Interventional Therapies for Cancer Related Pain

Transcript

• 00:00Years now.
• 00:02Most of my practice is
• 00:04interventional pain.
• 00:06My house is Long Wharf
• 00:07Spine Center, and we do
• 00:09have a Smito Cancer Pain
• 00:10Clinic that we staff once
• 00:11a week.
• 00:12My passion is, in cancer
• 00:14related pain.
• 00:16I think it's a huge
• 00:17unmet need,
• 00:19that we can do a
• 00:20lot more for.
• 00:22So before further ado, I
• 00:24will get started.
• 00:27I have nothing to disclose.
• 00:30These are the learning objectives.
• 00:32We'll brush up on the
• 00:33WHO ladder to initiate analgesia
• 00:35for cancer related pain,
• 00:37and we'll learn a little
• 00:38bit about some common basic
• 00:40interventional pain procedures that we
• 00:41can offer cancer related,
• 00:43cancer pain patients.
• 00:45We'll also go over indications
• 00:47and contraindications,
• 00:48and then I will
• 00:50introduce intrathecal pumps or intrathecal
• 00:52drug delivery systems,
• 00:54just a basic introduction,
• 00:56because of the limited amount
• 00:58of time that I have.
• 01:00Cancer associated pain may present
• 01:02at any time during the
• 01:03disease course.
• 01:05Overall prevalence of cancer related
• 01:07pain is believed to be
• 01:08around forty four percent,
• 01:10with thirty percent patients experiencing
• 01:12at least moderate to severe
• 01:13pain. The prevalence increases as
• 01:16a stage,
• 01:17of cancer or metastases,
• 01:19occur, and it is, assumed
• 01:22about two thirds of patients
• 01:23with advanced cancer will have
• 01:25pain. About a third of
• 01:26them will complain of, very
• 01:28severe pain.
• 01:29Despite these numbers, inadequate analgesia
• 01:32is prevalent in about forty
• 01:33percent of patients, which is,
• 01:35unfortunate reasons often cited,
• 01:38for that huge,
• 01:40gap in care versus symptoms,
• 01:42is cited to be,
• 01:44pain being often a second
• 01:46afterthought or a lower down
• 01:48on the priority list for
• 01:49both patients, their families, and
• 01:51their clinicians.
• 01:52Although we know that if
• 01:53we assess pain
• 01:56appropriately and are able to
• 01:57manage it appropriately, about seventy
• 01:59to eighty percent patients, even
• 02:00with advanced or metastatic cancer,
• 02:02can be,
• 02:04treated,
• 02:05with some, analgesia.
• 02:08Not only that, we now
• 02:09have a novel cancer survivor
• 02:10group with the advances in
• 02:12oncologic treatments.
• 02:14Forty per forty seven percent
• 02:15of cancer survivors
• 02:17will end up with some
• 02:18kind of chronic pain syndrome,
• 02:19either related to the chemotherapeutic
• 02:21agents that they've
• 02:23had to,
• 02:24endure or surgeries or interventions
• 02:26that they've endured.
• 02:29Cancer pain syndromes broadly may
• 02:31be related to either the
• 02:33cancer itself
• 02:34or as a result of
• 02:36interventions and surgeries that are
• 02:37performed,
• 02:39for,
• 02:40oncologic treatment.
• 02:42It could be acute or
• 02:43chronic,
• 02:44could be nociceptive or neuropathic.
• 02:46It is important to delineate
• 02:48characteristics of nociceptive versus neuropathic
• 02:51pain so as to be
• 02:51able to tailor our, analgesic
• 02:53treatments towards the specific underlying
• 02:55cause. Nociceptive pain, is believed
• 02:58to be perceived as a
• 02:59result of constant afferent nociceptive
• 03:02input as a result of
• 03:03ongoing tissue injury. It could
• 03:05further be subdivided as somatic
• 03:06or visceral.
• 03:07Somatic pain is often described
• 03:09as sharp, aching, throbbing,
• 03:11comes from somatic structures, including
• 03:13bones, scared, musculus
• 03:15muscular skeletal system,
• 03:17ligaments, injury, ligaments,
• 03:20tendons, and muscles,
• 03:21while visceral pain, originates more
• 03:23from visceral structures, and it's,
• 03:25less well defined, diffuse, cramping,
• 03:27and knowing. Neuropathic pain, by
• 03:28definition,
• 03:29arises from damage to the
• 03:31central or peripheral nervous system.
• 03:32The descriptors often used by
• 03:34patients are burning electric shock,
• 03:37sharp shooting kind of pains,
• 03:38allodynia, hyperalgesia.
• 03:40It's important to distinguish the
• 03:41characteristics of pain since treatment,
• 03:44for nociceptal neuropathic pain could
• 03:46be very different.
• 03:48In addition,
• 03:49the cancer pain patients will
• 03:51often have
• 03:52prominent
• 03:55underlying neuropathic pain, which can
• 03:56be extremely severe to treat
• 03:57and really affects their quality
• 03:59of life.
• 04:01You've all seen the numerical
• 04:03rating scale and the visual
• 04:04analog scale.
• 04:06Commonly used scales,
• 04:08such as these help
• 04:09eliminate cultural and linguistic barriers,
• 04:12and the data is more
• 04:13reliable.
• 04:14In addition, we also have
• 04:16the McGill and,
• 04:18McGill Malzac pain questionnaire and
• 04:20the brief pain inventory, which
• 04:22we often use in cancer
• 04:23pain patients to further hone
• 04:25down on the characteristics of
• 04:26pain.
• 04:28This is the traditional WHO
• 04:30step ladder, which was introduced
• 04:31in nineteen eighty six.
• 04:34It basically
• 04:37it basically,
• 04:39wants wants us to manage
• 04:40pain based on, the severity
• 04:42of pain symptoms.
• 04:44Use step one, step two,
• 04:45or step three medications
• 04:47for mild, moderate, or severe
• 04:49pain. Step one medications include
• 04:50Tylenol and NSAIDs. Step two
• 04:52medications are weak opiates. Step
• 04:53three medications are stronger opiates.
• 04:55Quaenogestics and adjuvant such as
• 04:57muscle relaxants and neuropathics could
• 04:59be used at any step
• 05:00of, the ladder.
• 05:02The overarching principle of the
• 05:04WHO ladder is by the
• 05:05patient, appropriate dose is one
• 05:07that relieves pain in a
• 05:08particular patient, so individualized treatment.
• 05:11By the mouth, oral route
• 05:12is preferred. By the schedule,
• 05:14instead of PRN, try to
• 05:16do scheduled dosing.
• 05:18And by the ladder, meaning
• 05:20if pain is not relieved
• 05:21with step one,
• 05:24don't go drug to drug
• 05:26along the ladder. Go up
• 05:27the ladder.
• 05:28This is the most recent
• 05:30iteration of the WHO ladder
• 05:32where a fourth step, that
• 05:33is the interventional pain options,
• 05:36has been added, and that's
• 05:36where we come in as
• 05:37interventional pain specialists.
• 05:40So what are some common
• 05:41scenarios that we get consults
• 05:42for? Somebody with pancreatic cancer
• 05:44with meds to the liver
• 05:45experiencing worsening abdominal pain despite
• 05:47escalating opiates,
• 05:49somebody with locally advanced cervical
• 05:50cancer experiencing perennial and rectal
• 05:53pain not well controlled in
• 05:54opiates,
• 05:55somebody who has pleural based
• 05:56meds and now has chest
• 05:57wall pain also on poorly
• 05:59also on high doses, opiates
• 06:01and pain is, worsening with
• 06:03adverse effects related to opiates.
