Orthopedic Oncology

As a Board Certified, Fellowship trained Neurosurgeon, Dr. Assina..............

CANCER PAIN

Pain may be caused by the disease itself or by treatments. Although not all people with cancer will experience pain, it is common in people with cancer. Nearly 30% to 50% of people with cancer experience pain while undergoing treatment, and 70% to 90% of people with advanced cancer experience pain.

About 95% of people suffering from chronic cancer pain can be successfully managed and treated by the drug and non-drug therapies that are now available. Along with chronic cancer pain, some sufferers experience acute flares of pain when not all pain is controlled by the medication or therapy. This pain, known as breakthrough pain, may also be controlled by medications.

Causes

The most common causes of cancer pain include the disease cancer itself and the treatments used to treat the disease.

The pressure of a tumor on one of the body's organs or on bone or nerves may cause pain. In some instances, cancer can cause pain when blood vessels become obstructed by the tumor.

There are numerous treatments for cancer and some are less than pleasant. However, it is important to note that not all people being treated for cancer experience all of the side effects of these treatments. One person may experience a side effect that another will never experience. Another important item to remember is that many treatment-related side effects may be successfully prevented in some cases, and treated if they occur.

Treatment-related pain

Chemotherapy: Depending on the medication being used, chemotherapy may often cause numerous side effects. Common side effects of chemotherapy include mouth sores, numbness, painful sensations in the feet, legs, fingers, hands and arms, constipation, diarrhea, nausea, vomiting and abdominal cramps. Bone and joint pain may result also.

Surgical options: Post surgical pain may result from surgical treatments for cancer. Procedures such as biopsies, blood draws, lumbar punctures and laser treatments may cause pain. No matter what the cause, most types of cancer pain can be managed with drug and non-drug therapies.

Treatment

It is important to note that cancer pain is very treatable. Nearly 90% of cancer pain patients will find relief using a combination of medications. While cancer pain is usually treated with medicine, other treatments such as injection therapy, radiation therapy, surgery, relaxation, biofeedback and imagery can be used with medicine to give even more pain relief.

Pain Medicine

To treat mild to moderate pain, nonopioids, such as acetaminophen, and (NSAIDs), such as aspirin and ibuprofen, may be used. Many of these medications are available over the counter, while others need a prescription.

To treat moderate to severe pain, opioids, such as morphine, hydromorphone, oxycodone, hydrocodone, codeine, fentanyl and methadone, may be used. These medications are available with prescription. Nonopioids may be partnered with opioids for moderate to severe pain.

Antidepressants, such as amitriptyline, imipramine, doxepin and trazodone, may be used to treat tingling and burning pain. Another option is an antiepileptics, such as gabapentin. A prescription is needed for these medicines.

Cancer pain caused by swelling may be treated by steroids such as prednisone and dexamethasone. A prescription is needed for these medicines.

How Pain Medicine is Taken

Most pain medicine is taken by mouth (orally). Oral medicines are easy to take and usually cost less than other kinds of medicine. If it is difficult for you to swallow or you cannot take a tablet or liquid for some other reason, there are other ways to get these medicines. These include:

Medicine that dissolves in the rectum and is absorbed by the body, known as Rectal suppositories.

Patches that are filled with medicine and placed on the skin, known as transdermal patches.

Injections

Many kinds of injections can give pain relief. Most injections use a tube or needle to place medicine directly into the body.

Types of injection include:

Subcutaneous - medicine is placed just under the skin using a small needle.

Intravenous - medicine is placed directly into a vein through a needle that remains in the vein.

Epidural or intrathecal - medicine is placed directly into the back using a small tube. The majority of these injections give pain relief that lasts for many hours.

Subdermal and intramuscular - more commonly known as "shots," these injections are placed more deeply into the skin or muscle using a needle. These injections are not recommended for long-term cancer pain treatment. Constantly having shots into the skin and muscle can be painful.

SPINAL CORD STIMULATOR

Spinal cord stimulation helps to relieve chronic pain of the back, arms and legs. The main purpose implanting a spinal cord stimulator is to help a patient manage pain without ongoing dependence on narcotics that can damage internal organs and shorten lifespan.

A spinal cord stimulator is used when nonsurgical pain treatment options have failed to provide pain relief. It is an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain.

Spinal cord stimulators are generally indicated for patients with back and leg pain that has failed other methods of pain control and had a successful spinal cord stimulator trial. Most patients have had back surgery in the past, and others may have other chronic pain syndromes.

