Part of TopicBrowse Topic in full-screen mode
INTRATHECAL ZICONOTIDE IN PHANTOM LIMB PAIN, REPORT OF 2 CASES
Carvajal G, Rocha A, Dupoiron D
INTRODUCTION:Phantom limb pain (PLP) occurs in 50% to 80% of amputees. PLP is a chronic debilitating condition that currently has no standard of care, we present two complex cases that were successfully treated with a combined intrathecal regimen including ziconotide.
MATERIALS AND METHODS:
Research was approved by the Institutional research committee, patient informed consent was obtained, two clinical cases are presented.
A 79-year-old woman was diagnosed with clear cell renal cancer suered pathologic right humerus fracture. Due to an extensive soft tissue invasion she was required to receive an upper limb amputation and
This impaired her sleep and she reported pain 9 /10 on a Numeric rating scale (NRS). Despite gabapentin 600mg bid, amitriptyline 10mg and Oxycodone up to 80 mg per day with an unsuccessful rotation to transdermal fentanyl.
During her follow up a nonsymptomatic metastatic lesion was discovered on her left femur. (Figure 1) It was decided to begin intrathecal analgesia with a SYNCHROMED II® (Medtronic, USA) and a catheter placed facing C1.
She was initially treated with morphine 0.5 mg, ropivacaine 6 mg and ziconotide 0.2ug per day. 4 months later her pain and sedation were well controlled (NRS 2) and even if phantom sensations were still present, these were less unpleasant.
A 60-year-old male came to our pain center after 3 decades of pain story. In 1983 he had a work accident with brachial plexus avulsion and an upper right limb amputation and developed PLP.
Several pharmacological (tricyclic antidepressants, anticonvulsants) and non-pharmacological (transcutaneous nerve stimulation, spinal cord stimulation,DREZotomy, motor cortex stimulation) treatments were unsuccessfully trialed.
An intrathecal catheter with the tip above thecysternamagnawas placed inseptember2017. A Synchromed II (Medtronic, USA) intrathecal pump was placed under general anesthesia,catheterwas placed in the pontocerebellar cisterna (Figure 2).
He was prescribed a multimodal intrathecal treatment and titrated during the following weeks up to morphine 1,7mg, ropivacaine 9.9 mg, Ziconotide 1.1μg daily, obtaining 50% pain relieve, specially irruptive component.
We present two complex cases of patients that developed PLP and were successfully treated using a continuous intrathecal analgesia combined regimen. This option may be considered in cases where other less invasive options have failed.
1) Richardson C, Kulkarni J. A review of the management of phantom limb pain: challenges and solutions. J Pain Res. 2017 Aug 7;10:1861-1870. doi: 10.2147/JPR.S124664. eCollection 2017.
2) Talu GK, Erdine S. Intrathecal morphine and bupivacaine for phantom limb pain: a case report. Pain Pract. 2005 Mar;5(1):55-7.
3) Dahm PO, Nitescu PV, Appelgren LK, Curelaru ID. Long-Term Intrathecal Infusion of Opioid and/or Bupivacaine in the Prophylaxis and Treatment of Phantom Limb Pain. Neuromodulation. 1998 Jul;1(3):111-28. doi: 10.1111/j.1525-1403.1998.tb00005.x.
4) Dupoiron D, Bore F, Lefebvre-Kuntz D, Brenet O, Debourmont S, Dixmerias F, Buisset N, Lebrec N, Monnin D. Ziconotide adverse events in patients with cancer pain: a multicenter observational study of a slow titration, multidrug protocol. Pain Physician. 2012 Sep-Oct;15(5):395-403
5) Intracerebroventricular Pain Treatment with Analgesic Mixtures including Ziconotide for Intractable Pain. Staquet H, Dupoiron D, Nader E, Menei P. Pain Physician. 2016 Jul;19(6):E905-15