Complications of Postoperative Epidural Analgesia For Oncologic Surgery: A Review of 18,895 Cases.

OBJECTIVE: The risks of epidural analgesia (EA) differ depending on the population studied. We describe our experience with postoperative EA for oncologic surgery. MATERIALS AND METHODS: We searched our Acute Pain Medicine database for cases in which postoperative EA was used between 2003 and 2012. We used word search to identify and catalog cases of neurological changes, magnetic resonance imaging or computed tomography of the spine, electromyography studies, and neurologist or neurosurgeon consultations. Medical records of patients with documented persistent neurological deficits and patients who had spine imaging or neurology consultations were reviewed further. In addition, we cross-checked medical records with billing diagnosis codes for spinal epidural abscess or hematoma. RESULTS: We reviewed 18,895 cases in which postoperative EA was used. Complications included neurological symptoms in 2436 cases (12.9%), epidural insertion site abnormalities in 1062 cases (5.6%), complete epidural catheter migration in 829 cases (4.4%), epidural replacement in 619 cases (3.3%), and inadvertent dura puncture in 322 cases (1.7%). There were 6 cases of persistent deficits of uncertain etiology, 4 deep spinal infections (1:4724), and 2 cases of catheter tip shearing. No spinal epidural hematomas were identified (95% confidence interval, 0-0.0002). DISCUSSION: Our findings provide a contemporary review of some risks associated with the use of postoperative EA for patients undergoing oncologic surgery. Despite a not-uncommon incidence of neurological changes, serious complications resulting in prolonged sequelae were rare.

Epidural Analgesia and Subcutaneous Heparin 3 Times Daily in Cancer Patients With Acute Postoperative Pain.

The use of epidural analgesia in conjunction with subcutaneous administration of unfractionated heparin 3 times per day could increase the risk of spinal epidural hematoma, but insufficient patient experience data exist to determine this. We retrospectively reviewed the incidence of spinal epidural hematoma in 3705 cases at our institution over a 7-year period of patients receiving acute postoperative epidural analgesia and heparin 3 times per day. No cases of spinal epidural hematoma were reported (95% CI, 0-0.0009952).

Cancer Seeding Risk from an Epidural Blood Patch in Patients with Leukemia or Lymphoma.

Introduction: Lumber punctures are a common procedure in patients with cancer. However, a potential complication of a lumbar puncture is a postdural puncture headache. The risk of neoplastic seeding to the central nervous system has led to concern over performing epidural blood patches (EBPs) for the treatment of postdural puncture headaches in patients with cancer. The goal of this retrospective study was to evaluate cancer seeding in the central nervous system in patients diagnosed with leukemia or lymphoma. Methods: Institutional electronic records were queried over a 13-year period from 2000 to 2013 for patients with leukemia and/or lymphoma and who received at least one EBP. Demographic and procedural data, cancer treatments, and mortality were all examined. Patient records were reviewed for evidence of new-onset neoplastic central nervous system seeding after an epidural blood patch. Results: A total of 80 patients were identified for review. Eighteen patients had a diagnosis of leukemia, and 62 had lymphoma. Following an EBP, none of the patients experienced new cancer or cancer seeding in the central nervous system following an epidural blood patch at a median follow-up of 3.74 years. Discussion: Though the risks of EBP in the cancer patient population have been hypothesized, no previous studies have assessed the risk of seeding cancer to the central nervous system. Based on our results, an epidural blood patch bears low risk of cancer seeding when used to treat postdural puncture headache that is unresponsive to conservative treatments.

Using computed tomography scans and patient demographic data to estimate thoracic epidural space depth.

Background and Objectives. Previous studies have used varying methods to estimate the depth of the epidural space prior to placement of an epidural catheter. We aim to use computed tomography scans, patient demographics, and vertebral level to estimate the depth of the loss of resistance for placement of thoracic epidural catheters. Methods. The records of consecutive patients who received a thoracic epidural catheter were reviewed. Patient demographics, epidural placement site, and technique were collected. Preoperative computed tomography scans were reviewed to measure the skin to epidural space distance. Linear regression was used for a multivariate analysis. Results. The records of 218 patients were reviewed. The mean loss of resistance measurement was significantly larger than the mean computed tomography epidural space depth measurement by 0.79 cm (p < 0.001). Our final multivariate model, adjusted for demographic and epidural technique, showed a positive correlation between the loss of resistance and the computed tomography epidural space depth measurement (R (2) = 0.5692, p < 0.0001). Conclusions. The measured loss of resistance is positively correlated with the computed tomography epidural space depth measurement and patient demographics. For patients undergoing thoracic or abdominal surgery, estimating the loss of resistance can be a valuable tool.

