Mercadante Sebastiano, Candido Kenneth, Staats Peter, Davis Mellar
La Maddalena Cancer Center, Palermo, Italy.
Advocate Illinois Masonic Medical Center, Chicago, IL, USA.
Support Care Cancer. 2025 Jul 9;33(8):674. doi: 10.1007/s00520-025-09685-2.
Patients with cancer pain refractory to conventional medical management may benefit from spinal analgesia, although there are some critical points regarding some aspects which cannot be examined by an evidence-based approach. A group of experts was selected by MASSC to provide clinical practice advice on the use of spinal drug delivery in patients with cancer-related pain. Refractory cancer pain should be considered a condition in which a patient has failed to receive adequate analgesia or has developed uncontrolled side effects after comprehensive pain management. The intrathecal route (IT) with an implantable drug delivery system allows the administration of minimal doses of analgesics with significant clinical effects while avoiding major adverse effects and lower risks with prolonged use. Morphine and hydromorphone are the opioids of choice for IT treatment. Local anesthetics are an added value because of their additive-synergic effect on segmental areas. The efficacy of adding small amounts of local anesthetics to an ITDD relies on the positioning of the tip of the catheter close to the dermatome where the origin of the pain comes from. Their use, however, depends on the delivery system, because larger volumes are necessary. Ziconotide requires a slow dose titration, but it can be used in small volumes. In addition, once doses are stabilized, no tolerance occurs. A conversion ratio of 100:1 between oral and IT morphine is suggested for patients who receive high doses of systemic opioids. A higher ratio (300:1) should be used in patients prevalently switched to the IT route for uncontrollable adverse effects, receiving lower doses of systemic opioids. The use of boluses of hydrophilic opioids, like morphine, for treating breakthrough pain may be inadequate, as intrathecal opioids alone may be unable to adequately treat an episode of rapid pain onset and duration. The decision-making process for employing interventional therapies, like spinal analgesia, should be shared, taking into account the actual indications and needs, previous treatments, prognosis, timing, advantages and disadvantages, and complications, in any individual situation, managing all the aspects of care.
对传统药物治疗难治的癌症疼痛患者可能从脊髓镇痛中获益，尽管在某些方面存在一些关键点，无法通过循证方法进行研究。MASSC挑选了一组专家，就癌症相关疼痛患者使用脊髓药物输送提供临床实践建议。难治性癌症疼痛应被视为患者在综合疼痛管理后未能获得充分镇痛或出现无法控制的副作用的一种情况。采用可植入药物输送系统的鞘内途径（IT）允许给予最小剂量的镇痛药并产生显著临床效果，同时避免主要不良反应且长期使用风险较低。吗啡和氢吗啡酮是IT治疗的首选阿片类药物。局部麻醉药因其对节段区域的相加协同作用而具有附加价值。向植入式药物输送装置中添加少量局部麻醉药的疗效取决于导管尖端靠近疼痛起源皮节的定位。然而，其使用取决于输送系统，因为需要更大的容量。齐考诺肽需要缓慢滴定剂量，但可小剂量使用。此外，一旦剂量稳定，不会产生耐受性。对于接受高剂量全身性阿片类药物的患者，建议口服与IT吗啡的转换比例为100:1。对于因无法控制的不良反应而主要转为IT途径且接受较低剂量全身性阿片类药物的患者，应使用更高的比例（300:1）。使用亲水性阿片类药物（如吗啡）的推注来治疗爆发性疼痛可能不足，因为仅鞘内阿片类药物可能无法充分治疗疼痛发作迅速且持续时间短的情况。在任何个体情况下，采用介入治疗（如脊髓镇痛）的决策过程都应共享，要考虑实际适应症和需求、既往治疗、预后、时机、利弊及并发症，全面管理护理的各个方面。