• 06:06This is obviously not an
• 06:07exhaustive list, of all the
• 06:09procedures we can offer,
• 06:11but I'll try to touch
• 06:12upon,
• 06:13procedures that have the most
• 06:14robust evidence.
• 06:18So one of the procedures,
• 06:20that we perform quite often
• 06:21and get consults for is
• 06:23a celiac plexus block.
• 06:25It is used for treatment
• 06:26of cancer pain originating from
• 06:28upper abdominal viscera.
• 06:31Just a review of anatomy,
• 06:32celiac plexus is the largest
• 06:34plexus of the sympathetic nervous
• 06:35system, provides sensory innovation,
• 06:38to four gut structures, including
• 06:40the stomach,
• 06:41small bowel, all the way
• 06:42up to the mid transverse
• 06:43colon, as well as liver,
• 06:44pancreas, spleen, and gallbladder.
• 06:46It contains both preganglionic sympathetic
• 06:48fibers from the greater and
• 06:50lesser splanchnic nerves
• 06:52as well as postganglionic sympathetic
• 06:54fibers and preganglionic
• 06:55parasympathetic fibers. The plexus itself
• 06:58is located
• 06:59anterior to the aorta behind
• 07:00the cilia artery takeoff just
• 07:02at the l one level.
• 07:05This is where we access
• 07:06it.
• 07:07There are several different techniques
• 07:09that have been described
• 07:10for cilia plexus block, percutaneous
• 07:12versus endoscopic ultrasound guided blocks,
• 07:15the latter performed by GI
• 07:17doctors. Percutaneous blocks can be
• 07:19performed by CT guidance,
• 07:21or fluoroscopic guidance. We typically
• 07:22do them with fluoro guidance.
• 07:25If you look at the
• 07:25literature,
• 07:26there is no significant
• 07:28difference in outcomes as to
• 07:30how you do these blocks,
• 07:32as long as it's done
• 07:33safely.
• 07:37There is percutaneously,
• 07:39you could either do this
• 07:40retrocrual technique versus transaortic.
• 07:43Transaortic is what I was
• 07:44trained with, although it has
• 07:46fallen out of distribute because
• 07:47of some case reports,
• 07:49of complications.
• 07:51Retrocrual versus transaortic basically means
• 07:54where the needle tip ends
• 07:56up being parked. Is it
• 07:57going through the aorta,
• 07:59right after the cilia plexus,
• 08:00or you're really blocking the
• 08:02splanchnic nerves?
• 08:05Not to belabor,
• 08:06everyone with procedural
• 08:08details, but this is how
• 08:10we perform a fluoroguided cilia
• 08:11plexus block.
• 08:13The left image is, an
• 08:15oblique image of the needle
• 08:16being advanced.
• 08:18Under lateral, you place a
• 08:20right and a left sided
• 08:21needle. Under lateral, you'll see
• 08:22these two needles, and the
• 08:23needle tip would be parked
• 08:24right at the anterior edge
• 08:26of the l one vertical
• 08:27body. This is a little
• 08:28bit low needle placement. We
• 08:30really would prefer the needles
• 08:31to be placed at t
• 08:32twelve l one,
• 08:34disk space or right underneath
• 08:35there.
• 08:36Most common side effects of
• 08:38this block are diarrhea and
• 08:40hypotension, and that's because the
• 08:41medication that we use for
• 08:42the neulysis is either ninety
• 08:44eight percent alcohol or six
• 08:45percent phenol.
• 08:47Honestly, it's one of the
• 08:48most gratifying,
• 08:49blocks to do. Patients have
• 08:50a pretty immediate pain relief,
• 08:52and the side effects are
• 08:53usually self limited.
• 08:54Diarrhea is reported in about
• 08:56forty four to sixty percent
• 08:57of patients, so quite common.
• 09:00But usually patients don't mind,
• 09:02the diarrhea. It's, often a
• 09:03welcome change from the constipation
• 09:05that they've been experiencing,
• 09:07due to the high doses
• 09:08of opiates.
• 09:09And it is usually transient.
• 09:11Although if you look at
• 09:12literature, there'll be case reports
• 09:13of more prolonged diarrhea, usually
• 09:15lasts about two, three days.
• 09:17Hypertension is the second most
• 09:18common side effect,
• 09:20reported in about ten to
• 09:22fifty percent of patients. Also,
• 09:24transient, lasting one to five
• 09:25days. Often, patients are dehydrated.
• 09:27We try to avoid this,
• 09:29side effect by preloading with
• 09:31fluids.
• 09:35So what's the evidence?
• 09:38This was a systematic review
• 09:39that was published in twenty
• 09:40fifteen that looked at sympathetic
• 09:42blocks for visceral cancer pain.
• 09:44It clubbed all celiac plexus
• 09:46and superior hypogastric block studies
• 09:48that compared these blocks with
• 09:50conventional analgesics.
• 09:51There were fourteen studies for
• 09:53celiac plexus block.
• 09:54Although twelve of the fourteen
• 09:56were very low quality, two
• 09:58studies were extremely high quality,
• 10:00randomized controlled trials, and I'll
• 10:02discuss one of them in
• 10:03this, doc.
• 10:05The overall conclusion of the
• 10:07systematic review was celiac plexus
• 10:09blocks
• 10:11have strong evidence in in
• 10:12their favor
• 10:13for analgesia,
• 10:14for reducing opioid consumption.
• 10:16Some studies also touched upon
• 10:18quality of life and survival.
• 10:21The timing of the block
• 10:22has been,
• 10:23evaluated.
• 10:24When should we do this
• 10:25block? Should we do it
• 10:26at diagnosis? Should we do
• 10:27it when patients, are not
• 10:29in high doses of opiates?
• 10:30So this study actually randomized
• 10:32sixty patients to three groups.
• 10:34One group received a neurolytic,
• 10:36celiac texas block when the
• 10:37MME,
• 10:38average morphine milligram equivalent for
• 10:40the patient was less than
• 10:41ninety.
• 10:42The second group,
• 10:44received blocks when their MMA
• 10:45was already above ninety, and
• 10:46the third block third group
• 10:48received no blocks.
• 10:49These authors found that the
• 10:51first two groups had significant
• 10:53pain relief and reduced opioid
• 10:54consumption as well as a
• 10:55better quality of life compared
• 10:57to the third group, but
• 10:58there was no significant difference
• 10:59between the first or the
• 11:00second group. So these authors
• 11:02concluded that irrespective of the
• 11:04amount of MMA that they're
• 11:05consuming,
• 11:06patients',
• 11:07anagenic response is similar. So
• 11:09celiac plexus block should be
• 11:11offered.
• 11:12Then there's another school of
• 11:13thought that,
• 11:14feel that MME is not
• 11:16necessarily an indication of stage.
