|Year : 2007 | Volume
| Issue : 1 | Page : 50-52
Pain Management in a Rare Malignant Spinal Cord Tumor
PF Kotur1, Anu Annie Abraham2, Vijay Umarani3, Raviraj Ghorpade4
1 M.D., D.A., Prof. & Head, Department of Anesthesiology, J.N Medical College, Belgaum, India
2 D.A., Resident, Department of Anesthesiology, J.N Medical College, Belgaum, India
3 M.D., Lecturer, Department of Anesthesiology, J.N Medical College, Belgaum, India
4 M.Ch.(Neurosurgery), ConsultantNeurosurgeon KLE's Hospital & MRC, Belgaum-10, India
|Date of Acceptance||20-Nov-2006|
|Date of Web Publication||20-Mar-2010|
Anu Annie Abraham
D.A., Resident, Department of Anesthesiology, J.N Medical College, Belgaum
Source of Support: None, Conflict of Interest: None
Primary Intraspinal Primitive neuroectodermal tumor is a rare tumor with a poor prognosis. Only few cases have been reported in literature. An 18-year-old girl presented with acute low back pain with no neurological deficit. The tumor could be excised in total. MRI done 6 weeks post operatively was suggestive of a recurrence of the tumor at an alarming rate. The case was referred to our Department for pain management until a definitive treatment plan could be executed
Keywords: PNET (primitive neuroectodermal tumor), Pain management, Epidural opioid, Oral morphine, Opioid tolerance, Opioid rotation
|How to cite this article:|
Kotur P F, Abraham AA, Umarani V, Ghorpade R. Pain Management in a Rare Malignant Spinal Cord Tumor. Indian J Anaesth 2007;51:50-2
|How to cite this URL:|
Kotur P F, Abraham AA, Umarani V, Ghorpade R. Pain Management in a Rare Malignant Spinal Cord Tumor. Indian J Anaesth [serial online] 2007 [cited 2020 Sep 23];51:50-2. Available from: http://www.ijaweb.org/text.asp?2007/51/1/50/61116
| Introduction|| |
Primitive neuroectodermal tumor (PNET) is a malignant small blue cell neoplasm of children but can occur at any age. This term originally proposed by Hart and Earle, denotes a neoplasm of presumed neural crest origin.  Todate only 19 cases have been reported in the medical literature. 2 The clinical characteristics of spinal PNET in cases described so far appear to be  :
Majority of the cases were not referred for pain management. We report a rare case of Primary intraspinal PNET in an 18-year-old girl who came to us for pain management during postoperative recurrence.
- more common in adults than in children.
- males predominantly affected than females (in a ratio of 2:1). 
- aggressive nature of the tumor is evidenced by rapid recurrence.
- survival is usually less than 2 years. Less than 40% of the cases were alive for 2 years after diagnosis and only about 10% after 3 years.
| Case report|| |
A previously healthy 18-year-old girl presented with acute low back pain radiating to the right posterolateral aspect of the thigh and leg. Pain was severe in nature and she was able to walk with assistance. She had no history suggestive of raised intracranial pressure or any cranial nerve palsy nor symptoms of sensory or motor weakness. She had restricted 'straight leg raising test' on the right side. Deep tendon reflexes were intact. Radiography of the lumbosacral spine was normal. MRI images showed an intensely enhancing tumor [Figure 1]. The patient underwent L 4 -L 5 laminectomy and total excision of the tumor [Figure 2]. Histopathology reported as Ependymoma Grade I-II. Hence, patient was planned for close follow-up.
Patient improved after surgery as regards her pain and returned home ambulating. Six weeks later, she presented again with severe back pain with no neurological deficits subsequently she developed saddle paresthesia and paraparesis. She was started on tab gabapentin. There was no loss of urinary sphincter control. The pain was progressive and repeat MRI showed huge tumor recurrence [Figure 3]& [Figure 4]. Patient was planned for review of Histopathology report (HPR), with further immunohistochemistry study and was planned for radiotherapy and chemotherapy. Meanwhile pain management was planned methodically. Definitive HPR was confirmed as spinal PNET.
| Pain management executed|| |
Pain was assessed using Visual analogue scale. The treating neurosurgeon was consulted as regards the method of pain relief, and the duration of pain relief required. It was planned to administer opiates thru epidural route. After obtaining written informed consent patient was taken to the OR and epidural catheter inserted under aseptic precautions. An 18G Touhey needle was initially inserted at the level of L2-L3 interspinous level and a 20G catheter was passed cephaloid and fixed at 9cm, so that 3-4 cms of the catheter was in the epidural space, to lie near T 10 -T 11 dermatome level. buprenorphine 300µg diluted to 10ml with 0.9% normal saline was administered. Pain relief was obtained within 10min and lasted for about 18 hours. Subsequent dose of 150 µg was effective for only six hours. Further more the duration of pain relief with subsequent doses of buprenorphine went on decreasing gradually and was only four hours in the next two days. So it was decided to modify the treatment regime. Triamcilone 40mg with 10ml of 0.125% bupivacaine was given over three consecutive days  with rescue dose of buprenorphine.
