https://doi.org/10.53964/jmmo.2024002

https://www.innovationforever.com

Journal ofModern Medical Oncology
Open Access

ISSN 2708-0005 (Online)

Case Report
Successful Management of Opioid-refractory Pelvic Cancer Pain Using Continuous
Local Anesthetic Infusion via a Tunneled Epidural
Jamie Young1,2, Angelina Koh3*, Walston R Martis1,2,4
1

Anesthesia and Pain Department, Peter MacCallum Cancer Centre, Melbourne, Australia

2

Department of Critical Care, The University of Melbourne, Melbourne, Australia

3

The Royal Melbourne Hospital, Melbourne, Australia

4*

Department of Anaesthesia, Monash Health, Melbourne, Australia

Correspondence to: Angelina Koh, MD, The Royal Melbourne Hospital, 300 Grattan Street, Parkville,
Victoria 3052, Australia; Email: angiejxkoh@gmail.com
Received: January 25,2024 Revised: April 12, 2024 Accepted: April 23, 2024 Published: April 30, 2024

Abstract
Opioid refractory pelvic cancer pain is common and difficult to manage, which often results inanalgesic 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 spaceinstead, 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 onreview in the community one month after discharge. This case demonstrated that epidural catheterswith local anesthetic as the sole neuraxial analgesic agent over a short duration could potentiallyprovide 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.
Keywords: anesthesia, epidural catheter, local anesthetic, pain management, tunneled epidural
Citation: Young J, Koh A, Martis WR. Successful Management of Opioid-refractory Pelvic Cancer Pain using Continuous Local
Anesthetic Infusion via a Tunneled Epidural. J Mod Med Oncol, 2024; 4: 2. DOI: 10.53964/jmmo.2024002.
Copyright © 2024 The Author(s). This open-access article is licensed under a Creative Commons Attribution 4.0 International License(https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, sharing, adaptation, distribution, and reproduction in any
medium, provided the original work is properly cited.

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J Mod Med Oncol 2024; 4: 2https://doi.org/10.53964/jmmo.2024002
1 INTRODUCTION
Pelvic and abdominal cancer pain is difficult to manage,
frequently being associated with significant reduction inquality of life[1]. Pain syndromes that may be experienced
include a combination of radiculopathy from nerve root
invasion, inflammatory and bony pain from tissue invasion,and tenesmus with rectal pain from distension[2]. Due tothe complex nature of this pain, including nociceptive
and neuropathic elements, there is usually analgesic
polypharmacy with a consequential escalation of opioids[3].
Up-titration of opioids is limited by systemic side-effects
including respiratory depression, sedation, and constipation[4].
Interventional targets that have been explored include
the hypogastric plexus, ganglion impar, pudendal nerve,transforaminal nerve roots and the caudal-epidural space[5].
However, these procedures are limited by their efficacy,
duration of action, as well as the risk of nerve injury andpotential denervation pain from neurolysis[6,7].
Intrathecal pumps have been used as a more permanent
pain management option in these patients, as these are
implantable devices with the ability to provide localized
therapy through the delivery of medications to theintrathecal space[8]. Opioids have been the mainstay of
intrathecal therapy due to the pharmacological benefit ofaccess to the blood brain barrier and the opioid receptors in
the central nervous system[9]. This may be advantageous inthose with opioid tolerance and opioid-related side-effects.
Along with opioids in intrathecal pumps, the adjunctmedications commonly used include ziconotide, a N-type
calcium voltage channel blocker, and clonidine, an alpha-2adrenergic receptor agonist[10]. However, they are limited bya need for careful titration and pump volume constraints[10].
Ziconotide has been suggested as monotherapy inintrathecal pumps, but its availability is limited in different
countries and there are concerns with regards to side-effects
such as nausea (30%), dizziness (42%), psychosis andsuicidal ideation[11].
An alternative to intrathecal opioids and ziconotide are
local anesthetic agents such as ropivacaine and bupivacaine,
however, there is a narrow therapeutic index withconcerns regarding motor blockage, urinary retention, andhypotension. These risks can be mitigated by targeting the
epidural space instead, and we propose the use of a tunneledepidural catheter technique for continuous local anesthetic
infusion in opioid-refractory pelvic and abdominal cancer
pain. This study is unique in demonstrating the efficacy andfeasibility of utilizing a tunneled epidural with the sole useof local anesthetic as an alternative to intrathecal pumps ina cancer palliative care patient with the potential to provide
preventive analgesia. Although tunneled epidural catheters
have been used in cancer pain, they are mainly used during
end-of-life care and local anesthetics are often combinedwith opioids. This case is different in that tunneled epidural
was used before end-of-life care and only local anesthetic