• 11:19So there was another study
• 11:20that,
• 11:21decided to
• 11:22compare patients who received the
• 11:24block at the time of
• 11:25diagnosis before
• 11:27opioid analgesics have reached, high
• 11:29doses
• 11:30versus,
• 11:32bring the pain down to
• 11:33a level four with some
• 11:34opioid analgesics and then do
• 11:35the block. The latter group
• 11:37actually performed better as far
• 11:39as the
• 11:40duration of pain relief from
• 11:42the block itself for unknown
• 11:43reasons.
• 11:45This was one of the
• 11:46high quality randomized control trials
• 11:48out of Mayo Clinic that
• 11:49was cited in the systematic
• 11:51review.
• 11:52This was a long study
• 11:53where they randomized,
• 11:55forty nine page ninety
• 11:57ninety eight patients, I believe.
• 11:59One half to see neurallytic
• 12:01cilia plexus block, the other
• 12:02half to opioid only.
• 12:05These authors showed that cilia
• 12:06plexus block afforded better pain
• 12:08relief, reduced opioid consumption, reduced
• 12:10adverse effects.
• 12:12Quality of life was not
• 12:13different,
• 12:14but what they did report
• 12:15interestingly is that sixteen percent
• 12:18of patients
• 12:19were alive at twelve months
• 12:21with a block and six
• 12:22percent were alive with opiates
• 12:24only.
• 12:25The issue of survival is
• 12:26a contentious one.
• 12:28Previous studies have shown that
• 12:30survival can actually be prolonged.
• 12:32This was from the nineties,
• 12:34where interop splanchnectomy
• 12:36actually helped,
• 12:37improve survival.
• 12:40But I wanna bring to
• 12:41your attention this study that
• 12:42was recently published in anesthesiology.
• 12:45This is from twenty twenty
• 12:46one. This is a multicenter
• 12:47randomized controlled trial
• 12:49where the authors,
• 12:51randomized patients to a neuroleptic
• 12:53block with alcohol
• 12:55versus neuroleptic block with saline.
• 12:57Both groups were allowed as
• 12:59much opioid as they need
• 13:00for adequate pain relief. And
• 13:02if you see in the
• 13:03graph on the right hand
• 13:04side, the neuroleptic block group
• 13:06actually had much better pain
• 13:08relief compared to
• 13:09the group that had the
• 13:11block with saline,
• 13:12because they were also taking
• 13:14opiates. Although this difference starts
• 13:16to level off around
• 13:18month three. They also had
• 13:19reduced opioid consumption,
• 13:22and that starts to level
• 13:24off by
• 13:25five months. And that is
• 13:26more clear in this table.
• 13:28If you notice,
• 13:29the starting pain scores for
• 13:30both groups are similar.
• 13:32The pain reduction
• 13:33is
• 13:35present even in the control
• 13:36group, but notice the amount
• 13:38of opiates that the control
• 13:39group is taking. The opioid
• 13:41consumption is increasing in the
• 13:43control group that received only
• 13:45saline blocks, and it's in
• 13:46fact decreasing in the neuroendocrine
• 13:49plexus block group. Although it's
• 13:51that different status disappear
• 13:53as even neurolytic blocks,
• 13:55patients
• 13:56start to have an increase
• 13:57in the opioid consumption.
• 13:59The reason I bring this
• 14:00study up is,
• 14:02because there was an interesting
• 14:04post hoc exploratory analysis performed
• 14:06by these authors where they
• 14:08showed a state survival discrimination
• 14:10difference between the block and
• 14:13the control group,
• 14:15especially in stage four patients.
• 14:16That is patients who are
• 14:18receiving neurotic blocks are actually
• 14:20living
• 14:21shorter.
• 14:22So
• 14:23these authors didn't delve much
• 14:25into what the reasons
• 14:27might be. They did tickle
• 14:28with the idea, maybe the
• 14:29autonomic nervous system and the
• 14:31sympathectomy that you're causing might
• 14:32have something to do with
• 14:33survival,
• 14:34but they didn't delve much
• 14:35into it.
• 14:37They just reported it, as
• 14:38a conclusion that maybe we
• 14:40should offer patients
• 14:42celiac plexus blocks early, not
• 14:44necessarily at diagnosis,
• 14:45but before they reach stage
• 14:47four.
• 14:49That is a good general
• 14:50club discussion, so I will
• 14:51move on to the next
• 14:53block.
• 15:01I often about the patient
• 15:03selection
• 15:03for celiac collections blocks.
• 15:06And I was just curious
• 15:07if you have any experience
• 15:09to share or data
• 15:11that would help us know
• 15:12in terms of pain pattern
• 15:14or characteristics
• 15:16whether a patient may do
• 15:18better or not?
• 15:19So if every so every
• 15:21patient is variable, which is
• 15:22why the studies say that
• 15:24don't depend on the MME,
• 15:26as to when to offer
• 15:27the block. Some patients need
• 15:29very little MMA till the
• 15:30end of life. Patients who
• 15:31are on escalating doses of
• 15:33opiates,
• 15:35would be good candidates, especially
• 15:36if they have visceral pain
• 15:37in the upper abdomen,
• 15:39referable to,
• 15:40four gut structures. A pancreatic
• 15:42cancer pain patient, for example,
• 15:43who's on escalating doses of
• 15:45opiates and is constipated. Opiates
• 15:47work, but constipation and quality
• 15:49of life is declining. That
• 15:50would be a great candidate
• 15:51for a celiac plexus block.
• 15:54But I I wouldn't do
• 15:55it at diagnosis.
• 15:57Not everybody needs a celiac
• 15:58plexus lock, and that's also
• 15:59been shown
• 16:00that you wanna see some
• 16:02pain, and pain needs to
• 16:03become brought down with some
• 16:05opioid,
• 16:06before you consider it. So
• 16:07it's not a first step,
• 16:07but it should also not
• 16:08be a last step based
• 16:10on the pain characteristics and
• 16:11the patterns is what I
• 16:12would say.
• 16:17Mhmm.
• 16:19Related to pancreatic cancer. So,
• 16:21yep, any foregut structure
• 16:23causing upper abdominal epigastric pain.
• 16:26If it's classic, that's a
• 16:27slam dunk, but oftentimes we've
• 16:29done blocks,
• 16:30for,
• 16:31you know, cholangiocarcinomas,
• 16:32a patient with splenomegaly having
• 16:34upper abdominal pain. I did
• 16:36one for renal cell carcinoma
• 16:38patient,
• 16:39will really depend on the
• 16:40pain characteristics.
• 16:43Superior hypogastric plexus blocks do
• 16:45not have as robust an
• 16:47evidence as celiac plexus blocks.
• 16:49There is
• 16:50only one randomized controlled trial
• 16:52that I could find, although
• 16:53it was a low quality,
• 16:55that compared pelvic
• 16:57that compared superior hypogastric plexus
• 16:59block to opioid analgesia for
• 17:01patients with gynong malignancies
• 17:03and showed superior pain relief
• 17:04and lesser opioid consumption.
• 17:06The plexus itself lies anterior
• 17:08to the l five s
• 17:09one disc space and receives
• 17:10l three to l five
• 17:11sympathetics and s two to
• 17:13s four parasympathetics.
• 17:16The indications
• 17:17are for
• 17:18lower abdominal pain related to
• 17:20distal gut or pelvic
• 17:22cancers.
• 17:24There's two different approaches that
• 17:25are described. This is a
• 17:27classic approach, although a little
• 17:28bit
• 17:32challenging sometimes, especially in women
• 17:34with the huge iliac crest
• 17:35in the way. This is
• 17:36a preferred technique. There's always
• 17:38a risk of neurovascular injury.