On the seventh day of epidural catheter placement, it was decided to administer epidural Morphine along with adjuvant drugs (Amitriptylline, Gabapentin, Piroxicam and Zolpidem. The patient was initially started on Gabapentin by the treating neurosurgeon) She had pain relief with 3 mg of Morphine diluted to 5 ml lasting for 12-15 hours. Following morphine administration, the patient developed itching of face and trunk and constipation. She was started on Ondansetron 8 mg I.V. stat and 4 mg bd for the next 5 days to counter opioid induced urticaria and Syrup Cremaffin 10ml at night for constipation. The epidural catheter was removed after 10 days. Taking into consideration the need for a effective mode of drug administration, the patient was asked to continue Morphine orally.
With written informed consent and after ensuring good venous access and basic monitoring devices, the patient was started on morphine trial with increments of 1.5 mg I.V. every 30 min until pain relief. She had pain relief with 40 mgs of Morphine I.V. She was then started on morphine 40 mgs oral tablets on a four hourly dose with double the dose at night and rescue dose of 40 mgs if she had complaints of pain. The adjuvant drugs also were continued along with Morphine. Patient was comfortable and could be sent home on the above-mentioned regime. She was subsequently treated with radiotherapy and chemotherapy and the dose of Morphine was reduced side by side. The tumor has regressed considerably following radiotherapy and chemotherapy. At the time, she was not writing this case report on any medication and was totally pain free with better quality of life.
| Discussion|| |
Many cancer patients develop significant pain during the course of their illness. Most of this pain can be controlled with the use of opioids. It is important to remember that better pain control can be achieved with round-the-clock dosing, with the addition of rescue doses for breakthrough pain.
One often-identified adverse effect of opioid administration is that of the development of tolerance to the analgesic effect. While it is generally agreed that tolerance to opioid analgesia does occur, it does not appear to be a limiting factor. Numerous studies and clinical experience suggest that tolerance to different opioid effects develop at different rates, which has been termed selective tolerance.
Poor responsiveness is a complex phenomenon that may be related to one or more of a diverse group of factors, including co morbid medical disorders that predispose to toxicity, a pain pathophysiology associated with relatively limited analgesic response, and pharmacologic effects such as the accumulation of active metabolites caused by dehydration or renal insufficiency. ,, after an initial good response to buprenorphine, In our case tolerance was noticed due to which pain relief was limited for 4-5 hours only. Mercadante states that in cancer patients, opioid rotation should be considered in case of adequate in pain relief.  The switch from one opioid to another when treatment-limiting toxicity establishes poor responsiveness has become known as opioid rotation. This rotation can be achieved by providing the same opioid but using a different route or by using a different opioid by the same route. The practical and theoretical advantages of opioid rotation include improved analgesia and reduced side effects. However, the evidence to support the practice of opioid switching is largely anecdotal or based on observational and uncontrolled studies. Once tolerance to the analgesic effect of one opioid is observed co-administration of other receptor-mediated analgesics is advocated in order to avoid unnecessary further development of tolerance. 
The optimal route for morphine in pain management is oral.  We administered intravenous morphine for more rapid titration to the therapeutic dose. The dose should be increased in steps until either adequate analgesia is attained or intolerable or unmanageable side effects occur.
Drug dose, interval and pain relief chart was prepared and the patient and her sister were instructed. This was done for ease of self-medication. Patient was asked to take rescue doses of morphine if she developed pain in between the 4-hour interval. Patient had adequate pain control until radiotherapy and chemotherapy was completed.
| Conclusion|| |
Cancer pain is very common and often undertreated. Successful management of pain is essential in the care of patients living with cancer or facing the end of life. Principles of pain management include a) Detailed and regular assessment of pain b) Education and encouragement of patients and relatives to use opioids c) Aggressive management of side effects. Pain is subjective and is best described by the patient. Pain control is possible and should be pursued aggressively.
For those patients who experience a poor response during routine opioid therapy, many strategies can be implemented to improve analgesia. Opioid rotation is a simple strategy and within the purview of all clinicians. With a comprehensive assessment, and a commitment to reassess and adjust therapy, clinicians can pursue this approach and potentially identify the most favorable opioid for an individual patient.
Therefore, we conclude that guidelines are useful in the treatment of cancer pain. However, because patients have varying responses to opioids, pain management must be individualized. Based on our successful management plan in this case we have defined a flow chart of pain management in such cases (Flow chart 1). When patients are unable to tolerate opioid therapy because of adverse effects (in this case, inadequate pain relief), it is appropriate to change the route of administration or switch to another opioid.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]