1st month, admissionIntra-arterial embolization in the tumoral territory irrigated by the left lateral sacral artery |
PainPain intensified (score 10/10) |
Morphine, 10 mg every 6 hoursAmitriptyline, 50 mg/dayReplacement with transdermal fentanyl (200 mcg) and gabapentin (1,200 mg/day) |
3rd month, unchanged tumoral volumeTumoral embolizationInterferon alfa 2A (1.1MU/m2) |
Pain flare-up |
Gabapentin, 600 mg every 8 hoursTransdermal fentanyl (200 µcg), Tenoxicam, 20 mg/dayParacetamol, 750 mg every 6 hoursAmitriptyline, 75 mg/day |
4th month |
Pain when walking. Difficulty in using transdermal fentanyl patches due to profuse sweating. |
Intrathecal catheter placement with fentanyl PCA pump (5 µcg; blocking interval: 30 minutes; continuous infusion: 0.5 µcg/h; total continuous dose: 12 µcg/day) |
5th month, interferon alfa 2A (2.2MU/m2) |
Fentanyl withdrawal syndromeStabbing pain throughout the lower right limb due to L4 spondylolysis, grade I L4-L5 listhesis and neural foramen stenosis. |
Synchromed II intrathecal pump placement, approximately at L3/L4 level. Fentanyl infusion started at a continuous daily dose of 10 µcg.Intrathecal fentanyl dose was progressively adjusted; latter, fentanyl was replaced with morphine.Increased intrathecal drug infusion, with tramadol addition and morphine maintenance for salvage therapy.Bilateral L4/L5 periradicular block with bupivacaine and methylprednisolone. Second bilateral L4/L5 periradicular block with bupivacaine and methylprednisolone. |
10th month, tumoral growthInterferon alfa 2A (4.4MU/m2) |
Severe pain and burning sensation from the buttock to the posterior region of the lower right limb; profuse sweating, weight loss, moaning and pressure sore at the ulnar region due to load support. |
Amitriptyline, 75 mg/dayGabapentin, 2,400 mg/day; intrathecal morphine, 2.5 mg/day; Bupivacaine, 1.25 mg/day (Pain score went from 9/10 to 4/10). |
11th month, Radiotherapy – 4,500 cGy at the tumoral bed |
Severe burning sensation at the left plantar area, unable to touch the floor with the foot. Catheter in the subarachnoid space. |
Clonidine, 42 µcg/day; intrathecal morphine solution; Gabapentin, 2,700 mg/day.The catheter was replaced; it was intact, but it rolled under the pump. |
12th to 14th month – hydrotherapy and physical therapy |
The patient is unstable and requiring assistance in all daily life activities. |
Morphine (3.5 mg/day); bupivacaine; amitriptyline, 125 mg/day; gabapentin, 2,400 mg/day; tizanidine, 6 mg/day; methadone, 15mg/day; and naproxen, 1 g/day. |
29th month – ankle-foot orthosis |
Pain relapse |
Increase intrathecal morphine dose to 2 mg/day; methadone, 5 mg every 12 hours; amitriptyline, 25 mg/night; naproxen, 250 mg every 12 hours. |
87th month |
End of PCA pump working time |
PCA pump replaced |
91st month |
PCA pump exteriorization |
Intrathecal injection system removal; continuous venous infusion of morphine, 4 mg/hour, and methadone, 10 mg every 8 hours, reduced to 5 mg every 8 hours for 1 year; gabapentin, 300 mg 12 hours, and amitriptyline, 25 mg/night. |
96th month, tumoral growth stabilization |
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With no specific oncologic treatment, no pain or any analgesic medication, the patient resumed his daily life activities and returned to work |