• 17:40Not the most comfortable block.
• 17:42Patients often have to be
• 17:43sedated since we're going through
• 17:44the psoas muscle, which can
• 17:45irritate their lumbar plexus.
• 17:47Contraindications
• 17:48are similar to celiac plexus
• 17:49block. Any patients with bleeding
• 17:51diathesis,
• 17:52inability to hold blood thinners,
• 17:54platelet count less than one
• 17:56hundred thousand, INR more than
• 17:57one point two,
• 17:59infection either intra abdominal or
• 18:01at the site of injection
• 18:03in the back,
• 18:05or systemic
• 18:06infection, positive blood cultures.
• 18:08Big one is patient refusal.
• 18:12So that was the classic
• 18:14approach. This is a picture
• 18:15of the trans disco approach,
• 18:17which in addition to the
• 18:18risk of neurovascular injury adds
• 18:20the risk of discitis. So
• 18:21this is not something we
• 18:22perform often.
• 18:25The next few slides are
• 18:26just pictures,
• 18:28and names of blocks that
• 18:29we do because we have
• 18:30limited time. I can't delve
• 18:32deep into every single block.
• 18:33But this is a picture
• 18:35of ganglion Impar block that
• 18:36we offer for patients with
• 18:37perineal pain with gynoc malignancies,
• 18:40prostate cancer pain.
• 18:41The needle is placed anterior
• 18:43to the sacrococcygeal
• 18:44ligament. You see contrast
• 18:46dye spread here.
• 18:48Pudendal nerve blocks can be
• 18:50done for pudendal neuralgia,
• 18:52often also,
• 18:54as a diagnostic block prior
• 18:55to peripheral nerve stems. We
• 18:57place the needle medial to
• 18:58the ischial spine under fluoro
• 19:00guidance. Outcomes have been shown
• 19:02to be similar. Safety has
• 19:04been similar to ultrasound guidance,
• 19:06although ultrasound guidance does,
• 19:08afford the benefit
• 19:10of,
• 19:11seeing the pudendal artery.
• 19:13Iliohypogastric,
• 19:14ilioinguinal nerves, blocks can be
• 19:16done for groin pain as
• 19:17long as there's no lymphadenopathy
• 19:19in the tract of the
• 19:20needle.
• 19:21These are pretty easy to
• 19:22perform with ultrasound guidance.
• 19:24So I know I'm running
• 19:25out of time, but I
• 19:26do wanna introduce intrathecal pump.
• 19:30This is something,
• 19:32one of the most advanced
• 19:33therapies that we as international
• 19:34pain physicians can offer.
• 19:37The essence of intrathecal pump
• 19:38is delivering the medication directly
• 19:40into into the CSF via
• 19:42a catheter in the intrathecal
• 19:43space that is connected to,
• 19:45a permanent pump that is
• 19:47implanted in the anterolateral
• 19:49abdominal on the subfascial layers.
• 19:50The advantage of
• 19:53putting medication right into the
• 19:54CSF is reduce is the
• 19:56ability to reduce the amount
• 19:57of opioid that the patient
• 19:59is consuming by an order
• 20:00of ten to hundred times,
• 20:01thereby reducing adverse effects,
• 20:03improving functionality, quality of life,
• 20:05appetite, etcetera.
• 20:07There's at least one randomized
• 20:08controlled trial in several prospective
• 20:10observational studies that have shown,
• 20:13benefit in favor of intrathecal
• 20:15pumps, not necessarily a salvage
• 20:16therapy for cancer related pain,
• 20:18but even earlier.
• 20:21So we go by what
• 20:23we call the PACT guidelines,
• 20:25to select and identify patients
• 20:26and manage these patients later
• 20:28on. PACT stands for polyanalgesia
• 20:30consensus conference.
• 20:31This is a group of,
• 20:33international neuromodulation society members that
• 20:35are world experts both nationally
• 20:37and internationally
• 20:38based on their clinical experience
• 20:40and research,
• 20:42contributions to the field.
• 20:44These guidelines
• 20:45provide us overarching principles
• 20:47of how to select patients
• 20:49and how to manage these
• 20:50patients.
• 20:51So an ideal candidate would
• 20:52be somebody who is becoming
• 20:54opioid tolerant with prohibitory,
• 20:56side effects.
• 20:58Opiates work but can't take
• 20:59them because of the side
• 21:00effects and someone who's failed
• 21:02other less invasive,
• 21:03conservative,
• 21:04options.
• 21:06Life expectancy used to be
• 21:07six months, has been reduced
• 21:09to three months.
• 21:10Important consideration before we select
• 21:12patients for an intrathecal pump
• 21:14is a discussion with our
• 21:15implanting neurosurgeon.
• 21:17Proximity to the cans proximity
• 21:19of the cancer to mets
• 21:20or mets close to the
• 21:22neuraxis or the implantation site
• 21:25becomes tricky for our neurosurgeons
• 21:27to implant the pump.
• 21:28Again, our surgeons also decide
• 21:30what size pump to place
• 21:31twenty versus forty ml,
• 21:33based on body habitus, the
• 21:35amount of cachexia.
• 21:36A forty ml pump usually
• 21:37would last patients two to
• 21:38three months.
• 21:39And, of course, we have
• 21:40to have systems in place,
• 21:41including family and social support
• 21:43system for these patients to
• 21:44come in for follow ups
• 21:45and refills.
• 21:47As far as intrathecal trials
• 21:48go, the guideline says it's
• 21:50discretionary or optional and really
• 21:52depends on patient and clinician
• 21:55preference,
• 21:56as well as practice pattern.
• 21:58Some insurers need an intrathecal
• 22:00trial before a permanent pump
• 22:01is approved, but most times,
• 22:03this provision is waived.
• 22:05Other than the single cone
• 22:07that the guideline describes
• 22:09delay of getting a clamsopine
• 22:11patient a permanent pump, there's
• 22:12a lot of disadvantages to
• 22:14doing an intrathecal trial.
• 22:17So in our practice, we
• 22:18typically, after selecting patients, get
• 22:20them admitted for an inpatient
• 22:22continuous catheter trial.
• 22:24One, it gives the patient
• 22:25a sneak peek as to
• 22:26what to expect from therapy.
• 22:28Second, we are able to
• 22:29trial different drugs, which would
• 22:31take weeks in an outpatient
• 22:32setting after the permanent pump
• 22:33already goes in. A patient
• 22:35doesn't tolerate morphine may do
• 22:36better with hydromorphone.
• 22:38With the trial, we have
• 22:39an externalized catheter connected to
• 22:40a CAD pump, and we
• 22:41can simply change the medications
• 22:43every few hours. So our
• 22:44trials usually last two to
• 22:45five days.
• 22:47We often end up uptitrating
• 22:49the dose pretty rapidly because
• 22:51we're in a monitored inpatient
• 22:52setting. So a trial allows
• 22:54us,
• 22:55that benefit,
• 22:56and we often end up
• 22:57adding second line agents such
• 22:58as bupivacaine
• 23:00during the trial to figure
• 23:01out what medication provided the
• 23:03most analgesic relief, and that
• 23:04would be something that would
• 23:06go in the pump.
