Successful Management of Opioid-refractory Pelvic Cancer Pain Using Continuous Local Anesthetic Infusion via a Tunneled Epidural

Abstract

Opioid refractory pelvic cancer pain is common and difficult to manage, which often results in analgesic polypharmacy and escalating opioid doses, alongside the use of interventional techniques. However, up-titration of opioids often results in systemic side effects, and interventional procedures have limitations in their duration of action, efficacy, and risk of nerve damage. Therefore, intrathecal pumps have been utilized as a more permanent option for pain management. Their ability to deliver localized therapy using a variety of pharmacological agents makes it an attractive option for cancer pain management. However, they are limited by a need for careful titration, pump volume constraints, and risks of severe side effects. These limitations can be mitigated by targeting the epidural space instead, and we propose the use of a tunneled epidural catheter technique for continuous local anesthetic infusion in opioid-refractory pelvic and abdominal cancer pain. In this case report, we describe a patient with pelvic and abdominal cancer pain due to stage IV sigmoid adenocarcinoma with widespread metastases, who received adequate pain management from a continuous local anesthetic infusion through a tunneled lumbar epidural catheter. Throughout this patient’s hospital admission, their opioid requirements remained the same, and their pain remained well controlled on review in the community one month after discharge. This case demonstrated that epidural catheters with local anesthetic as the sole neuraxial analgesic agent over a short duration could potentially provide preventive analgesia. This case highlights that a local anesthetic tunneled epidural, without addition of neuraxial opioids, is an effective alternative to intrathecal pumps in managing complex cancer pain and has potential for preventive analgesia.