title: A retrospective review and treatment paradigm of interventional therapies for patients suffering from intractable thoracic chest wall pain in the oncologic population.
abstract: BACKGROUND
  Tumors invading the chest wall and pleura are often incurable, and treatment is targeted toward palliation of symptoms and control of pain. When patients develop tolerance or side effects to systemic opioid therapy, interventional techniques can better optimize a patient's pain. We performed a retrospective review of 146 patients from April 2004 to January 2014 who underwent diagnostic and therapeutic procedures for pain relief. Using four patients as a paradigm for neurolytic approaches to pain relief, we present a therapeutic algorithm for treating patients with intractable thoracic chest wall pain in the oncologic population.
  
  
  METHODS
  For each patient, we describe the use of intercostal/paravertebral nerve blocks and neurolysis, pulsed radiofrequency ablation (PRFA) of the thoracic nerve roots, or intrathecal pump placement to successfully treat the patient's chest wall pain. Analysis of 146 patient charts is also performed to assess effectiveness of therapy.
  
  
  RESULTS
  Seventy-nine percent of patients undergoing an intercostal nerve diagnostic blockade (with local anesthetic and steroid) stated that they had improved pain relief with 22% having prolonged pain relief (average of 21.5 days). Only 32% of successful diagnostic blockade patients elected to proceed to neurolysis, with a 62% success rate. Seven patients elected to proceed to intrathecal drug delivery.
  
  
  CONCLUSIONS
  Intercostal nerve diagnostic blockade with local anesthetic and steroid may lead to prolonged pain relief in this population. Furthermore, depending on tumor location, we have developed a paradigm for the treatment of thoracic chest wall pain in the oncologic population.
authors.affiliation: Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
authors.forename: Amitabh
authors.initials: A
authors.lastname: Gulati
authors.forename: Rajiv
authors.initials: R
authors.lastname: Shah
authors.forename: Vinay
authors.initials: V
authors.lastname: Puttanniah
authors.forename: Joseph C
authors.initials: JC
authors.lastname: Hung
authors.forename: Vivek
authors.initials: V
authors.lastname: Malhotra
mesh_terms: D000328:Adult; D000465:Algorithms; D000700:Analgesics / Q000008:administration & dosage; D017115:Catheter Ablation; D002637:Chest Pain / Q000209:etiology / Q000628:therapy; D005260:Female; D006801:Humans; D015918:Infusion Pumps, Implantable; D007367:Intercostal Nerves; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000150:complications; D009407:Nerve Block / Q000379:methods; D059408:Pain Management / Q000379:methods*; D010148:Intractable Pain / Q000209:etiology / Q000628:therapy*; D010166:Palliative Care / Q000379:methods*; D035441:Thoracic Wall
chemical_list: D000700:Analgesics
keywords: Cancer Pain; Intercostal Nerve; Intercostal Neurolysis; Intrathecal Drug Delivery; Thoracic Chest Wall Pain