Effects of postoperative epidural analgesia on recurrence-free and overall survival in patients with nonsmall cell lung cancer.

STUDY OBJECTIVE: To determine whether postoperative epidural analgesia is associated with better recurrence-free survival and overall survival after lung cancer surgery. DESIGN: Retrospective study. SETTING: Academic hospital. MEASUREMENTS: Data of patients with stage 1, stage 2, and stage 3 nonsmall cell lung cancer, who underwent tumor resection surgery, were studied. Patient data were grouped into three different postoperative pain management interventions: intravenous patient-controlled analgesia, patient-controlled epidural analgesia, and their combination. Univariate and multicovariate Cox proportional hazards models were applied to assess the effects of covariates of interest on overall survival and recurrence-free survival. MAIN RESULTS: The type of postoperative analgesia used for patients who underwent surgery for nonsmall cell lung cancer did not affect recurrence-free survival or overall survival. However, certain variables, including age ≥ 65 years, male gender, body mass index ≥ 25 kg/m(2), ASA physical status 4, and the need for preoperative blood transfusions, pneumonectomy, and postoperative radiation, were associated with decreased recurrence-free survival and overall survival. CONCLUSIONS: The type of postoperative analgesia used after surgery for nonsmall cell lung cancer is not associated with better 2-year or 5-year recurrence-free survival or overall survival rates.

Epidural versus ON-Q local anesthetic-infiltrating catheter for post-thoracotomy pain control.

OBJECTIVE: The authors compared thoracic epidural with ON-Q infiltrating catheters in patients having open thoracotomy to determine whether one method better relieves postoperative pain and would allow earlier discharge from the hospital and, hence, cost savings. DESIGN: Retrospective chart review. SETTING: University hospital. PARTICIPANTS: Fifty adult patients (24 to 81 years old) undergoing open thoracotomy by one surgeon. INTERVENTIONS: One group had thoracic epidural catheters placed by an anesthesiologist and then managed by the acute pain service. The other group had intraoperative ON-Q (ON-Q; I-Flow; Lake Forest, California) infiltrating catheters placed by the surgeon, wound infiltration with a local anesthetic, plus patient-controlled analgesia with an intravenous opioid. MEASUREMENTS AND MAIN RESULTS: The authors measured and compared average daily pain rating, maximum pain rating, time to discharge from the hospital, and total bill for hospital stay. Patients who received epidural analgesia had lower average pain scores on day 2 than did patients in the ON-Q group. Patients in the ON-Q group reported higher maximum pain scores on days 1 and 2 and at the time of discharge. Patients in the ON-Q group were discharged an average of 1 day earlier; hence, their average total bill was lower. CONCLUSIONS: Even though the maximum pain score was higher in the ON-Q group, patients were comfortable enough to be discharged earlier, resulting in cost savings. ON-Q infiltrating catheters present a good option for providing postoperative analgesia to patients having an open thoracotomy.

Transversus abdominis plane neurolysis with phenol in abdominal wall cancer pain palliation.

Pain is commonly perceived by patients during cancer and its treatment. Although most patients respond to conservative management implemented according to the World Health Organization guidelines, a subset of patients with advanced disease develop intractable pain that may require additional interventions such as regional blocks and intrathecal therapy. Patients with terminal abdominal or pelvic cancer who have high tumor burdens are often offered a diagnostic visceral nerve block followed by neurolysis for pain palliation. Conventional visceral blocks usually require fluoroscopic guidance for correct needle placement in the vicinity of the neuroaxis or abdominal cavity. These techniques carry risks of injury to vessels, bowels, and nerves. Transversus abdominis plane (TAP) block is a technique that is easy to perform (particularly when ultrasonographic guidance is used), has a good safety record, and effectively reduces pain levels and opioid requirements after abdominal and gynecological surgery. Although numerous studies have demonstrated the effectiveness of TAP blocks in acute pain management, the role of TAP block in chronic pain management is very limited. We believe that chemical neurolysis with phenol can prolong the effects of analgesia in patients with terminal cancer. We describe a case of terminal abdominal sarcoma with intractable pain that responded well to a TAP block followed by TAP neurolysis. The patient tolerated the procedure well and demonstrated sustained analgesia for 45 days before dying of the disease. We also demonstrated that TAP block significantly reduces the total opioid requirement as demonstrated by the morphine equivalent daily dose score after the neurolytic procedure. This result supports our belief that TAP block with TAP neurolysis is an effective and inexpensive modality that can be used to palliate intractable abdominal wall pain in patients with terminal abdominal cancer.

