Sushma Bhatnagar

A Comparative Efficacy of Amitriptyline, Gabapentin, and Pregabalin in Neuropathic Cancer Pain: A Prospective Randomized Double-Blind Placebo-Controlled Study

Neuropathic pain is difficult to diagnose and difficult to treat with certainty. So the aim of the study was to evaluate comparative clinical efficacy of pregabaline with amitriptyline and gabapentin in neuropathic cancer pain. A total of 120 patients with cancer having severe neuropathic cancer pain were enrolled in the study after taking approval from Institutional Ethics Committee and divided in to 4 groups: group AT—amitriptyline, group GB—gabapentin, group PG—pregabalin, and group PL—placebo. Oral morphine was used for rescue analgesic for continued pain. Pain score (Visual Analogue scale) and secondary outcome measures such as intensity of lancinating, dysesthesia, and burning on numerical rating scale, Global satisfaction score (GSS), Eastern Co-operative Oncology Group scoring (ECOG), and adverse effects were assessed. At the end of study there was significant decrease in pain score in group PG as compared to the other groups; group AT (P = .003), group GB (P = .042), and group PL (P = .024). Percentage of patients with lancinating pain and dysesthesia were significantly less in group PG as compared to groups GB and PL. All the patients in group PL needed rescue morphine. After 4 visits, maximum improvement in ECOG scoring and GSS scoring was observed in group PG patients. Our results suggested that all antineuropathic drugs are effective in relieving cancer-related neuropathic pain. There was statistically and clinically significant morphine sparing effect of pregabaline in relieving neuropathic cancer pain and neuropathic symptoms as compared to other antineuropathic drugs.

Ultrasonography Reinvents the Originally Described Technique for Ganglion Impar Neurolysis in Perianal Cancer Pain

Visceral pain in the perineal area associated with malignancies may be effectively treated with neurolysis of the ganglion impar. Since the first description of the technique of accessing the ganglion impar through anococcygeal ligament, many techniques for ganglion impar block have been described. We present a patient diagnosed with carcinoma of the anal canal who was successfully given ultrasound-guided ganglion impar block using a Chiba needle inserted through the anococcygeal ligament. In summary, ultrasound-guided ganglion impar neurolysis is a fast, safe, and cost-effective method, which can be used as a first-line pain relief intervention for good quality of life in patients with perianal cancers.

Airway management of patients undergoing oral cancer surgery: a retrospective study

Objective: This retrospective study aims to describe the airway management and benefits of nasotracheal intubation over tracheostomy in 260 patients with oral cancer undergoing surgery. Methods and Results: The medical records of 260 patients undergoing surgery for oral cancer were reviewed for airway management during the perioperative period. Eighteen patients had previous surgery for oral cancer and were scheduled for flap reconstruction, recurrence or other complications. In 28 cases neck movement was restricted and decreased mouth opening was found in 50% of all patients because of a large growth or fixation of tissues of head and neck, oral cavity, pharynx or larynx by tumour, or radiation fibrosis. In 53 patients intubation was undertaken under spontaneous ventilation. In 20 cases the trachea was extubated in the immediate postoperative period. In 220 cases patients were extubated next morning in the intensive care unit. In none of the cases was elective tracheostomy under local anaesthesia performed before surgery for the maintenance of the airway for anaesthesia. Elective tracheostomies were done in 17 cases. Three patients remained intubated for 24‐48 h because of a high suspicion of airway obstruction following extubation due to a large pectoralis major flap. These three patients received a tracheostomy because of increased oropharyngeal and laryngeal oedema. In three cases emergency tracheostomies were performed due to upper airway obstruction after extubation and in one case prolonged elective ventilation was required due to severe chest infection. Conclusion: Oral cancer patients have a potentially difficult airway but, if managed properly during perioperative period, morbidity and mortality can be reduced or avoided. Oral cancer patients can be managed safely without the routine use of a tracheostomy. Nasotracheal intubation is a safe alternative to tracheostomy in oral cancer patients except in some selected patients.