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was given through the epidural catheter.
2 CASE PRESENTATIONA 52-year-old female with stage IV sigmoid adenocarcinoma and metastases to the bladder, pelvis, lung, andliver was admitted to hospital due to increasing cancerassociated pain. Her abdominal and anterior pelvic pain
were nociceptive and neuropathic in nature, and she
also had radicular pain in the right gluteal region andright upper leg, in addition to right-sided vulvodynia.
Computed tomography (CT) imaging showed diseaseprogression, evidenced by increased size of sigmoid mass
with infiltration into the urinary bladder and increased
size of right pubic ramus osseous metastases. Her pain
control regimen included continuous subcutaneous
morphine infusion of 50mg over 24h (with breakthroughsubcutaneous morphine 15mg twice daily as needed),fentanyl transdermal patch 75mcg per hour, whichamounted to 225mg oral morphine equivalent daily
dose (oMEDD), oral methadone 5mg twice daily (30mg
oMEDD) and pregabalin 150mg nocte. However, she
continued to have poor pain control, significantly affecting
her quality of life with regards to her function and mobility,
therefore requiring hospital admission.
During admission, she received a tunneled lumbar
epidural catheter with continuous local anesthetic infusion
to manage her pain. An epidural catheter was inserted at the
lumbar (L3-L4) level under sterile conditions. A test doseof 5ml of 0.2% ropivacaine was given, with no subsequent
motor block or hemodynamic instability. The epidural
catheter was then tunneled under the skin, without leaving
a skin bridge, secured with DERMABOND™ (Johnson& Johnson, USA ) and Ioban™ (3M, USA) dressings. An
infusion of 0.2% ropivacaine (2mg/mL) was maintained
at a rate of 5mL/h using an infusion pump. A dermatomal
assessment performed two hours following the procedure
showed adequate block at the level of L3-S2. The patient’s
pain was controlled, her Bromage score was 0, and power
was normal (5/5) on the Medical Research Council
muscle power scale in both left and right lower limbs.
The patient’s opioid requirements remained the same, andno further issues were noted over the next four days. The
epidural catheter was ceased after five days as the patient
was discharged to the community. During her one monthfollow up, it was reported that her pain remained wellcontrolled and at the time of this review, she was still in thecommunity.
3 DISCUSSION
This case highlighted that pelvic cancer pain managed
using epidural catheters, with local anesthetic as the soleneuraxial analgesic agent, over a short duration can provide
potentially preventive analgesia. As demonstrated in thispatient, a pure local anesthetic epidural infusion of five days
was able to manage her escalating cancer pain and allowed

J Mod Med Oncol 2024; 4: 2https://doi.org/10.53964/jmmo.2024002
Table 1. Advantages and Disadvantages of Administering Local Anesthetic via an Epidural Catheter
Compared to an Intrathecal Pump
Epidural Catheter

Intrathecal Pump

Advantages

Less invasive
Less motor blockLA agents given through the epidural space have awider therapeutic index with lower risk of toxicity.
Lower risk of infection, especially with tunneling of thecatheter.

Provides a more permanent option for patients withrequirements for longer term analgesia.

