Introduction: Tumors invading the sacrum and/or ilium often represent incurable metastatic disease and treatment is targeted toward palliation of symptoms and control of pain. As systemic opioid therapy is frequently inadequate and limited by side effects, a variety of interventional techniques are available to better optimize analgesia. Using our therapeutic algorithm for treating sacroiliac tumor-related pain in the oncologic population, we present six index cases as well as the results from all 25 patients treated according to this paradigm approach.
Materials & Methods: As according to our IRB-approved protocol, the interventional therapeutic paradigm above was employed in the treatment of patients with oncologic pain secondary to sacroiliac tumors presenting to MSKCC between March 2013 and July 2016. Ultrasound-guided proximal sacroiliac joint corticosteroid injection, sacroiliac lateral branch radiofrequency ablation, percutaneous sacroplasty, implantable neuraxial drug delivery and spinal cord stimulation were utilized as indicated in a step-wise fashion. Pre- and post-procedure NRS pain scores, duration of pain relief, and post-procedure pain medication requirements were studied for each patient. The above metrics were analyzed for the 25 patients with sacroiliac disease treated according to this paradigm during the collection period. Case 1 underwent bilateral ultrasound-guided proximal sacroiliac joint corticosteroid injections. Case 2 and 3 underwent sacroiliac lateral branch radiofrequency ablation. Case 4 underwent percutaneous sacroplasty. Case 5 underwent implantable neuraxial drug delivery. Case 6 underwent spinal cord stimulator implantation.
Results: An assessment of 25 patients with sacroiliac disease, including the six discussed cases, is presented in Table 1. Each patient was managed with the described paradigm and included is the last resulting procedure performed for improved pain control and the subsequent results. In all cases, opioid medications were successfully reduced (30% refers to an absolute reduction in daily morphine equivalents). In 13 of the 25 patients, sacroiliac joint injection was sufficient for adequate pain control.
Discussion: We present an interventional therapeutic paradigm and case series illustrating pain treatment options for patients suffering from sacroiliac metastatic disease. Often pain symptoms can mimic sacroiliitis or lumbosacral radiculopathy. Factors to consider when deciding between pain control options include tumor location, invasion of the SI joint space, and presence of insufficiency fracture, neural foraminal compromise, and patient preference. While further prospective research is warranted, this case series can be used as a preliminary guide to manage sacral pain in oncologic patients suffering from sacral metastatic disease.