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Indian J. Anaesth. 2007; 51 (1) : 50 - 52 INDIAN JOURNAL OF ANAESTHESIA, FEBRUARY 2007

50
CASE REPORT

PAIN MANAGEMENT IN A RARE MALIGNANT

SPINAL CORD TUMOR
Dr. P. F. Kotur 1 Dr. Anu Annie Abraham 2
Dr. Vijay Umarani3 Dr. Raviraj Ghorpade4

SUMMARY
Primary Intraspinal Primitive neuroectodermal tumor is a rare tumor with a poor prognosis. Only few cases have been reported in
literature. An 18-year-old girl presented with acute low back pain with no neurological deficit. The tumor could be excised in total.
MRI done 6 weeks post operatively was suggestive of a recurrence of the tumor at an alarming rate. The case was referred to our
Department for pain management until a definitive treatment plan could be executed.
Keywords : PNET (primitive neuroectodermal tumor), Pain management, Epidural opioid, Oral morphine,
Opioid tolerance, Opioid rotation.

Introduction aspect of the thigh and leg. Pain was severe in nature and
Primitive neuroectodermal tumor (PNET) is a she was able to walk with assistance. She had no history
malignant small blue cell neoplasm of children but can suggestive of raised intracranial pressure or any cranial
occur at any age. This term originally proposed by Hart nerve palsy nor symptoms of sensory or motor weakness.
and Earle, denotes a neoplasm of presumed neural crest She had restricted ‘straight leg raising test’ on the right
origin.1 Todate only 19 cases have been reported in the side. Deep tendon reflexes were intact. Radiography of the
medical literature.2 The clinical characteristics of spinal lumbosacral spine was normal. MRI images showed an
PNET in cases described so far appear to be2 : intensely enhancing tumor (fig. 1). The patient underwent
L4-L5 laminectomy and total excision of the tumor (fig. 2).
i. more common in adults than in children. Histopathology reported as Ependymoma Grade I-II. Hence,
ii. males predominantly affected than females (in a ratio patient was planned for close follow-up.
of 2:1).3
iii. aggressive nature of the tumor is evidenced by rapid
recurrence.
iv. survival is usually less than 2 years. Less than 40%
of the cases were alive for 2 years after diagnosis and
only about 10% after 3 years.
Majority of the cases were not referred for pain
management. We report a rare case of Primary intraspinal
PNET in an 18-year-old girl who came to us for pain
management during postoperative recurrence.

Case report
A previously healthy 18-year-old girl presented with Fig. 1 Fig. 2
acute low back pain radiating to the right posterolateral
Patient improved after surgery as regards her pain
1. M.D., D.A., Prof. & Head and returned home ambulating. Six weeks later, she presented
2. D.A., Resident again with severe back pain with no neurological deficits
3. M.D., Lecturer
subsequently she developed saddle paresthesia and
Dept. of Anesthesiology, J.N Medical College, Belgaum
4. M.Ch.(Neurosurgery), Consultant Neurosurgeon paraparesis. She was started on tab gabapentin. There was
KLE’s Hospital & MRC, Belgaum-10 no loss of urinary sphincter control. The pain was progressive
Correspond to : and repeat MRI showed huge tumor recurrence (fig. 3 & 4).
Dr. Anu Annie Abraham Patient was planned for review of Histopathology report
E-mail : anuannieabraham@yahoo.com
(HPR), with further immunohistochemistry study and was
(Accepted for publication on 20 - 11 - 2006 )
planned for radiotherapy and chemotherapy. Meanwhile
KOTUR, ANU, VIJAY, RAVIRAJ : MALIGNANT SPINAL CORD TUMOR : PAIN MANAGEMENT
Fig. 3 Fig. 4
pain management was planned methodically. Definitive HPR
was confirmed as spinal PNET.
Pain management executed
Pain was assessed using Visual analogue scale.
The treating neurosurgeon was consulted as regards the method
of pain relief, and the duration of pain relief required. It
was planned to administer opiates thru epidural route. After
obtaining written informed consent patient was taken to
the OR and epidural catheter inserted under aseptic
precautions. An 18G Touhey needle was initially inserted
at the level of L2-L3 interspinous level and a 20G catheter
was passed cephaloid and fixed at 9cm, so that 3-4 cms of
the catheter was in the epidural space, to lie near T10-T11
dermatome level. buprenorphine 300µg diluted to 10ml with
0.9% normal saline was administered. Pain relief was
obtained within 10min and lasted for about 18 hours.
Subsequent dose of 150 µg was effective for only six hours.
Further more the duration of pain relief with subsequent
doses of buprenorphine went on decreasing gradually and
was only four hours in the next two days. So it was decided
to modify the treatment regime. Triamcilone 40mg with
10ml of 0.125% bupivacaine was given over three
consecutive days 4 with rescue dose of buprenorphine.
On the seventh day of epidural catheter placement,
it was decided to administer epidural Morphine along
with adjuvant drugs (Amitriptylline, Gabapentin, Piroxicam
and Zolpidem. The patient was initially started on
Gabapentin by the treating neurosurgeon) She had pain
relief with 3 mg of Morphine diluted to 5 ml lasting for
12-15 hours. Following morphine administration, the
patient developed itching of face and trunk and constipation.
She was started on Ondansetron 8 mg I.V. stat and 4 mg
bd for the next 5 days to counter opioid induced urticaria
and Syrup Cremaffin 10ml at night for constipation. The
epidural catheter was removed after 10 days. Taking into
consideration the need for a effective mode of drug
administration, the patient was asked to continue Morphine
orally.
51
With written informed consent and after ensuring
good venous access and basic monitoring devices, the
patient was started on morphine trial with increments of
1.5 mg I.V. every 30 min until pain relief. She had pain
relief with 40 mgs of Morphine I.V. She was then started
on morphine 40 mgs oral tablets on a four hourly dose with
double the dose at night and rescue dose of 40 mgs if she
had complaints of pain. The adjuvant drugs also were
continued along with Morphine. Patient was comfortable
and could be sent home on the above-mentioned regime.
She was subsequently treated with radiotherapy and
chemotherapy and the dose of Morphine was reduced side
by side. The tumor has regressed considerably following
radiotherapy and chemotherapy. At the time, she was not
writing this case report on any medication and was totally
pain free with better quality of life.
Discussion
Many cancer patients develop significant pain during
the course of their illness. Most of this pain can be controlled
with the use of opioids. It is important to remember that
better pain control can be achieved with round-the-clock
dosing, with the addition of rescue doses for breakthrough
pain.
One often-identified adverse effect of opioid
administration is that of the development of tolerance to
the analgesic effect. While it is generally agreed that
tolerance to opioid analgesia does occur, it does not
appear to be a limiting factor. Numerous studies and
clinical experience suggest that tolerance to different
opioid effects develop at different rates, which has been
termed selective tolerance.
Poor responsiveness is a complex phenomenon that
may be related to one or more of a diverse group of factors,
including co morbid medical disorders that predispose to
toxicity, a pain pathophysiology associated with relatively
limited analgesic response, and pharmacologic effects such
as the accumulation of active metabolites caused b y
dehydration or renal insufficiency.5,6,7 after an initial good
response to buprenorphine, In our case tolerance was
noticed due to which pain relief was limited for 4-5 hours
only. Mercadante states that in cancer patients, opioid
rotation should be considered in case of adequate in pain
relief.8 The switch from one opioid to another when
treatment-limiting toxicity establishes poor responsiveness
has become known as opioid rotation. This rotation
can be achieved by providing the same opioid but using
a different route or by using a different opioid by the
same route. The practical and theoretical advantages of
opioid rotation include improved analgesia and reduced
side effects. However, the evidence to support the practice of
52 INDIAN JOURNAL OF ANAESTHESIA, FEBRUARY 2007