Disadvantages

Unable to be used in the ambulatory setting in thecommunity.
Higher systemic
absorption and risk of LAST

Invasive procedure to install and remove intrathecal
pumps.
Post-dural puncture headache
Higher risk of infection
Risk of spinal-cutaneous fistula
Limited to small doses of LA
LA agents given through intrathecal pumps have anarrow therapeutic index with great risk of toxicity.
Limited to small doses of LA
More motor block

Notes: Abbreviations: LA, Local Anesthetic; LAST, Local Anesthetic systemic toxicity .

her to be discharged back into the community without
needing a prolonged hospital stay. This patient did not require
an intrathecal pump, and no neuraxial opioids were given.
Local anesthetic epidural infusions can attenuate central
sensitization and have anti-inflammatory properties to prevent
development and exacerbation of pain[12,13]. Therefore, local
anesthetic epidural infusions have the potential to provide
preventive analgesia in patients with uncontrolled cancer pain
through short-term admissions for epidural infusions.
This case study illustrates several advantages of epidural
catheters over intrathecal pumps for cancer pain that has
not reached end-of-life stages. Epidural catheters allow for
flexibility in the type of medication administered, in contrast
to intrathecal pumps which are more difficult to alter thetype or dose of medications[14]. Epidural catheters are also
more easily removed compared to intrathecal pumps, which
require more invasive procedures. This is especially useful incancer pain which is dynamic and evolves with the disease
process. Patients would therefore benefit from a more readily
adaptable system for pain relief. In light of the recent use of
intrathecal pumps in cancer pain in the literature[15], this casestudy demonstrates the importance of considering epidural
catheters as an alternative to intrathecal pumps for cancer
pain patients who are not at the end-of-life stages.
This patient had a tunneled epidural technique which has
the advantage of reducing risk of catheter dislodgment[16].
Tunneling an epidural reduces dislodgment by up to
50%, which is especially important as the leading causeof late epidural failure is dislodgment[17,18]. This case also
further highlights that tunneling should be done withoutleaving a skin bridge as it can potentially reduce the risk ofinfection and can increase the length of time the catheter
can be kept in the epidural space[19,20]. It is postulated thattunneling results in better fixation and less movement
between the skin and catheter, therefore reducing bacterial
migration along the catheter[20]. This case also shows that
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securement with DERMABOND™, Ioban™ dressingsand suture fixations are beneficial in securing the catheter.
The advantages and disadvantages of administering
local anesthetic via an epidural catheter compared to an
intrathecal pump in our patient are outlined in Table 1.
In addition to describing the technical aspects andadvantages of epidural catheters, this case shows that there
is potential in adapting epidural systems that would allow
their use in the community, which would help with cost
reduction. Potential modifications that can be made include
the use of computerized ambulatory delivery devices(CADD) pumps or elastomeric infusion systems that could
be connected to the epidural catheter. This has been donein postoperative pain where elastomeric pumps have beenshown to be non-inferior in postoperative epidural analgesia
compared to conventional patient controlled epidural
analgesia whilst enabling patients to be managed in thecommunity[21]. The use of elastomeric or CADD pumps
could be an area of exploration in cancer pain to provide
ambulatory continuous epidural analgesia.
4 CONCLUSION
This case demonstrates that a tunneled epidural local
anesthetic catheter may be an effective alternative to an
intrathecal drug delivery system to provide analgesia forcancer pain as part of a multimodal strategy. This casestudy is unique in that only a local anesthetic agent wasadministered via the epidural without a need for addition ofneuraxial opioids and analgesia persisted for a prolonged
period.
Acknowledgements
Not applicable.
Patient Consent
Written patient consent was obtained prior to the writing of
this report, for publication of this report.
J Mod Med Oncol 2024; 4: 2https://doi.org/10.53964/jmmo.2024002
Conflicts of Interest
The authors declared no conflict of interest.

[10]

Author Contribution
Young J was responsible for supervision of the projectand reviewing the final draft for submission. Koh A was
responsible for writing the original draft. Martis W was
responsible for editing and reviewing the final draft for
submission. All authors contributed to the manuscript andapproved the final version.
Abbreviation List
CADD, Computerized ambulatory delivery devices
CT, Computerized tomography
oMEDD, Oral morphine equivalence daily dose

[11]

[12]

[13]

[14]

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