Comprehensive Pain Management of Metastatic Lesions in Spine

This assignment focuses on the pain management and treatment strategies for metastatic lesions in the thoracic and lumbar vertebrae, a spinal disease affecting neurological condition. The primary symptom is back pain, often exacerbated by movement. The solution discusses the importance of diagnosing neurological symptoms using pain assessment and MRI scans to differentiate metastatic bone tumors from nerve root pain. Treatment approaches generally include chemotherapy, surgery, and radiation therapy. The assignment further explores the use of NSAIDs for moderate pain relief, considering their limitations and side effects, such as renal insufficiency. It also emphasizes the WHO guideline-based approach to pain management, including the use of weak opioids for initial intense pain and stronger opioids like hydromorphone, morphine, or oxycodone for more severe pain. The importance of managing side effects like nausea and constipation is also addressed, with prochlorperazine suggested for nausea.

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23 Mar 2019
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Answer 1
Metastatic lesion in thoracic and lumbar vertebrae is a spinal disease which affects
the neurologic condition. Back pain is the most common symptom which is elevated
by weeks (Suzuki et al., 2017). In the present case, David is suffering from tumour-
related pain which may be exacerbated which movement and increase the load on
the axial spine. The associated pain is mediated by inflammation and tumour
stretching in the periosteum of the vertebral body. In this case, radiculopathy causes
band-like pain which results from neural foraminal compression in lumbar vertebrae
(Serak, Vanni & Levi, 2015). Radiculopathy in the lumbar spine is also responsible
for weakness in the upper and lower extremities. Correct diagnosis of neurological
symptoms pain assessment with ASIA score is necessary for appropriate treatment.
Also, MRI scanning is required do access metastatic bone tumours which might
mimic nerve root pain (Sebro et al., 2017). The treatment approach for metastatic
spine tumours generally includes chemotherapy, surgery, and radiation therapy.
Answer 2
2a. NSAIDs are commonly used for pain management in metastatic cases, however,
it should be prescribed weight careful consideration. Note that NSAIDs as an
analgesic for this case should be used only to manage moderate pain. Cox-2
inhibitor is especially useful in case of bone pain. Acetaminophen is an effective
analgesic but with week anti-inflammatory action. Ketorolac can be equally useful for
relieving pain, but it should not be prescribed for continuation beyond five days, due
to high toxicity. Also, important is that NSAIDs can cause renal insufficiency. NSAID
Cox-2 inhibitors like meloxicam and celecoxib are important to avoid ulcer and
gastric side effect (Figura, Smith, & Yu, 2018).
2b.
For bone-related pain management, in accordance with the guideline of WHO, step 1
must include usage of NSAIDs, as it aims to reduce mild pain (Brogan & Odell,
2016). Step 2 is concerned to use initial intense pain with the weak opioid. Further,
step 3 is to control intense pain with stronger opioids. Keeping a view of the MRI
reports and persistent pain, opioid analgesics are of high effectiveness. In the
present case, to reduce the bone pain, immediate release and short-acting opioid
are of high choice for management of the condition. Immediate-release opioids such
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as hydromorphone, oxymorphone, morphine, and oxycodone will be highly efficient
to reduce the pain alleviation. In case of pain severity, fentanyl will be effective in
combination with sustained-release morphine or oxycodone. However, care should
be given to counteract the side effects of nausea and constipation (Frost, Hansen &
Heegaard, 2016). Prochlorperazine could be effective to minimize the nausea
symptoms.
References:
Brogan, S. E., & Odell, D. W. (2016). Pain Management in Metastatic Bone Disease.
In Metastatic Bone Disease, 1,155-168
Figura, N., Smith, J., & Yu, H. H. M. (2018). Mechanisms of, and adjuvants for, bone
pain. Hematology/Oncology Clinics, 32(3), 447-458.
Frost, C. Ø., Hansen, R. R., & Heegaard, A. M. (2016). Bone pain: current and future
treatments. Current opinion in pharmacology, 28, 31-37.
Sebro, R., DeLaney, T. F., Hornicek, F., Schwab, J., Choy, E., Nielsen, G. P., &
Rosenthal, D. I. (2017). Frequency and risk factors for additional lesions in the
axial spine in subjects with chordoma: indications for screening. Spine, 42(1),
E37-E40.
Serak, J., Vanni, S., & Levi, A. D. (2015). The extreme lateral approach for treatment
of thoracic and lumbar vertebral body metastases. Journal of neurosurgical
sciences.
Suzuki, T., Katagiri, H., Noda, T., Ota, S., Murata, H., Wasa, J., ... & Takahashi, M.
(2017). Asymmetrical vertebral collapse from spinal metastasis in lower
thoracic and lumbar spine. Journal of Orthopaedic Science, 22(3), 405-410.
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