Very clearly defined treatments for chest wall cancer makes it easy to know what to do.
A Retrospective Review and Treatment Paradigm of Interventional Therapies for Patients Suffering from Intractable Thoracic Chest Wall Pain in the Oncologic Population
Pain Medicine 2015; 16: 802–810.
Amitabh Gulati, MD, FIPP, Rajiv Shah, MD, Vinay Puttanniah, MD, Joseph C. Hung, MD,* andVivek Malhotra, MD
http://www.ncbi.nlm.nih.gov/pubmed/25236160
Options included:
- intercostal/paravertebral nerve blocks and neurolysis
- pulse radiofrequency ablation (PRFA)
- Intrathecal Pump Placement
75% had nerve blocks of local and steroid with 22% getting prolonged relief (average 21.5 days).- 1/3 of those blocked went on to neurolysis (destructive injection) and it had a 63% success rate.
Procedure for block:
- 25 guage 1/5 inch needle
- skin freeze with 2 ml 1% lidocaine (I would buffer with little 8.4% sodium bicarbonate)
- US control
- 2 ml of 0.5% bupivacaine plus 10 mg triamcinolone into nerve area
- repeat at all affected levels (often at least 3)
Neurolysis involved use of 2 mls of 90% ethanol
For pump:
- intrathecal catheter put in at l3-4 intespace and tip guided to mid thoarcic location.
- then a SynchroMed II pump implanted subcut
- often mix of bucivacaine and hydromorphone pumped
Algorithm used:
Comment -They weren’t able to find origins for 1/3. Possibilities:
- Lattisimus dorsi – Many years ago I heard Dr. Travell (yah I know – gives my age) talking about a case of chest wall pain that had rhizotomies done at all thoracic levels without relief. Turned out, pains were coming from C7 and affected the latissimus dorsi – injections of the Latissimus relieved the condition. (multiple triggers- axilla, where join onto ribs, near paraspinous all possible.)
- Posterior cutaneous nerves – Last week I have a ca breast case with metastases have superficial pains referring cutaneous thoracic nerves posteriorly:
Injecting along course of tender nerves with 3% glycerin in D5W – every cm. raise a bleb – I go more intradermal to avoid actually hitting the nerve. You can actually feel the nerves as threads. I injected 3 levels bilaterally where tender and her posterior thoracic pains went away. First shots last maybe 4 days but it last longer with multi repetitions. I suspect 5-10% lidocaine in Uremol topically would help too.
- Iliocostalis paraspinous – same lady had iliocostalis spasms bilateral multilevel by bra line. I injected them with 5% semineurolytic lidocaine (use 2 mls or less and warn could get dizzy). Inject medial to lateral to avoid getting to close to spine. Then work the muscles until soft. May need to be repeated up to 3 times to get a good “take”
Any suggestions?