Implanted intrathecal drug delivery systems and radiation treatment.

PURPOSE: Radiotherapy affects the functioning of pacemakers. Guidelines based on dosimetric data exist regarding tolerable doses to pacemakers. Little is known about the effects of radiation on implantable drug delivery systems (IDDS). The objective of our study is to evaluate the safety of radiation treatment delivered to patients with IDDS. METHODS AND MATERIALS: We evaluated patients who received external beam radiation therapy in our department after implantation of an IDDS between January 1, 2000 and November 30, 2011. Information was collected on IDDS function, treatment goals, treatment fields, prescribed doses, treatment energies, and cumulative radiation doses to the pump and the catheter. RESULTS: A total of 39 patients received 60 separate courses of radiation therapy, of which 12 patients received radiation with either the pump or the catheter in the field. The remaining patients received scatter radiation only. The goal of radiation was palliative in all but one of the patients. Cumulative pump doses ranged from 5 to 36 Gy, and catheter doses ranged from 15 to 45 Gy. Beam energies ranged from 6 to 18 MV photons. All devices were checked after the completion of radiotherapy with a median follow-up of 4.5 months, and all were found to be in good working condition. CONCLUSIONS: IDDS failures related to external beam radiation therapy seem to represent a rare occurrence. While we do not see reason to limit radiotherapy in patients with IDDS, we recommend device check after the completion of radiotherapy as well as if the patient has an increase in pain or analgesic requirement.

Comparing epidural analgesia and ON-Q infiltrating catheters for pain management after hepatic resection.

BACKGROUND AND OBJECTIVES: Pain control after hepatic resection presents unique challenges as subcostal incisions, rib retraction, and diaphragmatic irritation can lead to significant pain. Both epidural analgesia and ON-Q catheters have been used for postoperative pain management after hepatic surgery, but to our knowledge have not been directly compared. METHODS: The records of 143 patient between the ages 18 and 70 were reviewed who underwent hepatic resection by a single surgeon. Patients were categorized according to method of postoperative pain control. Average pain scores for both study groups were collected until POD#3. RESULTS: Demographic data and the length of surgery were similar between the groups (all p>0.05). On the day of surgery and POD#1, average pain scores for the epidural group were lower than the ON-Q group (P<0.0001 and P=0.0008 respectively). There was no difference in pain scores on POD #2 (P=.2369) or POD #3 (P=0.2289). CONCLUSIONS: Epidural analgesia provides superior pain control on the day of surgery and POD#1 when compared to On-Q catheter with IV PCA. There was no difference in pain scores on POD#2 or POD#3. Future prospective randomized trials comparing these analgesic methods will be required to further evaluate enhanced recovery after hepatic surgery.

Recent advances in select interventional approaches to cancer-related pain.

SUMMARY Interventional approaches for cancer-related pain have demonstrated utility and safety as a component of multimodal pain management. A number of techniques have been developed and implemented to manage the variety of cancer pain conditions and syndromes that exist as a result of the underlying malignant process and its associated oncologic treatment. These procedural pain modalities continue to evolve with advances in experience, understanding and technology in the field. Neurostimulation, vertebral augmentation with stabilization and intrathecal drug delivery, are prime examples of innovative approaches in interventional pain medicine for cancer pain with continued improvement in design to better achieve adequate analgesia and reduce risk. The intent of this article is to describe the aforementioned interventions and recent developments pertaining to them.

SynchroMed II intrathecal pump memory errors due to repeated magnetic resonance imaging.

