NUR231 Case Study: Pathophysiology, Analgesics for Metastatic Lesion

This case study, focusing on a patient named John with metastatic lesions in his spine, explores the pathophysiology of his lower back pain and evaluates the effectiveness of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) for pain management, particularly in older individuals. The study highlights the role of unbalanced bone resorption and remodeling due to cancer cells. The assignment then delves into prescribing appropriate analgesics, supported by evidence from MRI reports, with a focus on radiotherapy and bisphosphonates like zoledronic acid as effective treatments. The document cites several research papers to support the treatment recommendations and offers a comprehensive overview of pain management strategies for metastatic spinal lesions.

NUR231
(CASE STUDY)
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1. Explain the pathophysiology of John’s lower back pain and discuss
briefly the effectiveness of NSAIDS for pain management in older
people.
Mr. John was identified with a metastatic lesion in thoracic and lumbar
vertebrae that was identified by persisting and worsening lower back pain.
The physical examination identified the presence of acute tenderness over
T12-L1 region of the spine in his case. According to Samartzis, Gillis, Shih,
O'Toole & Fessler (2015) studies, metastatic cancer is the outcome of bone
destruction observed as osteoblastic or osteolytic lesions in the spine region.
The bone tissues in normal conditions perform balanced resorption by
osteoclast and remodelling by osteoblast but the presence of cancer cells
leads to unbalanced resorption by abnormal osteoclast and remodelling by
abnormal osteoblast. This unbalanced activity leads to the formation of
osteoblastic or osteolytic lesions in the bone region. The osteoblastic bone
metastasis is initiated because of the presence of tumor-secretion endothelin
1 in this region. Whereas, osteolytic bone metastasis is formed by tumour-
induced activates osteoclast cells (Wu, Tang, & Li, 2015).
Once the cancerous cells infect the bone they develop a tendency to
produce growth factors that abnormal initiate osteoblastic or osteoclactic
activities leading to bone destruction and growth of tumour cells in the spine
region (Samartzis et al., 2015). The similar process occurred in the case of
John where the presence of acute tenderness in T12-L1 region indicates bone
abnormalities leading to lesion formation.
The NSAIDs are considered to be safe and most common therapy to
manage pain and inflammation even for the old age people. With low steroids
level, these NSAIDs persist a safe profile for minor pain treatment in older
people. However, NSAIDs also develop a high risk of cardiovascular arrest,
cerebrovascular morbidities and gastrointestinal diseases if taken for a longer
duration (Czerniak, 2015).
2. Following the MRI report, and the pain being persistent, which
analgesics should be prescribed to Mr. John? Support your answer with
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evidence.
Analgesics are drugs considered first-line agent for managing chronic
pain and even cancerous pain. In the provided case study, The MRI report of
Mr. John indicates the presence of a metastatic lesion in the thoracic and
lumbar vertebrae of his spine region. The bone pain analgesics like
bisphosphonates; calcitonin, radiopharmaceuticals or radiotherapy might work
to manage his painful condition (Czerniak, 2015).
According to Heidenreich et al., (2014) study radiotherapy is
considered effective to control bone pain especially associated with a lesion
that poorly responds to opioids. In the case of Mr. John, radiotherapy
accompanied along with NSAIDs might work to manage pain in his present
old age condition. However, radiopharmaceuticals like radionuclides may be
functional to manage the metastatic bone disease as a monotherapy with
conventional radiotherapy if the NSAIDs don’t work to manage pain (Czerniak,
2015).
Further, the second in line analgesics after radiotherapy, which can
work to manage Mr. John’s pain is bisphosphonates that possess osteoclast
activity that can reduce or minimise bone resorption in different category of
illnesses. The bisphosphonates like pamidronate and zoledronic acid have
well-established name to manage bone-related pain. In the case of Mr. John,
zoledronic acid shall be more effective because it is effective on both
osteolytic and osteoblastic lesions. Further, Zoledronic acid is considered
better bisphosphonate for old age patients having bone issues (Hariri,
Takayanagi, Miulli, Siddiqi, & Vrionis, 2017).
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References
Czerniak, B. (2015). Dorfman and Czerniak’s Bone Tumors E-Book. Retrived
from https://www.elsevier.com/books/dorfman-and-czerniaks-bone-
tumors/czerniak/978-0-323-02396-2.
Hariri, O., Takayanagi, A., Miulli, D. E., Siddiqi, J., & Vrionis, F. (2017).
Minimally invasive surgical techniques for management of painful
metastatic and primary spinal tumors. Cureus, 9(3), e1114.
Heidenreich, A., Bastian, P. J., Bellmunt, J., Bolla, M., Joniau, S., van der
Kwast, T., ...Mottet, N. (2014). EAU guidelines on prostate cancer. Part 1:
Screening, diagnosis, and local treatment with curative intent—Update
2013. European Urology, 65(1), 124-137.
Samartzis, D., Gillis, C. C., Shih, P., O'Toole, J. E., & Fessler, R. G. (2015).
Intramedullary spinal cord tumors: Part I—Epidemiology, pathophysiology,
and diagnosis. Global Spine Journal, 5(05), 425-435.
Wu, P. F., Tang, J. Y., & Li, K. H. (2015). RANK pathway in giant cell tumor of
bone: pathogenesis and therapeutic aspects. Tumor Biology, 36(2), 495-
501.
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