When Failure of Intrathecal Pump warrants Spinal Cord Stimulator Placement in a Cancer Patient
Case Description:
Introduction:
Cancer‐related pain is associated with a decreased quality of life. A significant proportion of patients with cancer‐
related pain lack effective pain control. A more comprehensive control of cancer‐related pain is often necessary for
many patients. Spinal cord stimulation (SCS) may have a role in pain management which is based upon the gate
control theory.

The gate control theory of pain establishes that non-painful stimuli closes the nerve "gates" to
painful input, which then prevents painful sensation from traveling to the central nervous system. The most
commonly used forms of neuromodulation are peripheral nerve stimulation (PNS), spinal cord stimulation (SCS),
and deep brain stimulation (DBS).

Case:
Patient is a 63-year-old male with history of metastatic renal cell carcinoma to brain and bone on pazopanib therapy.
He had palliative right hip and acetabular fixation (2014) and cementoplasty (2018). His hospital course was
complicated by a septic joint with finding of group B strep where he was placed on antibiotics. The patient has had
several admissions in the past year for acute on chronic right inguinal and thigh pain, with interventional IR
cryoablation for an attempt at pain control. An electrodiagnostic study was done revealing severe right sided
lumbosacral plexopathy. Due to chronic unremitting pain he was cleared for placement of an intrathecal pump (ITP)
at the T10 level. Even after placement of the ITP he continued to have increased pain in right thigh and right knee.
He stated he was getting little relief from the ITP. He required an emergent admission to the inpatient unit and his
pain was managed with a hydromorphone IV PCA. Despite consistent progressive increased in the ITP with
hydromorphone-bupivacaine his was still refractory. The decision was made after several setting changes to opt for a
SCS in order to better manage his metastatic cancer pain. He was finally discharged with alleviation of pain after
successful trial and permanent SCS implantation.

Conclusion:
The use of SCS for ITP refractory pain is a novel approach in cancer-related pain treatment. This is a case of trial
and error to search for the right pain modulating therapy leading to the surgical placement of a spinal cord stimulator
with successful results leading to the safe discharge of the patient and the necessary pain relief and increase in
quality of life. The gate control theory of pain set up the development of spinal cord stimulation and provides
another alternative when managing complex hard to manage cancer pain cases related to metastasis.
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