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September/October 2006
Volume 2, Issue 5
In this Issue:
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Pain Management in the Geriatric Patient Population: Part II
An Original Contribution by Frank J. E. Falco, M.D.
Part one on pain management in the elderly (July/August 2006 issue) reviewed the physiological changes of aging and the use of acetaminophen, NSAIDs, tramadol and opioids for treating pain in the elderly. This article deals with some common disorders that afflict the elderly and interventional treatments that can provide pain relief.
Elderly patients can have one or more chronic diseases that can cause pain including osteoarthritis, rheumatoid arthritis, cancer, degenerative joint disease, osteoporosis, trauma, and surgical pain. Interventional therapies can reduce and, at times, eliminate the need for pain medications.
Degenerative spine disorders in the geriatric population include spinal stenosis and facet arthropathy. Stenosis is narrowing of the central spinal canal, lateral recesses and/or the foramen. Symptoms due to spinal stenosis include low back pain, sciatica, neurogenic claudication and limited ambulation. Facet joint arthropathy results from osteoarthritis or mechanical loading of the facets and presents as axial low back pain. Lumbar epidural and facet joint steroid injections often provide pain relief that can last months to years with improved function. Unfortunately, the pain often returns for both disorders necessitating repeat injections to provide ongoing pain relief. Over time, the therapeutic benefit of additional injections tend to diminish with shorter durations of pain relief. Surgical decompression or spinal cord stimulation can provide lasting relief of radicular leg pain and neurogenic claudication in those with spinal stenosis. In those with facet arthropathy, radiofrequency surgery can lead to lasting back pain relief.
Osteoporosis affects 10 million Americans, the majority of whom are seniors, resulting in 700,000 spine fractures a year. The fractures can cause significant back pain. Vertebroplasty (injection of cement into the fractured vertebral body) continues to demonstrate its effectiveness in significantly eliminating pain and improving function. Recent literature has advocated the use of vertebroplasty over kyphoplasty for several reasons including effectiveness, morbidity and cost. Even patients with fractures greater than a year can benefit from vertebroplasty.
Cancer pain is refractory to pharmacological management in 15% of cancer patients. Intrathecal pump drug delivery systems (IPDDS) have been successful in reducing pain and drug toxicity in these patients. IPDDS has demonstrated better pain control, less drug toxicity and longer survival rates compared to medical management in the most refractory of cancer patients.
Degenerative joint disease of the hips and knees can lead to significant pain and disability in the elderly. Total and partial joint replacement surgery combined with post operative rehabilitation provides complete pain relief and substantial improvement in function in the majority of these patients.
Percutaneous Radiofrequency Treatment of Hepatic Tumors
An Original Contribution by Frank J. E. Falco, M.D.
The two most common malignant tumors of the liver are hepatocellular carcinoma (HCC) and colorectal carcinoma metastases (CCM) to the liver. The prognosis is poor with zero percent survival rate at five years without treatment. In general, systemic chemotherapy and/or radiation are not effective. Surgical resection is the only option for cure but only five to 15% of patients with HCC or CCM are eligible for resection. The success rate for those who are eligible for resection is compromised by post operative morbidity, cost, and only a slight improvement in the long term prognosis with a survival rate of approximately 20% at five years. Furthermore, these patients are not suitable for additional resections. Unfortunately, most patients die from recurrent tumors.
Radiofrequency ablation (RFA) of hepatic tumors can be performed by a percutaneous, laproscopic or open surgical approach. Inclusion criteria for RFA consist of preoperative imaging demonstrating fewer than five tumors with diameters less than five centimeters and no evidence of extrahepatic tumor. Exclusion criteria include patients who are eligible for surgical resection of tumors; tumors that are too close to vital structures such as the diaphragm, gallbladder and subcapsular tumors abutting against other visceral structures. Contraindications to performing RFA include excessive intrahepatic tumor load, untreatable extrahepatic tumor, cirrhosis, and active infection.
Percutaneous RFA of HCC has demonstrated a 90% necrosis rate for tumors less than three cm at six months, but one-third of these patients will develop recurrent tumors at 15 months. The rate of necrosis for HCC is 50 to 70% at six months for three to five centimeter tumors and only 25% for tumors greater than five centimeters. The success rate of RFA in CCM is not as good as in HCC with a necrosis rate ranging from 50 to 90%. Recurrent tumor develops in 70% of these patients at 12 months and 90% at 18 months.
Complications include post-operative bleeding and a flu-like syndrome post ablation that typically begins three to five days after the ablation and lasts up to five days. RFA of the liver is otherwise a safe procedure with an extremely low rate of major complications. |
