Page 165 Guide to Pain Management in Low-Resource Settings

Osseous Metastasis with Incident Pain 153

sustained-release tramadol was added at a dose of 100 Case study (cont.)
mg twice daily.
Th e patient was put on patient-controlled analgesia, us-
Bisphosphonates (zoledronic acid) at a dose of 4
ing morphine to give her relief from severe pain. She has
mg monthly in a drip was prescribed, together with hy-
been transferred to an orthopedic unit for fi xation proce-
dration and advice for the patient to take lots of fl uids,
dures to help relieve her pain and help her to be able to
along with furosemide (one tablet daily with a potassium
move around.
supplement to guard against hypercalcemia).
Percutaneous vertebroplasty was done for both
L2 and T12, and this procedure was followed by a rapid What can be done by a dedicated
relief of back pain. orthopedic specialist?
Th e right lower-limb neuropathic pain was
treated with gabapentin, starting with 100 mg three About 10–30% of patients with bone metastases de-
times daily. Th is dose was gradually increased until a velop fractures of the long bones requiring orthopedic
1200-mg daily dose was achieved and maintained. Af- treatment. Th e femur is the most common site. Exten-
ter vertebroplasty, the neuropathic element disappeared, sive bone loss due to the local eff ects of chemotherapy
and the gabapentin was gradually withdrawn. and radiation should be supported during recovery.
Th e patient was satisfi ed with this treatment for Protection with orthotic devices, such as lightweight
9 months, during which tramadol was changed to sus- functional bracing, may be useful during upper-extrem-
tained-release morphine (90 mg daily dose). ity lesions. Th e lower extremities are not very amenable
After 9 months, the patient accidentally fell. She to this method because of the high degree of load. As
developed severe incidental pain in the right lower third a consequence, conservative treatment for fractures or
of the thigh. Plain X-ray demonstrated a fracture at the symptomatic impending fractures of the extremities is
site of the previous femur metastasis. rarely successful.
Prophylactic pinning is indicated and may pre-
What options would we have vent a long period of immobility. Conservative treat-
ment of bone fractures in the axial skeleton is more
in this case?
likely to be successful because such bones have a bet-
Guidelines have been developed using radiographic- ter blood supply and tend to heal more readily. Bracing
series criteria, although the reliability of a radiographic in combination with radiotherapy may be a successful
evaluation has been questioned because a bone metas- treatment for pathological vertebral fractures.
tasis becomes apparent only after major bone loss, and It is important to ensure that pathological frac-
some cancers, such as prostate cancer, are not charac- tures are stabilized to prevent pain and to facilitate
terized by evident bone destruction. Moreover, bone physiotherapy and radiotherapy. Diff erent surgical solu-
pain unresponsive to radiation has not been found to be tions may be proposed according to the kind of fracture,
correlated with fracture risk. the clinical situation, and the patient’s life expectancy.
Th e approach to treatment for bone pain may Orthopedic management includes internal fi xation and
require diff erent modalities depending upon the initial osteosynthesis, resection of joint and joint replacement,
assessment. Surgery should be considered if an impend- segmental resection of a large tract of bone and pros-
ing fracture is diagnosed, and radiation therapy should thetic replacement, and arthroplasty. Surgical treatment
be considered for painful bone metastases. Pharmaco- should be undertaken when a fracture occurs. Th e po-
logical therapy with NSAIDs and opioids, along with tential benefi ts of surgical intervention have to be tem-
medications for breakthrough pain, form the main pered with patient survival.
symptomatic treatment. In addition, many adjuvant ap- Surgical stabilization of the spine and extremi-
proaches have been recommended, such as calcitonin, ties may dramatically improve the quality of life, de-
bisphosphonates, or radionuclides. In vertebral metas- crease the pain and suff ering of these patients, and pre-
tasis with collapse, vertebroplasty may be an important vent complications associated with immobility, allowing
procedure, as well as cementoplasty for other bone me- many patients to be cared for at home. Recovery from
tastasis, particularly with weight-bearing pain, depend- prophylactic fi xation surgery is quicker and requires less
ing on availability. aggressive procedures.