Lecture 06 : Week 07

[Music] namaskar this is Dr anurag agal uh and today we are going to talk about the cancer pain and its Interventional pain management through the means of mipsy that is minimally invasive Pain and Spine interventions of pain medicine a new super specialy emerging super specialty of anesthesiology which deals exclusively with the chronic pain syndromes of all kind including the cancer pain so I'm working at a pain physician and professor in anesthesiology department at Dr Ram Manor Lya Institute of Medical Sciences lakau uttar Pradesh bhat uh I have done my mbbs from gsvm kpur and MD anesthesiology from snmc Agra as well as pdcc course uh in pain medicine from Banaras Hindu University uh my area of interest is Interventional Pain and Spine medicine as well as the perous spine endoscopy uh I am vice president of napim up chapter also the founder president of eips that is the first endoscopic spine and Interventional pain Society of India I am a member of pain medicine board uh of the national board of examinations for medical Sciences nbm a government of India autonomous statutary body and I am a member of cancer a society Ethics Committee also I am the Secretary of Indian Society of pain clinicians and this is Indian Society of pain clinicians is the body of formally trained pain physicians in India who has done at least pdcc or FNB or DM pain medicine course so to disclaimer I have no Financial relationship with any manufacturing company or pharmaceutical company consent have been taken from the patient to use their photos and videos for the academic purposes only and mention of trade name is purely for the sake of clarification and simplicity to understand so to iology of cancer pain as we know that incidence of cancer pain is up to 90% in the patients who are surviving with the advanced stages of cancer so there can be multiple causes it can be because of the cancer itself which may result in the visceral pain somatic pain or neuropathic pain it can be caused by the cancer pain which is postsurgical or due to the chemotherapy or due to the radiation therapy of the cancer treatment and then there can be patients who have pain because of the conditions causes unrelated to cancer like a patient of cancer can also have a prolapse invertible dis which may demand their treatment so cancer pain is highly prevalent 30 to 50% of patients of cancer who are in the active therapy they experience chronic unrelenting severe pain which needs to be managed and up to 90% of patients who are in the advanced diseases where the Curative therapies are over or are not working they are in The Chronic severe intractable pain which must be addressed to enhance the quality of life to preserve the dignity in the end of life uh and you need to uh may need to refer this patient to a specialized pain medicine OPD and a pain physician nearby to your place so classification of cancer pain can be done into the somatic cancer pain like the pain which have uh patients are having bone metastasis they have that somatic kind of pain then it can be visceral pain like in the gallbladder cancer or the pancreas cancer then it can be neuropathic pain like in the caroma lung involving uh the braal plexus or uh the group of nerves or post herpetic neuralgia and then there can be the reflex sympathetic destrophy sympathetically mediated pain like it happens in the Phantom limb syndromes so there is a baseline pain as I told you that cancer especially in the advanced condition is not likely to go away so when the disease is there pain is also to be there it is not like something acute event like the there is a fracture you fix it and three month after 3 months pain is gone fracture is healed but that is unfortunately not the case with the chronic pain conditions like the cancer itself where pain is going to remain so you need to give a baseline therapy Around the Clock therapy to cover the Baseline pain and then there can be a pain which is breakthrough in nature which is over and above the uh Baseline pain and which may be related to some activity like the patient of oral cavity can have severe pain while attempting to eat something patient of carcinoma rectal Canal can have severe pain which is over and above the Baseline pain when he tries to defecate so what can we do as a society what can we do as a medical practitioner what can we do as a pain physician so what I can tell you sympathy is not enough just to sympathize oh patient is having so much of pain patient is having that is not going to work we have to do something proactively and what I can tell you what we need to do proactively so first thing if you want to address a problem you need to assess the uh magnitude of the problem and what are the scales available that is the numeric rating scale visual analog scale or descriptive scale like numeric rating scale it is a very simple scale to use the most commonly used by a pain physician to assess the quantity of pain because uh you ask the patient how much pain you are having on the scale of 0 to 100 or 0 to 10 if the patient says zero that means patient is not having any pain if the patient says 100 or 10 on a scale of 0 to 10 patient is having most severe kind of pain and you need to treat it then whenever you provide any treatment as a treatment provider you need to find out the outcome measures there is no point of treating a patient if you are not try finding out whether it is your working or not your treatment is working or not so what are the scales there are pain intensity scale again the numeric rating scale or visual analog scale you use you ask the patient after my treatment how much relief you are having what are the signs of distress have they come down what is the relief and what is the Breakthrough dozing so the aim of any treatment especially in the chronic pain medicine uh you need to optimize the pain control you need to minimize the the side effects otherwise uh what will happen patient is not going going to comply with uh your advice and you need to take care of the cost also and the aim is to increase the functional abilities and to enhance the quality of life so what are the modalities of treatment for the cancer pain management pharmacological approaches we have a uh separate lecture on that you can go through the uh website to find that lecture minimally invasive pain intervention mses and Neurosurgical interventions cryon Alesia long-term epidural implantable devices we will show you later implantable pumps