Prof' Eric Buchser, MD, DEAA

1
Interventional treatments for the management of
pain
Prof. Eric Buchser, MD, DEAA Head of Anaesthesia
Pain Management Services Neuromodulation
Centre Morges and Lausanne, Switzerland
2
When should interventional techniques be used?
When the ladder is too short
3
Which interventional procedures?

• Nerve blocks
• Reversible
• Local anaesthetics
• Anti-inflammatory drugs - steroids
• Non-reversible
• Neurolysis
• Chemical
• Alcohol
• Phenol
• Hypertonic saline
• Thermal (radiofrequency)
• Intrathecal drug delivery

4
Benefits and risks of neurolytic blocks

• Benefits
• One-time, long-lasting, highly effective
• Decreased Side effects cost
• Increased quality of life cognitive abilities
• Risks
• Potential serious complications
• Neurological deficits
• Denervation pain and disaesthesia
• Do not last for ever (usually less than 1 year)
• Require highly experienced physicians

5
Efficacy and safety of NCPB
Eisenberg E. et al. Neurolytic celiac plexus
block for treatment of cancer paina
meta-analysis. Anesth Analg 199580290-25.

• 24 studies
• 21 retrospective
• 1 prospective
• 2 RCT

• Side effects
• Local pain 96
• Diarrhoea 44
• Hypotension 38
• Others (alcohol intoxication)
• Complications 2
• Paraplegia
• Intestinal infarction

• Good to excellent pain relief
• in 89 of patients
• At 2 weeks
• At 3 months (survivors)
• In 70-90 until death (even if gt3
  months)

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Does NCPB improved survival ?

• Pain is a predictor of poor outcome
• Survival is improved after chemical
  splanchniectomy
• RCT NCPB vs optimal medical treatment
• NCPB improves pain (plt0.001)
• NCPB does not improve
• QOL
• Survival
• Overall mortality unchanged

Kelsen DP et al, Surgery122(1)53-59 (1997)
Lillemoe KD et al, Annals of Surgery 217447-457
(1993)
Wong GY et al, JAMA291(9)1092-1099 (2004)
Survival after NCPB Brown DL et al, Anesth Analg
198766869-73
Patient survival ()
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Spinal drug administration - Why at all ?

• Administration of drugs that cannot be used
  otherwise
• Local anaesthetics
• Baclofen (?)
• Clonidine (?)
• Peptides

• Decreased side effects (opiates)

8
Spinal drug administration

• IT morphine first reported in the late sixties
• Only opiate approved for long-term IT
  administration
• Mixed results
• 38 of patients fail IT morphine
• 20 side effects
• 80 lack of efficacy

9
The Cancer Pain Trial

• Thomas J. Smith, M.D., Richmond, Virginia
• Peter S. Staats, M.D., Baltimore, MD
• Timothy Deer, M.D., Charleston, West Virginia
• Lisa J. Stearns, M.D., Phoenix, Arizona
• Richard L. Rauck, M.D., Winston-Salem, N.C
• Richard L. Boortz-Marx, M.S. M.D., Minneapolis, MN

• Eric Buchser, M.D., Morges, Switzerland
• Elena Català MD, Barcelona, Spain
• David A. Bryce, MD, Marshfield, Wisconsin
• Patrick J. Coyne, RN, MSN, Richmond, Virginia
• Michael Cousins, MD, Sidney, Australia
• George Pool, MPH, Minneapolis, MN

Journal of Clinical Oncology 20(19)4040-4049
(2002)
Annals of Oncology 16(5)825-833 (2005)
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Patient Disposition at 1 Month
202 Randomized
1 Protocol deviation 1 Withdrew consent
99 CMM
101 IDDS
16 Died 6 Withdrew consent 1 Lost to follow-up
7 Died 8 Withdrew consent
86 at 4-week follow-up
76 at 4-week follow-up
5 CMMImplanted
71 CMMNot implanted
62 IDDSImplanted
24 IDDSNot implanted
Smith TJ et al Journal of Clinical Oncology
20(19)4040-4049 (2002)
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Randomization
Smith TJ et al Journal of Clinical Oncology
20(19)4040-4049 (2002)
12
Types of Patient Pain
70
CMM
60
CMM IT
50
40
30
20
10
0
Neuropathic
Nociceptive
Mixed
Smith TJ et al Journal of Clinical Oncology
20(19)4040-4049 (2002)
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Pain Relief
Mean Reduction in VAS at 1 month
Error bars are /- 2 standard errors
6
5
4
3
VAS Mean Change
2
1
Non- Implanted (n89)
Implanted (n54)
Non- Implanted (n22)
Implanted (n49)
CMM (n72)
IDDS (n71)
Intention to Treat (as randomised)
CMM as Treated (adjusted)
IDDS As Treated (adjusted)
Smith TJ et al Journal of Clinical Oncology
20(19)4040-4049 (2002)
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Pain Relief - As Treated Analysis
Mean reduction in VAS at 1 and 12 months
Smith TJ et al Annals of Oncology
16(5)825-833 (2005)
15
Toxicity
Mean Reduction in Toxicity at 1 Month
Error bars are /- 2 standard errors
6
6
6
5
5
5
4
4
4
Drug Toxicity Mean Change
3
3
3
2
2
2
1
1
1
0
Non- Implanted (n92
Non- Implanted (n22)
Implanted (n56)
Implanted (n51)
CMM as Treated (adjusted)
IDDS as Treated (adjusted)
Smith TJ et al Journal of Clinical Oncology
20(19)4040-4049 (2002)
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Reduction in side effects
Smith TJ et al Journal of Clinical Oncology
20(19)4040-4049 (2002)
17
Survival
Smith TJ et al Journal of Clinical Oncology
20(19)4040-4049 (2002)
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Conclusion

• Interventional pain management
• Should be considered when therapy unsatisfactory
• Neurolytic nerve blocks
• Never on a peripheral sensory nerve
• Coeliac/splanchnic blockade are effective
• Never permanent
• Intrathecal drug delivery
• Has theoretical advantages
• Allows the administration of drugs that cannot be
  delivered by systemic routes
• Suffers from the lack of controlled studies

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Thank you for your attention