Management of Neuropathic Cancer Pain Following WHO Analgesic Ladder: A Prospective Study:

Cancer pain treatment according to the guidelines of World Health Organization (WHO) is effective and safe in majority of patients. 818 neuropathic cancer pain patients were enrolled in the study and pain was managed according to WHO analgesic ladder and followed up to six months. Main adjuvant drugs used were amitryptaline (29.9%), gabapentin (29.9%) and gabapentine with dexamethasone in (19.9%) and dexamethasone alone in (20.2%) patients. Opioids prescribed were mainly tramadol, codeine sulphate and morphine. 52% patients received morphine as rescue analgesic. At the end of six months 53.2% patients had no pain and 41.9% of patients had mild pain as compared to 0% and 10.2% patients respectively at the first visit. 4.9% of patients had moderate pain even after the treatment. Neuropathic cancer pain can be relieved by multimodal treatment following WHO guidelines as majority of cancer patients suffered multiple types of pain.

Early ultrasound-guided neurolysis for pain management in gastrointestinal and pelvic malignancies: an observational study in a tertiary care center of urban India.

Abstract:  Patients with advanced gastrointestinal and pelvic malignancies commonly present with pain of varying severity. In a majority of these patients, pain can be effectively managed using an integrated systemic pharmacological approach with oral morphine being the cornerstone of treatment. However, with escalating doses, intolerable side effects of oral morphine may lead to patient dissatisfaction. When oral pharmacotherapy fails to adequately address the issue of pain or leads to insufferable side effects, neurolytic blocks of the sympathetic axis are usually used for pain alleviation. As these blocks may reduce oral analgesic requirement, a reevaluation of their timing is merited. This article presents our hospital‐based in‐patient palliative care unit experience with early ultrasonography‐guided neurolysis of celiac plexus, superior hypogastric plexus and ganglion impar. Of the 44 patients we studied, 20 underwent celiac plexus neurolysis, 18 superior hypogastric plexus neurolysis, and 6 ganglion impar neurolysis. Their pain was being managed with oral morphine before neurolysis, but only 11.4% patients required oral morphine for satisfactory pain control, 2 months after neurolysis. The mean Visual Analog Scale score before block placement was 5.64 ± 0.69 and fell to 2.25 ± 1.33 at 2 months post neurolysis (P < 0.001). We suggest that bedside ultrasonography‐guided sympathetic axis neurolysis may be employed early in patients with incurable abdominal or pelvic cancer. Its use as a first‐line intervention for achieving pain control with minimal complications warrants further consideration and investigation. ▪

Breakthrough cancer pain: Review of prevalence, characteristics and management

Breakthrough pain has been associated with a reduced likelihood of adequate pain control. Despite the large and variable incidence of this phenomenon due to varied definitions of this type of pain, only a few studies have been conducted to assess and effectively treat breakthrough pain though the importance of managing breakthrough pain has been acknowledged by all. A large number of drugs from various classes and novel methods of administration like nasal and transmucosal buccal route, as in the case of fentanyl, have been used in these studies to manage this type of pain. A drug is needed with a quick onset of action and optimal duration that matches the characteristics of breakthrough pain. Some steps have been taken in earlier studies which used nasal formulation of fentanyl as it was found to achieve adequate and quick pain relief. However, further studies are required to confirm this so that in the future we can have as effective protocols for managing breakthrough pain as we have today for managing persistent pain as given by the World Health Organization.