and then there are other therapies so there is a letter uh of analgesics which was proposed and popularized by the World Health Organization where they suggested to start the treatment of any chronic pain especially the cancer pain with the uh easiest of available drugs which are available over the counter which are having less side effects less cost and easily administrable and what are these drugs commonly known as Bruen decopic aspirin paracetamol all these drugs they can be used in the first step of the ladder if the patient is having mild pain on the scale of 1 to 10 patient is telling that I am my pain is only uh two or three then you can start with the first step L but what if the patient says no my pain is five which increases up to seven that comes under the category of moderate pain and you need to step up your drugs uh with the nonopioids that is anets that is Bruen or diphenic as an example along with some weak opioid drugs what are the weak op commonly Ed Codine and tramadol in our country and what if the patient says I am having eight or 10 out of 10 pain I'm having the worst kind of pain then you directly go to the third step of the letter which includes the prescription of strong opioids like the oral morphine tablets and that is the cheapest and easily uh prescribable thing but they are controlled subject so you need to have some center nearby you or you need to refer the patient uh to get this uh step three later but you should know then there was a fourth step which was suggested by uh later on to include the myy minimally invasive p and spine interventions at any L step of this ladder if you feel that you can do or you know someone who can do an effective intervention for your patient which may decrease the requirement of opioids in your patient that it is amazing so that intervention part can be used and should be used uh perhaps in most of the patient if the facilities are available a train pain physician is around and you can refer the patient to get the benefit of this advanced therapy so what are the interventions I'm talking about so the target the aim of intervention is to there are two aim one is through delivery of opioids to the CNS so that the dose reduces drastically suppose you are giving oral tablet so you need to give a lot of drug in comparison to what you required to give if you are directly delivering it to the spinal cord so the do become drastic reduced if you can able you are able to deliver that drug to directly to the spinal cord where it is going to ultimately work or there can be ways to destruct the pain Pathways so that is the intervention so what are the pain pathway destruction this is reserved for the advanced cancer patients where the life expectancy is low we the aim is just to enhance the quality of life to decrease the doses of drugs and their side effects and patient is having sever localized pain so there are multiple Targets in the human body given by the god which we pain physician Target in the percutaneous minimally invasive manner uh to destruct that thing like start from the thalamus to cervical cordotomy at different places dorsal rot isot and all that so what are the common targets uh which we pain fishion Target that is one is the most common is trial neuralgia especially useful for the oral cancer patients even after the surgery or radiation or chemotherapy if the patient is having severe pain we go into the meel cave under a CM F oroscope guidance in a dedicated pain medicine OPD uh OT and we target the gastrin gangon and we do the radio frequency treatment of that the result is that patients requirement of analgesic drugs usually comes down drastically patient gets immediate and long-term pain relief then comes the celic plexus a wonderful intervention for the upper abdominal malignancy patient like the cancer of gallbladder cancer of lower part of the stomach cancer of pancreas and they can be targeted then in the lower part of abdomen cancer of uterus cancer of cervical uh cervix uh cancer of anal Canal they causes severe lower abdominal pain and that can be relieved with the help of superior hypogastric plexus risis and then cancer of anal Canal cancer of rectum they also respond to the gangon empar so the celic plexus destruction it is situated in front of aorta at the level of L1 and it is very useful intervention for the upper abdominal visal pain due to gallbladder cancer pancreas cancer stomach and lower part of esophagus cancer and up to 85% patient they report of wonderful pain relief after that then Super hypogastric plexus as I told uh it is in the lower part of abdomen in front of the spine V pain Physicians use a CR fluoroscope and x-ray machine in a pain medicine OT and we target this plexus and this results in a wonderful pain relief in the patients of carinoma of blader urinary bladder prostate cervix uterus ovary and colon then comes the gangon impar again minimally invasive intervention no big incision no big admission no long-term uh uh admission in the hospital and patient gets better uh with the sectum anal canal and vagina vva cancer patients then comes the most advanced treatment for the bone metastatic pain when there is a metastasis that means the spread of cancer to the Bone we pain Physicians are able to do upper cous cementoplasty in these patients and these patients are usually unresponsive to Conventional phaco and radiation therapy please remember radiation is considered to be the most uh firstline treatment for the bone metastatic patient but unfortunately it doesn't work for all it does work it takes up to 6 weeks to work and if after 6 weeks there is no relief it is not going to be relieved so what we do that we stabilize the bone with the metastasis with the perotinus delivery of bone specialized bone cement that is pmma cement and most commonly we treat the vertebral metastasis with kyphoplasty and vertebroplasty so here you can see that there is a patient who had collaps of vertebra and we have gone inside with our fine equipment under the cam fos scope picture and we have finally achieved The Filling of vertebra stabilization of vertebra with the cement and with the immediate relief then comes the intal morphine pump for cancer pin amazing treatment amazing treatment and here you can see this is one of our patient we put use a very fine catheter to deliver the medicine directly to the spinal cord and we fill this pump with the morphine drug morphine injection place it under the skin in the lower part of abdomen here