Principles & Practice of Pain Medicine > Part V. Pain Syndromes > C. Pain in the Terminally Ill > Chapter 46. Anesthetic Interventions in Cancer Pain Stuart W. Hough, Leonidas C. Goudas, and Daniel B. Carr

Invasive, Nonpharmacologic Palliative Procedures

"About one in ten patients with pain due to cancer continues to experience pain despite maximal application of noninvasive analgesic methods. With few exceptions, noninvasive analgesic approaches should precede invasive forms of palliation such as neurolytic blocks and other anesthetic techniques, neurosurgery, radiation therapy, spinal column stimulation, or neurosurgical division of ascending pathways. Among these exceptions are palliative radiotherapy for pain at the site of a long bone metastasis or an isolated brain metastasis, and celiac block for a patient with pancreatic or other retroperitoneal tumor who presents with pain. These procedures are designed to improve analgesia or minimize analgesic side effects. Most are intended for pain that is localized to a nerve or plexus distribution. Loss of sensory, motor, visceral, and autonomic function must be considered before proceeding to a neurolytic procedure. Because of their complexity, risk, and cost, invasive procedures are reserved for patients with intractable pain despite full application of the WHO guidelines,¹ and those with intolerable side effects from systemic pharmacologic pain treatment. However, it is important not to delay excessively when conventional pharmacologic management appears inadequate. Referral to a multidisciplinary pain clinic might be considered early in the course of cancer pain to optimize current pharmacologic, psychological, and physical management techniques, and to educate the patient, family, and referring physician about pain progression and future management..."