Spinal analgesia for cancer pain

Published on February 23, 2009 Reviewed on December 4, 2019   17 min

A selection of talks on Neurology

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My name is Jon Raphael, I'm a specialist in pain medicine and I'm going to be talking about spinal analgesia for cancer pain.
The place of spinal analgesia in cancer pain management is following the more conservative measures as outlined in the World Health Organization's well known ladder, thus following strong opioids together with adjuvants if pain relief cannot be controlled, then advanced strategies come into play. Of course the majority of patients' pain can be controlled by the more conservative measures, but nonetheless there's a significant number who require more advanced strategies. Spinal analgesia is generally preferred above the destructive procedures, either neurologic or neurosurgical.
The story of spinal analgesia in management of pain and cancer pain goes back some years now to seminal work in the mid seventies, in which it was demonstrated that opioids would inhibit, nociceptive transmission level of the dorsal horn of the spinal chord.
The rationale for delivering drugs to this area is based on a number of physiological principles which will be outlined. It mainly relies upon a fortuitous difference in the capillaries of the central nervous system, compared with almost all other tissues of the body. To look to the left of this slide, we see that drugs can pass from the capillaries into the tissues, either across the membranes of the endothelial cells, but also their passage is aided by the ability to go through clefts between cells and fenestrations. However, in the central nervous system as shown on the right, there are no such intercellular clefts or fenestrations, and therefore the passage of drugs into central nervous system tissue from the capillaries is impeded. This is, of course, a technological effect that protects us from toxins. But it can be used as we will demonstrate to the benefit of analgesia in patients by spinal drug delivery.