title: Treatment of medically refractory cancer pain with a combination of intrathecal neuromodulation and neurosurgical ablation: case series and literature review.
abstract: OBJECTIVE
  Up to 90% of patients with advanced cancer experience intractable pain. For these patients, oral analgesics are the mainstay of therapy, often augmented with intrathecal drug delivery. Neurosurgical ablative procedures have become less commonly used, though their efficacy has been well-established. Unfortunately, little is known about the safety of ablation in the context of previous neuromodulation. Therefore, the aim of this study is to present the results from a case series in which patients were treated successfully with a combination of intrathecal neuromodulation and neurosurgical ablation.
  
  
  METHODS
  Retrospective case series and literature review.
  
  
  METHODS
  Three institutions with active cancer pain management programs in the United States.
  
  
  METHODS
  All patients who underwent both neuroablative and neuromodulatory procedures for cancer pain were surveyed using the visual analog scale prior to the first procedure, before and after a second procedure, and at long-term follow-up. Based on initial and subsequent presentation, patients underwent intrathecal morphine pump placement, cordotomy, or midline myelotomy.
  
  
  RESULTS
  Five patients (2 male, 3 female) with medically intractable pain (initial VAS = 10) were included in the series. Four subjects were initially treated with intrathecal analgesic neuromodulation, and 1 with midline myelotomy. Each patient experienced recurrence of pain (VAS ≥ 9) following the initial procedure, and was therefore treated with another modality (intrathecal, N = 1; midline myelotomy, N = 1; percutaneous radiofrequency cordotomy, N = 3), with significant long-term benefit (VAS 1-7).
  
  
  CONCLUSIONS
  In cancer patients with medically intractable pain, intrathecal neuromodulation and neurosurgical ablation together may allow for more effective control of cancer pain.
authors.affiliation: Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.
authors.forename: J Nicole
authors.initials: JN
authors.lastname: Bentley
authors.forename: Ashwin
authors.initials: A
authors.lastname: Viswanathan
authors.forename: William S
authors.initials: WS
authors.lastname: Rosenberg
authors.forename: Parag G
authors.initials: PG
authors.lastname: Patil
mesh_terms: D000293:Adolescent; D000368:Aged; D001859:Bone Neoplasms / Q000503:physiopathology / Q000556:secondary; D002045:Bupivacaine / Q000008:administration & dosage / Q000627:therapeutic use; D002289:Carcinoma, Non-Small-Cell Lung / Q000503:physiopathology / Q000556:secondary; D002292:Carcinoma, Renal Cell / Q000503:physiopathology / Q000556:secondary; D002818:Cordotomy / Q000379:methods*; D005260:Female; D006801:Humans; D004091:Hydromorphone / Q000008:administration & dosage / Q000627:therapeutic use; D015918:Infusion Pumps, Implantable; D060186:Infusions, Spinal; D007414:Intestinal Neoplasms / Q000503:physiopathology / Q000556:secondary; D007680:Kidney Neoplasms; D008175:Lung Neoplasms; D008297:Male; D008545:Melanoma / Q000503:physiopathology / Q000556:secondary; D008875:Middle Aged; D009369:Neoplasms / Q000503:physiopathology*; D010148:Intractable Pain / Q000188:drug therapy* / Q000209:etiology / Q000601:surgery*; D010166:Palliative Care; D012004:Rectal Neoplasms; D012189:Retrospective Studies; D013133:Spinothalamic Tracts / Q000503:physiopathology / Q000601:surgery*; D013899:Thoracic Neoplasms / Q000503:physiopathology / Q000556:secondary
chemical_list: D004091:Hydromorphone; D002045:Bupivacaine
keywords: Ablation; Cancer Pain; Intrathecal; Surgery