• 23:07And we try to work
• 23:08with our neurosurgery colleagues to
• 23:09get the pump implanted within
• 23:11the week after the trial.
• 23:14The choice of medications depends
• 23:15on the characteristics of pain.
• 23:17Morphine, hydromorphone are first line
• 23:19agents,
• 23:20usually used for nociceptive pain.
• 23:22Ziconotide,
• 23:23although has FDA approval as
• 23:24a first line agent, is
• 23:26primarily for neuropathic pain, but
• 23:28its use is honestly limited
• 23:29in the cancer pain population
• 23:31because of the side effects.
• 23:32It's an l type calcium
• 23:33channel blocker and can cause
• 23:35dangerous ventricular arrhythmias, so it
• 23:37doesn't allow us to uptitrate
• 23:38rapidly as with morphine hydromorphone.
• 23:40So we hardly ever use
• 23:41Iconotide.
• 23:43Oftentimes, we'll add bupivacaine for
• 23:44the neuropathic
• 23:45component.
• 23:47Another advantage of the trial
• 23:49is that it lets us
• 23:50know where the catheter tip
• 23:52should be based on the
• 23:53dermatomal pain patterns and how
• 23:55the patient's response to the,
• 23:58medications is. This is what
• 24:00the pump looks like. It's
• 24:02a titanium disc about three
• 24:03inches wide and an inch
• 24:05thick, and it is placed,
• 24:08in the
• 24:09fascial layers, usually in the
• 24:10anti abdominal wall, sometimes,
• 24:12in the buttock.
• 24:15This is a pump broken
• 24:16apart.
• 24:17What I wanna draw your
• 24:18attention to is the magnetic
• 24:20rotor that actually drives the
• 24:21medication through the catheter.
• 24:24So if you think about
• 24:25getting an MRI in a
• 24:26patient with an intrathecal pump,
• 24:28the magnetic rotor will simply
• 24:29line with the magnetic field
• 24:31of the MRI
• 24:32and fail to deliver the
• 24:34medication. In other words, it
• 24:35stalls, but it should restart
• 24:36right after the MRI
• 24:38should, but there have been
• 24:39cases of it not restarting.
• 24:41So always a good idea
• 24:42to reinterrogate the pump.
• 24:44This is the reservoir fill
• 24:46port that allows us to
• 24:47refill medications, which I said
• 24:49as I said before, two
• 24:50to three months for a
• 24:51person with a forty ml
• 24:53pump. The catheter access port
• 24:55is occasionally used for a
• 24:56pump program if the pump
• 24:58is not functioning adequately.
• 25:00Pumps are safe, as far
• 25:02as the study goes in
• 25:03one and a half and
• 25:04three Tesla,
• 25:06MRIs.
• 25:07Stop here. In the interest
• 25:08of time, I'll invite doctor
• 25:09Zipli. Yes.
• 25:13Mhmm. Do you always do
• 25:14bilateral or?
• 25:17We typically wanna do bilateral.
• 25:20Okay.
• 25:22I'll give
• 25:23Thank you.
• 25:27Hey. Good afternoon.
• 25:28I know that I'm limited
• 25:29with time, so I'll do
• 25:30it fast so we can
• 25:31have lunch.
• 25:33I'm Zaan Zilb for neurosurgery.
• 25:34I'm the head of functional
• 25:35neurosurgery at Yale. I joined
• 25:37Yale,
• 25:38almost sixteen months ago,
• 25:41and I'll be talking about
• 25:42the the neurosurgical approach to
• 25:44cancer pain, basically.
• 25:46So,
• 25:49when we are talking about
• 25:50cancer pain,
• 25:51one thing that I have
• 25:54to say again and again
• 25:54again, it's all about multidisciplinary
• 25:56approach. Okay? I can do
• 25:57anything
• 25:58without her.
• 26:00Okay. I know.
• 26:01And, you know, she could
• 26:02do other things without me.
• 26:03I can do anything without
• 26:04her. Okay? So it's all
• 26:06about
• 26:07being a a multidisciplinary
• 26:08approach,
• 26:09seeing the patients together and
• 26:11choose the right patients for
• 26:12the right procedure. Okay?
• 26:17So what are the approaches
• 26:18that we have? We have
• 26:19to,
• 26:20like, three modules of, surgeries
• 26:22we can do. We can
• 26:22do the compression surgery.
• 26:24We can do normal no
• 26:25modulation surgeries, and we could
• 26:27do no abatement procedures.
• 26:30All of them are procedure
• 26:32that can use for cancer
• 26:33pain and non cancer pain.
• 26:34Today, I'm going to talk
• 26:35only about cancer pain because
• 26:37of the time limitations we
• 26:38have,
• 26:39and we'll start with
• 26:43is it oh, it's working.
• 26:44Okay. So we'll start with
• 26:47the patient selection,
• 26:49procedure selection, and timing.
• 26:55Kefoplasty.
• 26:56So kefoplasty is a procedure
• 26:57of what we do. For
• 26:58example, this is a patient
• 26:59who had a a compressed
• 27:01fracture. You can see it
• 27:02here. Whether it's trauma or
• 27:04a tumor inside,
• 27:05the vertebra,
• 27:07what we do, we insert
• 27:08a small needle
• 27:10into the
• 27:11compressed,
• 27:12vertebra no matter where we
• 27:14are. Usually, it's a thoracic
• 27:15columbra.
• 27:16Usually, we tend not to
• 27:17do to cervical,
• 27:19vertebra because of the proximity
• 27:21to the spinal cord.
• 27:22We inflate a small balloon
• 27:25in the vertebra,
• 27:27and then we
• 27:31it's not working.
• 27:32And then we insert cement.
• 27:36The role of cement is
• 27:37double.
• 27:37First, as you can see
• 27:39on the right corner,
• 27:42what the cement does, it's
• 27:44regains
• 27:45the the level of the
• 27:46vertebral bract from being compressed
• 27:49to the regular side. And,
• 27:50also, the cement, when you
• 27:51inject the cement of the
• 27:52vertebral, it heats up. Okay?
• 27:55And it burns the ends
• 27:57of the nerve roots
• 27:58along the,
• 28:00cortical aspect of the vertebra.
• 28:03Usually, we do it for
• 28:04trauma.
• 28:05We
• 28:06try to do it for
• 28:07oncology pain, especially with metastatic
• 28:09lesion. The issue with metastatic
• 28:11lesion is that some of
• 28:12the most of the metastatic
• 28:13lesion
• 28:14invade also the, foraminas that
• 28:16we cannot insert the balloon
• 28:17into the vertebral.
• 28:21Normodulation.
• 28:22When we talk about normodulation,
• 28:24something important that you have
• 28:25to understand that we're not
• 28:27we're not treating the tumor
• 28:28itself. Okay? We are treating
• 28:29the perception of pain. Okay?
• 28:31For example, if we do
• 28:32spinal cord stimulation,
• 28:34we simulate the, the spinothalamic
• 28:36tract.
• 28:37When you do a scingulotomy,
• 28:38you'll see it in the
• 28:39moment.
• 28:40We basically we treat the
• 28:41perception of pain. So if
• 28:43a patient has scingulotomy,
• 28:46when you see the patient,
• 28:47he is having the pain.
• 28:49When you ask him if
• 28:50you have pain, he will
• 28:51say yes, but he will
• 28:52never complain about the pain.