opioid switching is largely anecdotal or based on observational
and uncontrolled studies. Once tolerance to the analgesic
effect of one opioid is observed co-administration of other
receptor-mediated analgesics is advocated in order to avoid
unnecessary further development of tolerance.9
The optimal route for morphine in pain management
is oral.8 We administered intravenous morphine for more
rapid titration to the therapeutic dose. The dose should be
increased in steps until either adequate analgesia is attained
or intolerable or unmanageable side effects occur.
Drug dose, interval and pain relief chart was prepared
and the patient and her sister were instructed. This was
done for ease of self-medication. Patient was asked to take
rescue doses of morphine if she developed pain in between
the 4-hour interval. Patient had adequate pain control until
radiotherapy and chemotherapy was completed.
Conclusion
Cancer pain is very common and often undertreated.
Successful management of pain is essential in the care of
patients living with cancer or facing the end of life.
Principles of pain management include a) Detailed and
regular assessment of pain b) Education and encouragement
of patients and relatives to use opioids c) Aggressive
management of side effects. Pain is subjective and is best
described by the patient. Pain control is possible and should
be pursued aggressively.
For those patients who experience a poor response
during routine opioid therapy, many strategies can be
implemented to improve analgesia. Opioid rotation is a
simple strategy and within the purview of all clinicians.
With a comprehensive assessment, and a commitment to
reassess and adjust therapy, clinicians can pursue this
approach and potentially identify the most favorable opioid
for an individual patient.
Therefore, we conclude that guidelines are useful in
the treatment of cancer pain. However, because patients
have varying responses to opioids, pain management
must be individualized. Based on our successful management
plan in this case we have defined a flow chart of pain
management in such cases (Flow chart 1). When patients
are unable to tolerate opioid therapy because of adverse
effects (in this case, inadequate pain relief), it is appropriate
to change the route of administration or switch to another
opioid.
References
1. Babara J. Crain. Primitive neuroectodermal tumor. In:
Neurosurgery by Regachary Robert H Wilkins and Setti S
Rangachari 1996; 11: 1707-13.
2. Virani MJ, Jain S. Primary Intraspinal Primitive
neuroectodermal tumor (PNET): A rare Occurrence. Neurology
India. March 2002; 50: 75-80.
3. Roke LB, Harte MN, McLendon RE. Supratentorial primitive
neuroectodermal tumor. Embryonal Tumors in WHO
classification of tumors, Pathology and Genetics of tumors of
the nervous system 2002: 141-44.
4. Abram SE. Treatment of Lumbosacral Radiculopathy with
epidural Steroids. Anesthesiology 1999; 91(6): 1937-41.
5. Portenoy RK. Managing cancer pain poorly responsive to
systemic opioid therapy. Oncology 1999; 13: 25-29.
6. Mercadante S, Portenoy RK. Opioid poorly responsive cancer
pain: Part 3. Clinical strategies to improve opioid
responsiveness. J Pain Symptom Manage 2001; 21: 338-54.
7. Mercadante S, Portenoy RK. Opioid poorly responsive cancer
pain: Part 1. Clinical considerations. J Pain Symptom Manage
2001; 21: 144-50.
8. Mercadante S. Opioid rotation for cancer pain. Rationale and
clinical aspects. Cancer November 1, 1999; 86: 1856-66.
9. Freye E, Latasch L. Development of opioid tolerance-
molecular mechanism & clinical consequence. Anesthesiology
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