Prevalence and Characteristics of Breakthrough Pain in Patients with Head and Neck Cancer: A Cross-Sectional Study

BACKGROUND Approximately one half to two thirds of patients with cancer-related pain experience breakthrough pain (BTP) in their daily activities. OBJECTIVE This is the first report to determine the prevalence and characteristics of BTP experienced by patients with head and neck cancer. METHODS This was a prospective cross-sectional study conducted in patients with head and neck cancer on stable doses of opioid (morphine) for at least 1 week. This study was designed as a cross-sectional study using a series of breakthrough pain questionnaires (BPQ). RESULTS Prevalence of BTP in our study was 48% (average of 3.85 episodes per day) of which more than 50% of episodes were of gradual onset but with severe intensity. Incident pain was predominate (50%) followed by spontaneous (25%) and end of dose failure (20%) and in 5% the nature of pain was unknown or mixed. Unlike other studies the onset of BTP in this present study with head and neck cancer was more gradual and lasted longer than 30 minutes. CONCLUSIONS Patients with head and neck cancer do suffer a lot because of the high incidence of BTP (48%). The majority of patients suffering from BTP are not satisfied at all with the measures taken for their BTP. The majority of patients in India have head and neck cancer; we must approach this matter as a challenge and new technique and therapy should be introduced for the benefit of these patients.

Successful treatment of an intractable postherpetic neuralgia (PHN) using peripheral nerve field stimulation (PNFS).

Postherpetic neuralgia (PHN) is a chronic neuropathic pain syndrome that arises as a sequel of herpes zoaster eruption. The treatment of postherpetic neuralgia is medically challenging and often frustrating in some situation as the exact mechanism of neuralgia is poorly understood and multiple and complex pathophysiology is postulated requiring poly pharmacy, which itself leads to many side effects. Here, we present a successful management of supra-orbital PHN using peripheral nerve field stimulation (PNFS), which was refractory to the commonly used pharmacological treatment. After successful trial stimulation, permanent stimulator was placed successfully, patient medication were tapered off within 2 weeks. At present, patient is in 8-week poststimulation with excellent pain relief, without any side effect.

Bedside ultrasound-guided celiac plexus neurolysis with bilateral paramedian needle entry technique can be an effective pain control technique in advanced upper abdominal cancer pain.

The celiac plexus block is an approved method for the relief of upper abdominal cancer pain. Classically, fluoroscopy-guided posterior approach to the celiac plexus block has been used. Computed tomography-guided anterior approach and endoscopic ultrasound-guided approach have also been utilized. An ultrasound-guided anterior approach to celiac plexus neurolysis with median plane single-needle entry technique has been described that targets the preaortic area between the origins of celiac trunk and superior mesenteric artery. We describe our experience with and decision to use the bedside ultrasound-guided anterior approach to celiac plexus neurolysis using bilateral paramedian needle entry technique.

Efficacy of the Anterior Ultrasound‐Guided Superior Hypogastric Plexus Neurolysis in Pelvic Cancer Pain in Advanced Gynecological Cancer Patients

BACKGROUND AND AIMS Pelvic cancer pain is a chronic pain related to the involvement of viscera, neural, and pelvic muscular. The study was carried out to evaluate the efficacy of anterior ultrasound-guided superior hypogastric plexus neurolysis in pelvic cancer pain in gynecological cancer patients. MATERIAL & METHODS The study was conducted after approval of our Institutional Ethics Committee. A total of 50 patients diagnosed with the advanced stage of a gynecological malignancy with severe pelvic pain were enrolled and randomly divided in two groups; in Group I, patients were given oral morphine, while in Group II, patients underwent anterior ultrasonography (USG)-guided superior hypogastric neurolysis. Oral morphine was given as rescue analgesia in both the groups. The parameters recorded were pain, functional capacity, global satisfaction score, and adverse effects. RESULTS There was a significant decrease in visual analog scale (VAS) score in the both groups, but the decline in VAS scores from baseline in Group II was significantly (P < 0.05) greater. The daily morphine consumption in Group II decreased throughout the study, and more patients in Group II improved in their functional capacity, although it was statistically insignificant. It was observed that global satisfaction scores were better in Group II during the initial first (P = 0.001) week and 1 month (P = 0.04) compared with Group I. CONCLUSION The anterior USG-guided superior hypogastric plexus neurolysis is a useful technique in relieving pelvic pain in gynecological malignancies. However, it requires expertise to perform the block. It also avoids the radiation exposure involved with computed tomography-guided and fluoroscopy-guided superior hypogastric block.