• 28:53Okay? So it's all about
• 28:54perception. This is what neuromodulation
• 28:56does.
• 28:58So Krishna talked about intrathecal,
• 29:00pumps. I'm not going to
• 29:01spend
• 29:02time about it.
• 29:04And we'll talk about the
• 29:05no ablations.
• 29:06The procedure we can do
• 29:08in Yale, and since I
• 29:09came, we do only a
• 29:10bunch of them, not a
• 29:11lot, unfortunately.
• 29:14We can do, rhizotomies,
• 29:16and
• 29:17I'll talk about how we
• 29:18can choose the patients. So
• 29:20do you know what rhizotomy
• 29:21is? How it's done? Where
• 29:22it's done?
• 29:25No?
• 29:26So, basically, it's a dorsal
• 29:27root root entry zone in
• 29:29the spine,
• 29:30and it's usually done for
• 29:31unilateral somatic, non receptive, or
• 29:34neuropathic pain in cancer pain.
• 29:39We can do myelotomy,
• 29:41although along the, spinal cord,
• 29:43it's a midline incision.
• 29:45It's basically for a midline
• 29:47subdiaphragmatic pain,
• 29:48visceral pain, also again, especially
• 29:50for cancer.
• 29:52And we can do singulotomy,
• 29:53which is basically for
• 29:55disseminated cancer pain all over
• 29:57the body pain or pain
• 29:58that cannot be controlled with
• 30:00morphine pump or or etcetera.
• 30:06The rhizotomy
• 30:07that we do, it's mostly,
• 30:09a photogeminal pain. It can
• 30:10be chemical rhizotomy. It It
• 30:12can be,
• 30:13a radio surgery rhizotomy. It
• 30:14can be a balloon rhizotomy.
• 30:16The way I do it
• 30:17in Yale, and we are
• 30:18the only center along the
• 30:19East Coast who do it,
• 30:20we insert a balloon,
• 30:22and we'll inflate a balloon
• 30:24in the
• 30:30hi.
• 30:35I I I see two
• 30:36screens. What do you see?
• 30:37Okay.
• 30:39So, basically, this is how
• 30:40do do it we do
• 30:40the rhizotomy.
• 30:42As you can see, we
• 30:43insert a small needle. It
• 30:44can be done,
• 30:45with the CT guidance, MR
• 30:47guidance. We do it open.
• 30:48We do it in close.
• 30:49We insert a small other
• 30:50frequency needle, and we burn
• 30:52it, the the dress, the
• 30:53entry zone.
• 30:54And this is how it's
• 30:55done.
• 30:56You can see we we
• 30:58we move the this is
• 30:59the root zone. This is
• 30:59the spinal cord. We move
• 31:00it a bit laterally and
• 31:02we insert the needle and
• 31:03we do the,
• 31:04the lesion.
• 31:05Chordotomy,
• 31:07this is how it's done.
• 31:08This is the spinothalamic
• 31:09tract,
• 31:11and we can do it
• 31:12CT guide as as I
• 31:13can as you can see
• 31:14here, this is a myelography.
• 31:15We inject some, contrast media,
• 31:17so we can see the
• 31:18CSF is white.
• 31:20The code is black. Okay?
• 31:22And we insert
• 31:23a small
• 31:25needle, into the oh, you
• 31:26can see my
• 31:28we insert a small needle
• 31:29and then we can burn
• 31:30the, spinothalamic
• 31:32tract.
• 31:33And this is how it's
• 31:34done. This is an interpretive
• 31:35image. You can see we
• 31:36open the dura. We move,
• 31:54In the past, it used
• 31:55to be an open surgery.
• 31:56We developed a mini invasive,
• 31:58surgery using a small endoscope.
• 32:01And what we did was
• 32:02we inserted a small endoscope
• 32:03into the, cervical thoracic spine.
• 32:05As you can see here,
• 32:06we opened the doors minimally
• 32:08opening the door, we inserted
• 32:09a small needle, and we
• 32:11buried the spinothalamic tract. This
• 32:12way, the patient actually can
• 32:13go home the same day.
• 32:15It can be done with
• 32:16local anesthetics also, and we
• 32:17published it.
• 32:22Miloto me, we don't do
• 32:24it here. So
• 32:25wonder how much time do
• 32:26I have?
• 32:27Five
• 32:28minutes?
• 32:30Oh, plenty.
• 32:31What about singulotomy?
• 32:32So the single of the
• 32:34brain,
• 32:35as I said before, doesn't
• 32:36really do have to do
• 32:37anything with the pain. It
• 32:38has only to do with
• 32:40the perception of pain.
• 32:42The cingulum is a part
• 32:43of the brain that is
• 32:44located
• 32:46this is the axial, colon,
• 32:47sagittal. This is a signal
• 32:49of the brain. This is
• 32:49actually one of the patient
• 32:50that you referred me.
• 32:52This is a pain who
• 32:53had a huge tumor in
• 32:54the pelvic, a a nonresectable
• 32:56tumor.
• 32:57She was treated for, I
• 32:58think, in house for six
• 33:00months. Right? She was in
• 33:01house for six months. She
• 33:01couldn't go home because she
• 33:02was on ketamine, morphine, IV.
• 33:05And what we did, we
• 33:06inserted two needles, one into
• 33:08the right single room, one
• 33:09into the left single
• 33:11right your fegocine needles. We
• 33:12burned the single loom bilaterally.
• 33:14And when the patient woke
• 33:16up, she stopped complaining about
• 33:17the pain, and she was
• 33:18able actually to be discharged
• 33:20in two weeks, I think,
• 33:21after being in the hospital
• 33:23for,
• 33:24two months.
• 33:25Again, it's usually done for
• 33:27bilateral
• 33:28disseminated pain.
• 33:30This case was special because
• 33:33as, you know, the the
• 33:34as we we talked before,
• 33:36siglottomies
• 33:37are usually preserved for cancer
• 33:39pain, for malignant cancer pain.
• 33:41This patient has had
• 33:44nonmalignant
• 33:45cancer pain because the the
• 33:46the the the the cancer
• 33:47she had was a benign
• 33:48tumor,
• 33:49but it was a nonresectable
• 33:51tumor. So we tweeted it
• 33:52as a as a as
• 33:53a malignant tumor,
• 33:55and
• 33:55she
• 33:56she had she was pain
• 33:57free for almost a year.
• 33:58She came back a few
• 33:59months ago.
• 34:01We did the procedure again,
• 34:02and now she's back home.
• 34:03Hopefully,
• 34:04I hope she's doing well.
• 34:05I don't know. But no?
• 34:07No?
• 34:08I haven't seen anything since
• 34:09I don't know. I know
• 34:10she was doing great for
• 34:11a year, and then she
• 34:12came back.
• 34:15So, basically, this is what
• 34:16we do. The the third
• 34:17procedure we can do in
• 34:18in Yale, we haven't done
• 34:19it yet, unfortunately,
• 34:20is a hypophysectomy.
• 34:23It's a minimally invasive procedure.
• 34:25It's basically a gamma knife
• 34:26procedure. We do we radiate,
• 34:28the hypophysies.
• 34:30As you know, the hip,
• 34:31hiphopysy plays a crucial role
• 34:33in, pay perception.
• 34:35It's mostly done for hormonal
• 34:37related cancer pain.
