Cancer Pain: Bone Pain

MRI showing multiple areas of boney metastases. Patients such as these often benefit greatly from intrathecal pump therapy.

Bone pain is a serious problem for many patients suffering with metastatic cancer. Metastases are usually painless at first because there are no pain receptors in the marrow or boney trabeculae. Pain develops later when the tumor reaches the periosteum at the surface of the bone that is richly innervated.

Treatment of boney metastases usually employs a three pronged attack, radiation therapy, chemotherapy and pain therapy. In cases where the structural integrity of the bones is severely compromised, surgery may be necessary to prevent impending fracture.

For years radiation was considered the first line therapy for the pain of boney metastases and it is still widely used when the number of metastatic lesions is small, especially if the tumor is radiosensitive. Disadvantages of radiation include systemic toxicity of the radiation itself, neurotoxicity if important nerves lie within or close to the field. Finally from the point of view of pain, it is important to remember that radiation reduces pain by killing cancer cells, which usually occurs slowly over a period of 4-6 weeks. During that time pain may actually increase due to swelling caused directly by the radiation or by the death of the tumor cells. Clearly concomitant therapy focusing directly on the pain is necessary at least in the initial stages.

Chemotherapy is useful for control of the tumor itself. As a pain therapy it suffers from many of the disadvantages of radiation therapy. Its onset of action is slow and chemotherapy can be associated with a number of neuropathic pain syndromes.

The mainstay of pain therapy for boney metastases has been anti-inflammatory agents and oral narcotics. These therapies can be quite effective as long as the tumor load is small. When multiple lesions or widespread metastases are present, doses adequate to relieve the pain usually begin to cause significant side effects. Prominent among these are sedation, constipation, loss of appetite, loss of libido and depression of the immune system.

Fortunately the pain from boney metastases is nociceptive and is usually exquisitely sensitive to intrathecal pump therapy. The relative efficacy of intrathecal narcotics when compared to the same agents administered orally is between 100 and 1,000 to 1. This means that excellent pain relief is often possible with minimal or no side effects. Many studies have pointed out not only an increased sense of well-being but significantly longer survival in patients with intrathecal pump therapy.

We at Schlesinger Pain Centers are one of the largest implanters of intrathecal pumps in Los Angeles. We have developed the expertise to handle the difficult cases as well as the simple ones. Call for an appointment to discuss whether advanced pain therapies may be helpful to you. In some cases therapeutic pump trials can be initiated on the same day and significant pain relief achieved within 24-36 hours.

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