder spasm either from invasion of the bladder wall by tumor (2 patients) or from intravesical chemotherapeutic treatment. DESIGN: Case Report. SETTING: Cancer pain management hospital. METHODS: For each patient, we describe the use of lumbar sympathetic block to successfully treat the bladder spasms. Sympathetic blockade was performed at the left anterolateral border of lumbar vertebra L4. We used 10 mL of local anesthetic (0.25% bupivacaine) delivered in 2 mL aliquots, each given after negative aspiration for heme. Each procedure was performed with fluoroscopic guidance (both AP and lateral views) with the use of iodine contrast (Omnipaque-180) to confirm the location of the medication and its resulting spread. RESULTS: All 3 patients had a reduction in the frequency and intensity of spasms, with 2 out of 3 patients not having a recurrence of the spasms for up to 2 months post procedure and follow up. LIMITATIONS: Case Report. CONCLUSION: Lumbar sympathetic blockade could be a useful treatment for recurrent bladder spasm in the oncologic population. Based on these findings, we feel that the branches of the sympathetic nerve set at L4 may be a good target for neurolytic procedures, such as radiofrequency ablation, for long term treatment of bladder spasms. Further research is necessary to determine the efficacy of this technique for the treatment of bladder spasms in the oncologic population.