• 34:39It can be done for
• 34:40non hormonal,
• 34:41non hormonal cancer pain
• 34:45as long as there's no
• 34:46bone metastases.
• 34:48The target is basically located
• 34:50along the stalk of the
• 34:50epiphysis.
• 34:51The procedure takes around an
• 34:53hour and a half. The
• 34:54patient is awake. It's down
• 34:55as an outpatient procedure.
• 34:58And if you look at
• 34:59the data,
• 35:00the data is is is
• 35:02is quite good. You see
• 35:03that most of the patient
• 35:04are are pain free.
• 35:07When we're talking about indications,
• 35:08contraindication,
• 35:09I guess the only contraindication
• 35:11is, life expectancy, which is
• 35:13more than six months.
• 35:15If the life expectancy is
• 35:16more than six months, we
• 35:17prefer to do other procedures
• 35:18like baclofen pump or, spinal
• 35:20cord
• 35:23stimulators,
• 35:24etcetera.
• 35:26And this is how we
• 35:27do the planning. As you
• 35:28can see, there's an axial,
• 35:30coronal sagittal plane. These are
• 35:32MR sequences.
• 35:33We target the stock of
• 35:34the apo physis. We give
• 35:35it a high dose radiation,
• 35:36single dose,
• 35:38around an hour and twenty
• 35:39minutes for the gamma knife,
• 35:40and the patient can, go
• 35:42home the same day.
• 35:46So, again, these are the
• 35:47procedure we can do in
• 35:48Yale. We can do decompressive
• 35:50procedure, no modul no modul
• 35:52modulation procedures
• 35:53and ablative procedures.
• 35:56And, you know, again, it's
• 35:58all about being,
• 35:59in a multidisciplinary
• 36:01approach,
• 36:02choosing the right patient,
• 36:05the right procedure,
• 36:07and the right expectations
• 36:09from the patients.
• 36:11Thank you.
• 36:24We don't take any questions
• 36:26from the audience.
• 36:32Go ahead.
• 36:36Uh-huh.
• 36:45So
• 36:46with Celiac Texas Blob, the
• 36:47question is where the bowel
• 36:48obstruction is,
• 36:50a contraindication. It is considered
• 36:51a relative contraindication,
• 36:54because once you do a
• 36:55celiac plexus block, you're essentially
• 36:57doing a sympathectomy,
• 36:58and the unopposed parasympathetic
• 37:00tone will increase your bowel
• 37:02tone. It works similar to
• 37:04similarly to epidurals that we
• 37:06do for post op pain.
• 37:07The reason epidurals do great
• 37:09is because it doesn't cause
• 37:10an ileus, and it improves
• 37:11bowel motility. So it is
• 37:13a relative contraindication.
• 37:15If there is an ileus,
• 37:17partial obstruction, you could still
• 37:19consider it. The patient needs
• 37:20to know the risks.
• 37:21If it is,
• 37:23you know, surgical bowel obstruction,
• 37:24then surgery is usually the
• 37:25mainstay. We can wait for
• 37:27the bowel obstruction or partial
• 37:28bowel obstruction or ilias to
• 37:29get better before we can
• 37:31offer the block. So it's
• 37:32still an option,
• 37:33but symptomatically, they have to
• 37:34be better. The other issue
• 37:35with bowel obstruction is that
• 37:37these patients will need to
• 37:39go,
• 37:40all the way to sleep.
• 37:42They are unable to tolerate
• 37:43the prone positioning for the
• 37:45procedure itself. So oftentimes, they
• 37:46need sedation. And with the
• 37:48bowel obstruction, they're considered a
• 37:49full stomach. They need to
• 37:50be either wide awake or
• 37:52intubated with rapid sequence.
• 37:54When you intubate,
• 37:55the procedure becomes a little
• 37:57bit more challenging.
• 37:58We are using a a
• 38:00neurolytic in the prone position.
• 38:02We use contrast dye to
• 38:03assess the spread of the
• 38:04medication backwards towards the foramina.
• 38:06So we do oftentimes on
• 38:08the table ask the patient,
• 38:10for any signs of numbness
• 38:12related to the t twelve
• 38:13l one foramen by giving
• 38:15a small dose of local
• 38:15anesthetic. So the patient asleep
• 38:18makes it challenging
• 38:19to assess whether
• 38:21the there's going to be
• 38:22leakage backwards.
• 38:24So we prefer to do
• 38:25celiac plexus blocks with sedation,
• 38:27not all the way asleep,
• 38:28if possible. With the bowel
• 38:30obstruction, that's not possible. They'll
• 38:31be either wide awake or
• 38:33intubated.
• 38:34So it becomes procedurally a
• 38:35little challenging to offer a
• 38:36neuroleptic block.
• 38:38Hope that answers the question.
• 38:41Any questions regarding Zibley too?
• 38:42I'm just standing here as
• 38:43a yes.
• 38:45It's Doctor. Zibley. First,
• 38:47Dion, thank you for bringing
• 38:49your range of talents and
• 38:51expertise to Yale. It's been
• 38:53really remarkable.
• 38:56I was involved with the
• 38:57young woman that described it.
• 38:59It was
• 38:59really,
• 39:00as you said, a process.
• 39:03My question is, you know,
• 39:05in that situation,
• 39:07she was completely
• 39:09bed bound and non ambulatory.
• 39:12Are these procedures such as
• 39:14cingulotomy
• 39:15or myelotomy
• 39:16equally
• 39:18effective, and can they be
• 39:19used in patients who still
• 39:21wish to maintain some degree
• 39:23of motor function? Yes.
• 39:26So cingulotomy
• 39:27has no effect of I
• 39:28mean, she can do whatever
• 39:29she motor wise, there's no
• 39:31effect in singleotomy.
• 39:33With chordotomy, and this is,
• 39:34by the way, why we
• 39:35chose singulotomy or chordotomy for
• 39:36her because she wanted to
• 39:38be able although she was
• 39:39bedridden,
• 39:41with there's more risk of
• 39:42doing any motor damage in
• 39:44chordotomy than singulotin. With singulotin,
• 39:46there's almost no risk because
• 39:47you're going so until in
• 39:49the brain,
• 39:50far away from any motor
• 39:51aspect of the brain.
• 39:53Yeah.
• 40:04Yes. So
• 40:06so the issue with gamma
• 40:07knife is it takes a
• 40:08long time to to to
• 40:10get the effect of gamma
• 40:11knife. Okay? Like, for example,
• 40:12if you do gamma knife
• 40:13today, it would take around
• 40:14three to six weeks to
• 40:15start and see the effects.
• 40:16So that's why we didn't
• 40:18do gamma knife. When you
• 40:19do it with a retro
• 40:20frequency, the effect is immediate.
• 40:22Okay? It's because you do
• 40:23the the deletion. The lesion
• 40:24is done immediately.
• 40:26Gamma knife, it's it's it's
• 40:27it takes six, seven weeks
• 40:29sometimes until we get the
• 40:30effect.
• 40:31With hyper hypohazectomy,
• 40:33it will it takes around
• 40:34three weeks. Okay? Because the
• 40:36the hypothesis is the stock
• 40:38is so small
• 40:39and the dose is so
• 40:40high that the effect take
• 40:42around three, four weeks. But
• 40:43if you want to do
• 40:44singulotomies
• 40:45with gamma knives, it can
• 40:46takes weeks, even more, two
• 40:47months sometimes. And it's less
• 40:48effective than than the radiofrequency
• 40:50needle.