Stimulator Placement

Placement of a spinal cord stimulator consists of electrical leads and a battery. Placement of the stimulator requires two separate incisions. One in the mid-back, and one in the region above the buttock. Once the incision in the back has been made a small portion of bone is removed, exposing the spinal cord. The spinal cord stimulator leads are then placed under the bone, directly on the surface of the spinal cord. The leads are then passed under the skin to the region above the buttock where they are connected a battery.

Spinal Cord Stimulation for Pain: Am I a Candidate?

Risks and Possible Complications

As with any surgery, there are small, but possible complications. For spinal cord stimulators these include:

Weakness, numbness, new or worse pain
Paralysis
Blood clots in the legs or lungs
Infection requiring spinal cord stimulator removal
Bleeding
Malposition of the spinal cord stimulator lead
Spinal cord stimulator lead migration
Persistent pain despite placement of the spinal cord stimulator

There Are 4 Possible Outcomes From Any Surgery

Your symptoms or pain may be completely improved.
Your symptoms or pain may be partially improved.
Your symptoms or pain may be the same as before surgery.
Your symptoms or pain may be worse than before surgery.

After Surgery

You may have some soreness at the incision site immediately after surgery and will be encouraged to rest. However, you will be encouraged to walk the next day.

After surgery, patients usually stay overnight.
Risks of the procedure are bleeding, infection, lead migration spinal cord injury (which may cause leg weakness, numbness and difficulty walking), failure to relieve pain.
The stimulator is usually turned on 2 weeks after surgery.
Patients are encouraged not to perform any twisting, bending, or heavy lifting for 3 weeks. This allows the stimulator to settle in place.

KYPHOPLASTY

Kyphoplasty surgery is a procedure designed to stop the pain caused by a spinal fracture. This minimally invasive procedure fills the fractured bone with cement to relieve back pain caused by vertebral compression fractures.

Most common cause of compression fractures is osteoporosis, however other causes include tumors, infection and trauma.

Balloon kyphoplasty consists of a surgeon passing a balloon into the vertebral body and is inflated to provide room for the special cement. The liquid cement is inserted which quickly hardens. This procedure is usually repeated on the other side of the back. It is routine for the surgeon to collect a bone specimen (biopsy) studies to make sure the bone does not have evidence of tumor or infection.

Balloon kyphoplasty: A minimally invasive procedure that fills the fractured bone with cement and relieves back pain
Vertebral body: the bones in the back
Compression fracture: A flattening of the bones in the back which usually cause significant pain

What Are The Causes Of Compression Fractures?

Most common cause of compression fractures is osteoporosis, however other causes include tumors, infection and trauma.

How Is This Diagnosed?

Your doctor will obtain a thorough history and examine your spine and your strength, reflexes and sensations.
Your doctor may order imaging tests to look at the spine.
CT (computed tomography): you will be placed in a scanner for a brief period of time. This pictures show the fractures in the bone very well.
MRI (magnetic resonance imaging): this produces images using a magnet and radio waves. These pictures show the muscles, and nerves very well, and allow the physician to determine if the fracture is new or old.

Risks And Possible Complications

As with any surgery there are small, but possible complications. For kyphoplasty these include:

Weakness, numbness, new or worse pain
Paralysis
Blood clots in the lungs
Infection
Additional bone fractures
Bleeding
Pneumothorax–air leak into the chest cavity.

There Are 4 Possible Outcomes From Any Surgery

Your symptoms or pain may be completely improved.
Your symptoms or pain may be partially improved.
Your symptoms or pain may be the same as before surgery.
Your symptoms or pain may be worse than before surgery.

Surgery

The surgeon makes a 3 mm incision on one side of the back and a small tube is passed into the bone using x-ray guidance. Next a balloon is passed into the vertebral body and is inflated to provide room for the special cement. The liquid cement is inserted which quickly hardens. This procedure is usually repeated on the other side of the back. It is routine for the surgeon to collect a bone specimen (biopsy) studies to make sure the bone does not have evidence of tumor or infection. The procedure takes 45 minutes to 1 hour for a single level. Patients usually go home the next day.

Bone nailing / pinning

Bone pinning is a type of surgery to fix a broken (fractured) bone. Another name for bone pinning is fracture repair and internal fixation. Percutaneous pinning is a technique used by orthopedic surgeons for the stabilization of unstable fractures. Percutaneous pinning involves inserting wires through a person’s skin for stabilizing the fractured bone. Bone nailing uses pins, screws, or plates to help hold broken bones together so they can heal correctly. One of the current tenets of orthopedic fixation is bones heal better if the fracture fragments are pressed firmly together.

After Surgery

You may have some soreness at the incision site immediately after surgery and will be encouraged to rest. However, you will be encouraged to walk the next day. Some patients may be encouraged to wear a lumbar brace for back support as the back heals.