Page 162 Guide to Pain Management in Low-Resource Settings

150 M. Omar Tawfi k

clinical course of 10–20% of patients with lung A magnetic resonance scan delineates the whole
and breast tumors. spine, identifi es multiple sites of cord and vertebral in-
• Serum levels of alkaline phosphatase and osteo- volvement, shows the paravertebral epidural extension
calcin refl ect osteoblast activity. Patients with a and integrity of the spinal cord, and allows diff erentia-
myeloma presenting low values of serum osteo- tion between traumatic, osteoporotic, or pathological
calcin, a sensitive and specifi c marker of osteo- fractures and compression without the need of invasive
blastic activity, have advanced disease, extensive techniques, such as myelography. However, MRI is ex-
lytic bone lesions, frequent hypercalcemia, and a pensive. All the data deriving from these radiological
poor survival rate. studies should be interpreted in the context of the clini-
cal fi ndings.
Case study (cont.)

In questioning the patient, some specifi c symptoms about How can we make a plan
the presence of hypercalcemia should be assessed. Symp- for treatment?
toms related to hypercalcemia are nausea, vomiting,
anorexia, stomach pain, constipation, excessive thirst, Th e treatment plan should contain:
dry mouth or throat, fatigue or lethargy, extreme muscle • Management of osseous metastasis.
weakness, moodiness, irritability, confusion, irregular • Management of pain.
heartbeat, and frequent urination. Hypercalcemia can • Treatment of hypercalcemia.
be a life-threatening condition. Investigations related to • Prevention of incidental fracture or vertebral
hypercalcemia should test for free serum calcium level collapse.
corrected for albumin level, ECG, urinary hydroxypro-
line/creatinine, and serum alkaline phosphatase. Radio- Case study (cont.)
logical investigations are of course needed, such as ra- Th e investigations reveal osseous metastasis in the lower
diography, scintigraphy, CT scan, and MRI, which were medial end of the femur as well as in the lumbar spine,
ordered for this patient, particularly for the back and particularly L2, by bone scintigraphy and ordinary radi-
right thigh. ography. Some thoracic vertebrae show early signs on sin-
gle photon emission computed tomography/CT (SPECT/
How can we choose between CT). Hypercalcemia was proven by serum level.
radiographic investigations?
How is osseous metastasis treated?
Bone metastases may be diagnosed by a variety of
methods, including radiography, scintigraphy, com- Once bone cancer is discovered, attempts to treat the
puted tomography (CT) scan, and magnetic reso- cancer should be the primary concern, as all other com-
nance imaging (MRI). With conventional radiography plications including pain and hypercalcemia can then be
a change of about 40% in bone density is required be- alleviated. Th e most important is radiation therapy, or
fore bone metastases may be identifi ed, and small le- the use of radionuclides.
sions may remain undetected. A change of 5–10% is
suffi cient when using bone scintigraphy. Bone scintig- Radiation therapy
raphy is positive in 14–34% of patients who have no In 60–90% of patients, radiotherapy has been eff ective
radiographic evidence of bone metastases. However, using a standard treatment regime delivering 60 Gy in
the method is less sensitive for the detection of pure- 30 fractions over 6 weeks with daily treatment sessions.
ly osteolytic metastases. Bone scan abnormalities are Radiotherapy should be the fi rst step in the manage-
not specifi c, and several benign conditions give rise to ment of metastatic bone pain. Radiotherapy is used as
false-positive results. Scans may appear negative when an adjunct to orthopedic surgery to decrease the risk
lesions are predominantly osteolytic, after radiother- of skeletal complications. An actual or impending bone
apy, and when surrounding bone is diff usely involved fracture may require a short fractioned course of 20–40
with tumor. CT scans allow the identifi cation of the Gy over 1 week. Radiotherapy is used for bone metas-
type of metastases and yield more sensitive results tases to relieve pain, prevent impending pathological
than the previous methods. fractures, and promote healing of pathological fractures.