Introduction: Pain from terminal cancer is a debilitating disease with a prevalence of 90%. 10-30% of patients experience refractory pain despite medical management, and a subset report continued pain after a neuroablative or neuromodulatory procedure. We describe the use of intrathecal therapy, in combination with either cordotomy or myelotomy, for situations in which a single procedure is insufficient for adequate pain relief.

Methods: Retrospective chart review identified five patients at three institutions who initially received an implantable drug delivery system (IDDS), percutaneous radiofrequency cordotomy (PRFC), or midline myelotomy (MM), but continued to experience refractory pain. These patients underwent a second procedure (IDDS, PRFC, or PMM), and both short- and long-term Visual Analog Scale (VAS) scores were assessed.

Results: Patients experienced 10/10 pain on the VAS due to renal (n=1), rectal (n=1), or lung (n=2) carcinomas, or melanoma (n=1). Four patients received an IDDS, and one patient underwent PMM, with post-operative scores of 9-10. After continued refractory pain, a second procedure was performed. The patient receiving MM followed by IDDS reported a long-term VAS score of 7. Three patients underwent subsequent PRFC, with VAS scores of 0 and 4. One patient underwent subsequent MM and reported a VAS score of 3-4. One patient was lost to long-term follow-up.

Conclusions: Cancer pain reduces the quality of life in patients already suffering from a devastating illness. In those for whom medical management is inadequate, invasive procedures can be very effective. However, a proportion of patients will continue to be refractory to these. We present a multicenter case series of patients who underwent a second procedure, either IDDS, MM, or PRFC, as a complementary intervention, with excellent long-term pain relief. Performance of a second interventional treatment should be considered in these difficult cases.

Patient Care: This research presents the efficacy of a multimodality surgical approach in the treatment of refractory cancer pain, showing that the addition of a second neuroablative procedure or targeted drug delivery system should be considered in order to improve the quality of life in a challenging patient population.

Learning Objectives: By the conclusion of this session, participants should be able to 1) Summarize the available neuroablative or neuromodulatory therapies for treatment of refractory cancer pain, 2) Discuss possible treatment algorithms, 3) Determine which patients are appropriate candidates for a second surgical procedure in treating cancer pain.

References: 1. Collins K, Patil P: Flat-panel fluoroscopy O-arm-guided percutaneous radiofrequency cordotomy: A new technique for the treatment of unilateral cancer pain. Operative Neurosurgery 72:ons27-34, 2013 2. Kanpolat Y, Ugur HC, Ayten M, Elhan AH: Computed tomography-guided percutaneous cordotomy for intractable pain in malignancy. Neurosurgery 64:ons187-193; discussion ons193-184, 2009 3. Mercadante S, Fulfaro F: World Health Organization guidelines for cancer pain: a reappraisal. Ann Oncol 16 Suppl 4:iv132-135, 2005 4. Raslan AM: Percutaneous computed tomography-guided radiofrequency ablation of upper spinal cord pain pathways for cancer-related pain. Neurosurgery 62:226-233; discussion 233-224, 2008 5. Raslan AM, Cetas JS, McCartney S, Burchiel KJ: Destructive procedures for control of cancer pain: the case for cordotomy. Journal of Neurosurgery 114:155-170, 2011