• 40:51And, again, it's done with
• 40:52local anesthetics.
• 40:53So the patient basically can
• 40:55go on the same day.
• 40:56And, you know,
• 40:57the sooner we do it,
• 40:59the better they do.
• 41:01Okay?
• 41:03I have two Zoom questions.
• 41:06One question is how do
• 41:07we refer patients to your
• 41:08clinic?
• 41:09It's,
• 41:10easy referral, Milo
• 41:12pain management. Right, Adrian? Milo
• 41:14pain management,
• 41:15order.
• 41:16And one of our nurse,
• 41:18managers looks through the referral
• 41:19and refers to us, and
• 41:20I'm sure it's easy enough.
• 41:22Just put doctor Zivli's name.
• 41:23It'll come to us. The
• 41:25other question that was on
• 41:26Zoom was how does it
• 41:27apply to children and adolescents?
• 41:30Again, not a lot of
• 41:31data and literature,
• 41:33for children and adolescents.
• 41:36We did have,
• 41:37one patient, a teenager,
• 41:40who had huge thoracic,
• 41:42METs,
• 41:44and we
• 41:46did offer, I think, a
• 41:47pump. It was a few
• 41:48years ago,
• 41:50but, you know, the
• 41:51family basically declined.
• 41:54It is not very well
• 41:55studied in kids.
• 41:57In fact, in kids, it's
• 41:58so hard. You won't believe
• 41:59even pure morphine does not
• 42:01have FDA approval.
• 42:03In kids, we use IV
• 42:04morphine and transition them to
• 42:06p oxycodone because there's not
• 42:08enough large scale studies done
• 42:11to, assess the effectiveness,
• 42:13the pharmacokinetics
• 42:14and dynamics of pure morphine.
• 42:15So pure morphine is actually
• 42:16not even,
• 42:18a a drug that's approved
• 42:19by FDA to be used
• 42:20in kids. So in children
• 42:21in adolescents,
• 42:23systemic opiates,
• 42:24remains the mainstay.
• 42:27So surgeries in kids,
• 42:30I need a few. It's
• 42:32off label. Mostly singleotomies,
• 42:34not any not spinal, you
• 42:36know, procedures. Mostly mostly singleotomies
• 42:38and morphine pumps. This is
• 42:40what we usually do for
• 42:41kids, and it's effective.
• 42:43It's effective.
• 42:46And we don't have a
• 42:48pediatric,
• 42:49pain clinic yet, so we're
• 42:50not, ready to receive outpatient
• 42:52pediatric referrals. That was another
• 42:54question. How can we refer
• 42:55pediatric cancer pain? Outpatient do
• 42:57not have that service yet.
• 43:00Doctor. Cynthia, I was wondering
• 43:02with the cingulotomy,
• 43:04are there any risk
• 43:07factors for cognition
• 43:09in terms of long term
• 43:10studies
• 43:11or side effects?
• 43:13So, you know, talking about
• 43:15long long term survivors. Right?
• 43:17So, unfortunately, you know, it's
• 43:18it's a last resort. So
• 43:20this patient are not you
• 43:21know, she survived a year.
• 43:22Usually, we don't do to
• 43:23patient who has life expectancy
• 43:25of more than six month.
• 43:28And, you know,
• 43:29I didn't see any reports
• 43:33saying anything about
• 43:34any decline, though.
• 43:36But when you look at
• 43:37the patient, they do have
• 43:39some change in the way
• 43:40the habit is. Okay? Like,
• 43:42you have to ask them
• 43:43questions in order to get
• 43:44answers.
• 43:45They don't
• 43:46talk the way they used
• 43:47to talk before. You know,
• 43:48they're more quiet, more relaxed.
• 43:52They lose some sensations. Like,
• 43:54they lose a sensation of
• 43:55pain.
• 43:56So they lose some things,
• 43:57but not cognitively others, I
• 43:58would say. But, again, we're
• 44:00talking about long term survival
• 44:01and which is you know,
• 44:02unfortunately, we don't see a
• 44:03lot of patients with long
• 44:04term survival.
• 44:19Yeah.
• 44:19So
• 44:21when you look at the
• 44:21literature,
• 44:22the only I wouldn't say
• 44:24only. Most of the cases
• 44:25who
• 44:26when we did a single
• 44:27time singleotomy
• 44:29was immediately after following the
• 44:30first one, like, a week
• 44:31later because the the previous
• 44:33ones failed.
• 44:34Okay? Again, these patients,
• 44:37unfortunately,
• 44:38usually don't survive more than
• 44:40six months. Okay?
• 44:42She survived a year.
• 44:44So it was an off
• 44:45label procedure to do it
• 44:46again. Because, again, when we
• 44:47do a second procedure, it's
• 44:48it means that the first
• 44:49one failed and we do
• 44:50it a week later, even
• 44:51less than a week because
• 44:52something happened technically in surgery
• 44:54or we're walking the wrong
• 44:55place
• 44:56or it wasn't it wasn't
• 44:58really effective or half effective
• 45:00or whatever.
• 45:01So repeat synchrotomies,
• 45:03we barely do any repeat
• 45:04synchrotomies. There's no need to
• 45:06do repeat synchrotomies. Again, this
• 45:07patient, she had she has
• 45:08a benign tumor. It looks
• 45:09horrible,
• 45:10but it's a benign tumor.
• 45:12I think the only option
• 45:13she had was to do
• 45:14epicropectomy
• 45:15or whatever. I cut the
• 45:16body in half, and she
• 45:17refused.
• 45:18So this is what why
• 45:19we do the why we
• 45:20did the procedure.
• 45:24I have a question for
• 45:26you, doctor Zibley. On Zoom,
• 45:27what kind of patients or
• 45:28pain features are good candidates
• 45:30for hypophysectomy?
• 45:31Can you speak more to
• 45:32how this impacts pain perception?
• 45:35Yes. So so it's mostly
• 45:37as as I showed you
• 45:37in the slide, it's mostly
• 45:39for hormone related
• 45:41cancer like metastatic breast and
• 45:43etcetera.
• 45:44You know, it does affect
• 45:46the the hypothesis
• 45:47that that yeah. Some patient
• 45:49can can be,
• 45:53That? Yeah. Give me a
• 45:54second. Yeah. So some patient
• 45:56can develop
• 45:57abnormalities
• 45:58with hormones,
• 45:59but can it be treated
• 46:00medically?
• 46:02We don't know exactly how
• 46:04it works, to be honest.
• 46:05I mean, when you look
• 46:06at literature, how does a
• 46:07prophasecting work? Nobody knows exactly
• 46:09how it how it's done,
• 46:10but it was done, like,
• 46:11I think, thirty, forty years
• 46:13ago.
• 46:13Open epufystectomy
• 46:15by Cushing or etcetera,
• 46:17for pain, and it's mostly
• 46:18for hormonal related cancer pain.
• 46:21Okay? Like breast, etcetera.
• 46:29Any other questions?
• 46:33Thank you for having us
• 46:34both. It was
• 46:35a extreme honor, and
• 46:38happy to share my email,
• 46:40doctor Sibley,
• 46:42and get referrals and try
• 46:44to help these patients out.
• 46:45Thank you. Thank you.