What are the interventional pain management options for cancer pain from the thorax to the pelvis?

Interventional Pain Management for Cancer Pain from Thorax to Pelvis

For cancer pain in the thorax-to-pelvis region, interventional techniques should be considered early—even before strong opioids—when pain is likely to respond to nerve blocks or when systemic analgesics cause intolerable side effects. 1

Regional Anatomy-Based Interventions

Thoracic Wall Pain

• Intercostal nerve blocks are indicated for chest wall pain from rib metastases, post-thoracotomy pain syndrome, or mesothelioma-related pain 1
• Epidural neurolysis provides effective analgesia for thoracic wall pain when multiple dermatomes are involved 1
• Mid-thoracic epidural analgesia (T5-T8) delivers superior pain relief compared to IV opioids and should be maintained for 48 hours before transitioning 2

Upper Abdominal Pain (Visceral)

• Celiac plexus block is the primary intervention for pancreatic cancer and upper abdominal malignancies, offering pain relief lasting 3-6 months and reducing opioid requirements 1, 2, 3
• Thoracic splanchnicectomy serves as an alternative to celiac plexus block for upper abdominal visceral pain 1
• These blocks can be performed percutaneously, laparoscopically, endoscopically, or via open surgical approach 2
• Neurolytic celiac plexus block reduces adverse effects compared to systemic analgesics alone 1

Midline Pelvic Pain

• Superior hypogastric plexus block is recommended for midline pelvic pain from colorectal, bladder, prostate, cervical, or uterine cancers 1, 3
• This intervention targets sympathetically-mediated visceral pain in the lower abdomen and pelvis 1

Rectal and Perineal Pain

• Intrathecal neurolysis is indicated for severe rectal pain refractory to other treatments 1
• Midline myelotomy may be considered for intractable perineal pain 1
• Saddle block (intrathecal phenol block) serves as a last resort for perineal pain in terminal patients 1, 3

Spinal Interventions

Neuraxial Drug Delivery

• Intrathecal opioid administration should be considered when systemic opioids cause intolerable sedation, confusion, or inadequate pain control 1, 2, 4, 5
• This approach minimizes drug distribution to brain receptors, potentially avoiding systemic adverse effects 1
• Epidural analgesia provides regional pain control for multiple dermatome involvement 1, 5
• Both routes allow significant opioid dose reduction while maintaining or improving pain relief 3, 5

Vertebral Augmentation

• Percutaneous vertebroplasty is indicated for lytic osteoclastic spinal metastases causing vertebral compression fractures 1, 3
• Kyphoplasty restores mechanical stability while reducing pain and neurologic symptoms when surgery is not feasible 1, 3
• Both procedures are appropriate for spinal instability from pathological fractures 1

Neuroablative Procedures

Cordotomy

• High cervical cordotomy is effective for unilateral cancer pain below C4 dermatomes (below the shoulder) 1
• This technique achieves 80% success rate for early postoperative pain relief 1
• Particularly indicated for incident (movement-related) pain from pathological fractures in long bones, pubic rami, or pelvis that fails surgical treatment and radiation 1
• Should only be applied in patients with life expectancy less than 1 year 3
• The UK Department of Health specifically recommends availability for mesothelioma-related chest wall pain uncontrolled by conventional management 1

Neurolytic Blocks

• Dehydrated alcohol injection (50-100%) is FDA-approved for therapeutic neurolysis of nerves or ganglia for intractable chronic cancer pain 6
• Lower concentrations (40-50%) can be used for epidural or motor nerve injections 6
• Informed consent explaining side effects including numbness and dysesthesia is essential before any neuroablative technique 1

Advanced Neuromodulation

Spinal Cord Stimulation

• Spinal cord stimulation should be included in the overall pain management strategy for slow-growing cancers with severe neuropathic pain refractory to pharmacologic options 1
• MRI-compatible equipment now allows necessary imaging if required 1
• Applicable only in very small number of cases, managed by multidisciplinary teams with specialized skills 1

Radiofrequency Ablation

• Radiofrequency ablation targets bone lesions causing localized pain 1
• Neurodestructive procedures are appropriate for well-localized pain syndromes 1

Critical Contraindications

Absolute Contraindications

• Active infection at injection site 1, 7
• Coagulopathy that cannot be corrected 1, 7
• Very short life expectancy (though cordotomy requires <1 year) 1, 7, 3
• Distorted anatomy preventing safe needle placement 1
• Patient refusal 7
• Medications increasing bleeding risk including antiangiogenesis agents (bevacizumab) require careful assessment 1, 7

Technical Requirements

• Ultrasound guidance is mandatory for all nerve blocks to reduce local anesthetic systemic toxicity risk 7
• Experienced operator performing the technique is required 7
• Immediate resuscitation equipment must be available 7

Clinical Decision Algorithm

Major indications for interventional referral include: 1

1. Pain likely to be relieved with specific nerve block based on anatomic location
2. Failure to achieve adequate analgesia without intolerable side effects from systemic therapy
3. Patient preference for interventional therapy over chronic medication regimen

Common pitfalls to avoid:

• Delaying interventional consultation until terminal phase—earlier application improves quality of life 3, 8
• Using conversion tables to switch FROM fentanyl transdermal to other therapies (this overestimates new agent dose and risks overdosage) 9
• Performing deep/non-compressible blocks without appropriate discontinuation of P2Y12 inhibitors (5-7 days required) 7
• Attempting epidural neurolysis without understanding limited and unpredictable benefit (applicable only in terminal stages) 1