Cancer & Intractable Pain

Pain beyond what medication can control

This covers severe pain, often from cancer, that is no longer controlled by medication even at high doses, or where the side effects of the doses needed (such as overwhelming drowsiness) have become intolerable. It also covers other intractable pain that has exhausted standard treatment. For these situations there are well-established procedures that can give meaningful relief and improve quality of life. The right choice depends on where the pain is and whether it is one-sided or in the midline.

After medication has been maximized

These procedures are considered once medical therapy has genuinely been pushed to its limit, escalating pain medication until either the pain is controlled or the side effects cannot be tolerated. In general, gentler, reversible options are tried before any procedure that interrupts a pain pathway, and the plan is made together with the palliative care and oncology teams.

Surgical options

• Intrathecal drug delivery (pain pump)
  An implanted pump delivers pain medication directly into the spinal fluid, where it works at a tiny fraction of an oral dose, controlling pain with far fewer whole-body side effects. Often the first procedure considered, because it is powerful yet adjustable.
• Cordotomy
  Interrupts the pain pathway on one side of the spinal cord. It is the procedure of choice for severe, one-sided pain below roughly the upper chest, particularly in patients with a limited life expectancy, and is often performed through a needle (percutaneously).
• Midline (commissural) myelotomy
  A precise procedure aimed at midline and deep abdominal or pelvic (visceral) cancer pain, which is hard to treat by other means.

See also