Cancer Pain

Despite best pharmacological management, 20–30% of cancer pain patients have inadequate pain control due to: intolerable opioid side effects (severe nausea, constipation, sedation, confusion) limiting dose escalation; refractory neuropathic pain; specific anatomical pain patterns better targeted by interventional approaches; or patient preference to reduce opioid burden for quality of life reasons.

The WHO has extended the analgesic ladder to include a “Step 4” — interventional procedures — for patients who fail pharmacological management.

Celiac Plexus Neurolysis (CPN) — For Pancreatic and Upper Abdominal Cancer Pain

The celiac plexus is a network of sympathetic nerve fibres surrounding the aorta at the T12–L1 level, transmitting pain signals from all upper abdominal viscera — the stomach, pancreas, liver, gallbladder, small intestine, and upper colon. In pancreatic cancer — which causes some of the most refractory pain in oncology — celiac plexus neurolysis with absolute alcohol achieves 70–90% significant pain reduction in multiple randomised controlled trials, with reduced opioid requirements and improved quality of life. The effect typically lasts for the patient’s remaining disease duration (weeks to months).

Technique: Performed under CT or fluoroscopic guidance, with the patient prone; bilateral needles are placed retroperitoneally at the T12–L1 level; absolute alcohol (50–100%) is injected after contrast confirmation of position. Alternatively, endoscopic ultrasound (EUS)-guided celiac plexus neurolysis accesses the plexus through the stomach wall under direct endoscopic vision — safer and increasingly preferred at specialist centres with EUS capability.

Superior Hypogastric Plexus Neurolysis — For Pelvic Cancer Pain

For cancer pain arising from pelvic malignancies — cervical cancer, endometrial cancer, rectal cancer, bladder cancer, prostate cancer — neurolysis of the superior hypogastric plexus with absolute alcohol achieves significant pain reduction in 70–85% of patients. As with celiac plexus neurolysis, this is an irreversible procedure using neurolytic agents rather than the reversible PRF or cryoanalgesia preferred for benign pain conditions — appropriate when the prognosis is limited and permanent nerve disruption is acceptable for the purpose of pain control.

Ganglion Impar Neurolysis — For Perineal Cancer Pain

For perineal, rectal, and anal cancer pain — particularly in patients with advanced anorectal malignancy where sitting, bowel movements, and any perianal activity cause severe pain — neurolysis of the ganglion impar provides very effective relief. Studies report 70–90% significant pain reduction in perineal cancer pain after ganglion impar neurolysis.

Intrathecal Drug Delivery (ITDD) / Spinal Drug Delivery System

An intrathecal catheter is placed in the cerebrospinal fluid (CSF) space of the spinal canal, connected to an implanted or external programmable pump that delivers precisely controlled doses of morphine (or other analgesic combinations — ziconotide, bupivacaine, clonidine) directly to the spinal cord — requiring only 1/300th of the systemic opioid dose for equivalent analgesia.

Indications for ITDD in cancer pain: inadequate pain control despite high-dose systemic opioids; intolerable systemic opioid side effects; neuropathic pain refractory to conventional treatment; patients with reasonable performance status (PS 0–2) and life expectancy of at least 3 months. The PACC (Poly Analgesic Consensus Conference) guidelines support ITDD as providing superior pain control with reduced side effects compared to systemic opioids for refractory cancer pain. Studies report 50–80% reduction in systemic opioid requirements after ITDD implantation.

Vertebroplasty / Kyphoplasty — For Painful Spinal Metastases

Painful vertebral body metastases causing pathological compression fractures and spinal instability are treated by percutaneous vertebroplasty (injection of bone cement into the fractured vertebral body) or balloon kyphoplasty (balloon inflation to restore vertebral height before cement filling). Both procedures provide rapid, effective pain relief for vertebral metastatic pain — with 70–85% significant pain reduction reported in multiple studies. Kyphoplasty provides the additional benefit of partial vertebral height restoration, reducing kyphotic deformity.

Radiotherapy — An Underutilised Analgesic

Palliative radiotherapy is one of the most effective treatments for localised bone pain from metastases — achieving 50–80% pain response rates. A single fraction (8 Gy) is as effective as multi-fraction courses (30 Gy in 10 fractions) for pain control in uncomplicated bone metastases and has a more convenient schedule for patients with limited performance status. EBRT (external beam RT) and SBRT (stereotactic body radiotherapy) are both effective. SurgiPartner’s pain team coordinates with oncology and radiotherapy services to ensure patients who may benefit from RT for pain are appropriately referred.

Epidural Steroid Injections and Nerve Root Blocks — For Radicular Cancer Pain

Cancer-related nerve root compression — from vertebral metastases, leptomeningeal disease, or tumour infiltration of the neural foramina — causes severe radicular pain (sciatica pattern, brachial plexus pain). Epidural steroid injections and selective nerve root blocks under fluoroscopic guidance provide targeted anti-inflammatory treatment — rapidly reducing radicular pain while systemic treatments (corticosteroids, chemotherapy, RT) begin to act.