Director of Minimally Invasive Spine Oncology Memorial Sloan Kettering Cancer Center, USA New York, NY, US
Disclosure(s):
Ori Barzilai, MD: No financial relationships to disclose
Introduction: Pain affects up to 66% of cancer patients, with spine being the most common site of cancer pain. Spine tumor pain serves as the most common symptom and treatment indication for patients with spinal metastatic tumors. A large proportion of patients continue to experience significant pain after spine tumor-directed treatment. A systematic literature review of the key pain states associated with spinal tumors identified significant knowledge gaps in spine tumor-specific taxonomy, assessment, and treatment recommendations. The objective of this study is to generate a core set of spine tumor descriptors and develop a mechanism-driven classification system for systematic pain assessment, treatment selection and focused pain experience measurement.
Methods: A modified Delphi process was conducted among 66 participants including 62 AO Spine Knowledge Forum Tumor members (neurosurgeons, orthopedic surgeons, radiation oncologists) and 3 pain anesthesiologists and 1 physiatrist. Three survey rounds were followed by a structured virtual summary meeting. Consensus at a minimum threshold of 75% participant agreement was predefined.
Results: The survey included six categories, each with various subcategories 1) demographics included: age, sex, race, occupation, education and employment-status; 2) pain characteristics included: location, temporal-characteristics, pain-severity, pain-duration, pain-quality and response to treatment; 3) psychosocial factors included: cognitive, emotional, behavioral, social and education; 4) clinical exam included: findings over the pain site, range of motion, posture change, weight-bearing, Lasegue test, Duncan-Ely test, Spurling test, “heel-drop” test, Kemp test, sacroiliac provocation tests, paravertebral trigger points, presence of myelopathy; 5) diagnostic tests included: Imaging, EMG/NCS, diagnostic injection; and 6) medical comorbidities included: obesity, anxiety/depression, extent of cancer, smoking, spinal cord injury and pre-existing chronic pain diagnosis. Consensus was reached for three descriptive categories necessary to comprehensively describe and spine cancer-related pain including location, pain characterization and radiographic findings. Additional important variables helpful in guiding treatment decisions were included as modifiers. These were subsequently consolidated into a mechanism-based classification defining Mechanical (Axial/Radicular), Inflammatory (Axial/Radicular) and Neuropathic (Central/Peripheral)
Conclusion : Expert consensus was reached regarding the key spine tumor pain assessment elements and a classification system was developed. This will provide the foundation for systematic evaluation and reporting of spine cancer-related pain and facilitate research and therapeutic decisions.