Cancer patients with severe refractory pain are often managed with implantable drug delivery systems (IDDS). The only drugs with US Food and Drug Administration approval for intrathecal use are morphine, ziconotide, and baclofen. Other drugs used and mixed include, hydromorphone, bupivacaine, sufentanil, and fentanyl. These patients often undergo magnetic resonance imaging (MRI) for disease-related monitoring and diagnoses. Although uncommon, IDDS can fail to resume normal functioning after MRI, potentially causing complications. The magnetic field of an MRI will temporarily stop the rotor of the pump motor and suspend drug delivery for the duration of the MRI exposure. The pump should resume normal operation when removed from the MRI magnetic field, but there is a potential for a delay in the return of proper drug infusion and a delay in the logging of motor stall events after an MRI in the SynchroMed II pumps. A 57-year-old man who underwent multiple MRIs with an implanted IDDS experienced 2 separate memory failures leading to multiple complications. After the first pump malfunction, the patient developed withdrawal symptoms and was treated in the emergency department. The first time, a memory reset resolved the problem. The second time, 29 months later, the patient was admitted to the hospital to manage withdrawal symptoms and the pump had to be exchanged with a new device. Post-MRI pump interrogation should be performed on all patients with IDDS to ensure proper functioning of the pump. Special attention should be paid to patients receiving baclofen, as acute withdrawal can be very serious, even deadly.

Vertebral compression fracture treatment with vertebroplasty and kyphoplasty: experience in 407 patients with 1,156 fractures in a tertiary cancer center.

BACKGROUND: Painful vertebral compression fractures (VCFs), whether pathologic or osteoporotic, are a source of morbidity in cancer patients. At our tertiary cancer center, over the past decade we have used vertebroplasty (VP) and kyphoplasty (KP) to treat painful VCFs. More data are needed on the treatment of VCFs in cancer patients with these techniques. METHODS: We retrospectively reviewed the medical records of cancer patients with painful VCFs that had been treated at our institution between January 1, 2001 and May 31, 2008. Information was collected on demographic and clinical characteristics, features of the fractures, procedural details, and complications. Pre- and post-procedural pain and related symptoms were assessed using a subset of patients who had responded to the Brief Pain Inventory and the Edmonton Symptom Assessment Scale. RESULTS: A total of 407 cancer patients had 1,156 fractures that had been treated with VP or KP during 536 surgical procedures. Patients had an average of 2.8 fractures (range, 1-10). The majority of patients had pathologic fractures due to multiple myeloma (43%) or osteoporotic fractures (35%). Most fractures occurred in the thoracolumbar region. Adjacent-level fractures occurred in 18% of patients. Surgery provided significant relief from pain and several related symptoms. Symptomatic, serious complications requiring open surgery occurred in two cases (<0.01%) in our series. CONCLUSIONS: Our single-center experience revealed that a large number of cancer patients suffer from painful VCFs. The use of VP or KP in treating painful VCFs in cancer patients has good efficacy and an acceptably low complication rate.

Conversion from intrathecal morphine to oral methadone.

BACKGROUND AND OBJECTIVES: Methadone is an inexpensive and highly effective analgesic when titrated appropriately. Its equianalgesic ratio with other opioids is variable, however. We present a case of conversion from high-dose intrathecal (IT) morphine to oral methadone. CASE REPORT: A 37-year-old man was admitted to the orthopedic service due to increased lower back pain. He had a history of recurrent L5 plasmacytoma, an L5 corpectomy, and L3-S1 fusion with instrumentation. An implanted neuraxial drug delivery device had been placed at another institution for back pain. Evaluation suggested infection involving the hardware. The patient underwent hardware removal, debridement of osteomyelitis, and removal of the IT catheter. The patient's analgesia was converted from IT to intravenous morphine and then to oral methadone. CONCLUSIONS: The conversion from high-dose IT morphine to oral methadone has not been previously described. The case presents higher IT morphine to oral methadone conversion ratio than might be expected based upon conventionally used equianalgesic tables.

Adenoma gigante de la lactancia: reporte de un caso / Giant lactation adenoma

Se presenta el caso de una paciente con adenoma gigante de la mama, que fue clasificado como adenoma de la lactancia, ulcerado. Debido a lo extenso del tumor (50x45x22 cm), y apariencia macroscópica, el diagnóstico clínico fue de tumor Phyllodes ulcerado o carcinoma inflamataorio de la mama. Todos los ganglios resecados fueron negativos para neoplasia. La revisión de los casos publicados a la fecha nos confirman que se trata del adenoma de la lactancia más grande que se ha reportado. El seguimiento de la paciente 6 meses más tarde es satisfactorio