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Care at the Close of Life: Evidence and Experience
Stephen J. McPhee, Margaret A. Winker, Michael W. Rabow, Steven Z. Pantilat, Amy J. Markowitz
Part B Symptom Management
Chapter 10. Spinal Cord Compression in Patients With Advanced Metastatic Cancer: “All I Care About Is Walking and Living My Life”
Janet L. Abrahm, MD, Michael B. Banffy, MD, Mitchel B. Harris, MD
Chemotherapy and Hormonal Therapy

Topics Discussed: adjuvant analgesic, amitriptyline, chemotherapy regimen, dexamethasone, fentanyl, glucocorticoids, hydromorphone, intensity-modulated radiation therapy, measures of outcome, morphine, opioid analgesics, opioids, oxycodone, pain management, radiation therapy, radiosurgery, secondary malignant neoplasm of spine, spinal cord compression, spinal cord procedure, summarizing the evidence

Excerpt: "Table 10-1 lists common opioids and adjuvants that control neuropathic and bone pain from vertebral metastases and spinal cord compression.3,7,35,36 Opioid dosages shown are for opioid-naive patients; those already taking opioids may need substantially higher dosages. Patients who have moderate or severe pain often benefit from a continuous intravenous infusion of opioids administered through a patient-controlled analgesia device, which allows the patient to self-administer rescue doses should the initial basal rate chosen be inadequate or should pain occur with movement (so-called incident pain). A consensus document from the American Pain Society offers algorithms for safe titration of intravenous opioids.36 Corticosteroids, effective for both neuropathic and bone pain, are discussed below. The anticonvulsants gabapentin and pregabalin have been shown to decrease the paresthesias and the burning, shooting, "toothache" pain that arises from peripheral nerve or spinal cord injury,7,34,37,38 although no studies have specifically investigated patients with malignant spinal cord compression. To minimize sedation, both agents should be started at a low dose and titrated to effect (Table 10-1). Tricyclic antidepressant agents, which putatively act via a different mechanism than anticonvulsant agents,34 can be used at bedtime because most induce sedation.7,34 Although no randomized trials have investigated the effects of anticonvulsants in patients with malignant spinal cord compression, a single randomized controlled trial involving patients with spinal cord injury (from unspecified causes) showed that amitriptyline was no more effective than placebo.39..."
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