Our next patient was referred for a second opinion on implantation of an intrathecal morphine pump to treat thoracic pain cause by a left sided mesothelioma. The patient had already had close to full dose radiotherapy towards the left chest and chemotherapy without improvement of his pain.
His malignancy was known since two years and was clinically in a stable phase. Pain was situated in a segmental area in the posterior aspect of the left chest wall and did not irradiate beyond the posterior axillary line. There were no neuropathic pain characteristics and no signs of deafferentation. Pain was described as deep and diffuse. It poorly responded to all types of analgesics including oral morphine and transcutaneous fentanyl.
The area of pain was confined to a segment from T7 to T10 from the mid-line to the posterior axillary line. Sensory testing demonstrated decreased sensitivity for cold whereas tactile stimulation was felt normally. The skin temperature in the area of pain was 28 degrees C, 5 degrees lower than in the surrounding area and in the corresponding territory on the right side
The patient presented profuse sweating in the area of pain as observed on his shirt while undressing.
The findings were compatible with a complex regional pain syndrome (CRPS). A diagnostic sympathetic block with bupivacaine 0.5% at the level of T7 on the left side equilibrated skin temperature, removed the excessive sweating and made the patient completely pain-free for 7 hours.
On the following day, the patient underwent a chemical sympathectomy with 6% fenol in water. This removed all his pain and he remains pain-free on the first follow-up after two weeks.
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