you can see uh that patient this catheter is going into the spine and this is the catheter uh this is a pump which is filled with the morphine the most amazing part is that this this particular patient was on 150 mg of oral morphine per day 150 and currently through this pump this patient is only on 0.6 mgram morphine in 24 hours so you can see the DraStic reduction of morphine doses to the patient with immediate and wonderful relief and with almost nonexistent side effects while when patient was on the oral morphine patient was having severe Nosa vomiting severe constipation for that we were giving lot of medicine different medicine but now he's free of all medicines this pump is continuously working by itself every 4 month patient comes to us we refill it without any incision in a perous manner through an injection and patient goes back so at our Institute of Dr ramania Institute of Medical Sciences LNO at pain medicine OPD what we are providing we are providing acute pain service is for our inpatients we are providing pain medicine OPD where we are treating all kind of chronic pain patients including the low back pain spine pain vertebral fractures neuralgic pain trinal neuralgia post herpetic neuralgia uh joint pain arthralgia arthritis rheumatological diseases and all kind of different and difficult pain syndromes even after the pain after the spine surgery and after the total knee replace placement with the most advanced myses like the radio frequency ablation cooled radio frequency ablation pulse radio frequency ablation intrathecal pumps spinal cord stimulator vertebral stent like this is something new for you guys I believe uh like we put the stent in the heart for the heart condition now we are able to put the St in the vertebral body to stabilize it that is the most advanced treatment of the India of of the word and which we are able to provide to our patients and you will be happy on this here note to notice that in pain medicine we are no less than anyone across the globe so you should be proud of it uh cancer pain we are also treating so most of the cancer pain patients are managed with the wh letter uh but uh multiple mses are available which can be helpful and then pumps and for dienal therapies we are doing neck pain back pain spine pain with the epidurals transformal facet denervation with radio frequency and other things sacr joint rolis myses for trial neuralgia gasin gangion glossop neuralgia sphenopalatine lumber sympathectomies for bur disease and all that and for sympathetic mine cancer non-cancer patient start from the state gangon rolis to Lumar sympathectomies suia rolis plenn rolis hypogastric gangar all these so now few case reports this was a female uh she was post surgery post CT scan post radiotherapy of carcinoma cervix with locally invasive tumor and metastasis she complained of severe pelvic visceral pain not relieved with multiple analgesic like traod dool and morphine and we did Superior hypogastric plexus rolis with phenol and now patient has come down to the step one of wh letter from she was not relieved with step three after the intervention she she is stable at step one with acinic only so this is the picture of real patient where you can see that our fine canulas has gone inside the patient ahead of the spine and we have put some dye to localize the area and then we did the rolis another patient she was 55 year female back pain with no radiation sitting intolerance and on yday we found that she had a fracture of D12 vertebra and Sh abnormal shadow that was metastasis at her hip bone that is sacrum and on MRI the diagnosis was confirmed and here you can see that in the MRI of picture you can see that this is collapsed D12 vertebra and also at the sacrum you can see that is fill up of metastatic leson so we did a complete workup she was unresponsive to the wh lader we did a perous vertebroplasty as well as a perous sacroplasty and her pain was completely relieved so you can see that there's a bone cement in the sacrum left side of sacrum as well as bone cement in the D12 vertebra and she was completely relieved without any big incision without any multi Hospital stay now another patient she was a he was a patient of caroma lung and which was involving the IAL plexus which is the group of nerves which supplies the upper arm Upper Limb here you can see on the CT scan the Ed tumor on the left side of lung with the severe pain most severe pain and we what we did we did a high cervical cordotomy of this patient at c0 C1 level that is the most advanced intervention uh to the date and very few people uh in India and Globe practice it we fortunately do thanks to our teachers and uh bhagan Almighty we are able to help our patients here you can see our fine Cala is going into the spine spinal cord actually and we target the lateral spinothalamic tract uh with the radio frequency of this thing so the end point is that not everyone can bear pain so please treat it ours bat India is a land of sages big big sages who can be pain we have a story of bish Pama who laid on the uh multiple uh spikes but not everybody can treat it uh so please treat it as a doctor so and freedom from pain is a basic human right and this is my Institute Dr Ramya Institute of Medical Sciences as I told you earlier I a pain physician and a professor of anesthesiology we run a pain medicine OPD and a pain medicine W and pain medicine OT we do all kind of advanced myses and comprehensive care for all type of chronic pain patient uh we urge uh all the people listening to it who are from the anesthesiology background if you are interested uh in the field of pain medicine uh we are having pdcc one year course at our Institute you can visit the website of Institute Dr ramman Dr rml im. ac.in to find out about it you can also join us for the observership of 1 to 3 months at our Institute if you are interested in the pain medicine so with these words good luck and good wish from my Institute that is Dr Ram Loya Institute of Medical Sciences lakau uh I am having my uh Facebook page with the name of painfree India drag agrawal as well as a YouTube channel with the name of painf free India and where I put uh lot of videos of the procedures mses as well as uh of the different testimonials of the patient for the awareness purposes all only about the availability of most advanced treatment for the chronic pain syndromes so please use it please visit and thank you and good luck for your bright future thank [Music] [Music] you [Music]