Managing Severe Neuropathic Pain From a Chordoma: Case Report and Discussion From Belgium, With Commentaries From Sweden and Italy

ABSTRACT

A case in which severe neuropathic pain from a chordoma in a 45-year-old Belgian male is presented. Interdisciplinary neurolytic treatment and neuropathic pain pharmacotherapy were initiated and are discussed. Commentaries from pain specialists in Sweden and Italy follow.

KEYWORDS :

• Chordoma
• gabapentin
• ketamine
• methadone
• neurolysis
• pain

COMMENTRY FROM SWEDEN

Staffan Lundstrom

This case study illustrates the difficulties encountered when treating a patient with a slowly growing advanced cancer that causes severe pain. The balance between pain relief and functional impairment due to adverse effects of treatment should always be considered. As pointed out, this is preferably done within the context of a multidisciplinary team where different aspects of care will be highlighted in addition to the patient's own view. In cases with difficult pain problems and short expected survival, there is often more focus on achieving rapid symptom control, and less attention is paid to potential functional impairment. In the specific case, one could assume that, given the tumor's location, there were components of neuropathic pain present early in the history. Could amitriptyline and/or gabapentin be the first step to test whether or not the pain was less responsive to paracetamol, NSAIDs, and opioids? Or would the patient prefer functional impairment in the limbs over cognitive and gastrointestinal (GI) side effects from opioids and other drugs? Could a test injection of local bupivacaine help guide the patient in his decision? These are questions that could be raised within the multidisciplinary team.

The patient had a partial response to the combination of gabapentin and methadone and did not experience satisfying pain relief until ketamine was added orally. This case illustrates that, although both methadone and ketamine are N-methyl-d-aspartate (NMDA)-receptor antagonists, an insufficient response to one of the drugs does not preclude a successful response to the other.

It is interesting to note the effect on depression after successful treatment, which included ketamine. Intuitively, we think that it is the good pain control that results in less depression, but there are also case reports showing rapid, positive effects of ketamine on depression per se in patients with advanced disease.(1)

COMMENTARY FROM ITALY

Diego Beltrutti and Fabio Intelligente

In the case of Mr. P, our first comment concerns the 5 years that passed apparently without any specific therapy. This prevented the application of surgery or radiation, the most effective and appropriate treatments for chordoma. Oral imatinib could have been used; radiofrequency (RF) palliative ablation of the tumor could have been another useful option.

Patients complain of radicular pain that can progress up to a cauda equina syndrome with saddle anesthesia, asymmetric paraplegia, muscle atrophy, loss of tendon reflexes and autonomic symptoms, particularly rectal dysfunction, or urinary inconti- nence.

Because of severe pain, a colleague decided to perform a neurolytic block of Mr. P's cauda equina. According to Bonica,(1) neurolytic block should not be performed in cases like this because the diffusion of the agents in the cerebrospinal fluid (CSF) is unpredictable. The injection of a contrast medium and a diagnostic block with local anesthetic would allow evaluation of the spread of agents, pain relief, and adverse effects. Percutaneous sacral nerve or impar ganglion RF denervation could be useful options. We would not have suggested a neurolytic block. The price the patient paid was too high.

In Mr. P's case, an interdisciplinary, biopsychosocial pain relief program is the right choice. Opioids (methadone or oxycodone) and anticonvulsants (gabapentin or pregabalin), with some adjuvants, are drugs of choice in this case.

After positive testing, an intrathecal continuous infusion of a mixture of opioids and ketamine, by means of a pump, could have been another option.

Notes

Dr. Staffan Lundstorm is a Consultant in Palliative Medicine at the Stockholms Sjukhem, Sweden.

Drs. Diego Beltrutti and Fabio Inelligente are with the Servizio del Dolore Cronico, ICH Humanitas, Milan, Italy.