Unfortunately, the beneficial effect on pain produced by the thoracic sympathectomy did not last longer than 3 weeks after our positive 2-week control (see our message from March 12). However, the beneficial effect on transpiration in the pain-full area remains intact, indicating that the pain that returned might be caused by other mechanisms than tumour infitration of the thoracic sympathetic chain. We therefore sent the patient for an MRI of the thoracic spine, from which the following images have been extracted.
The MRI demonstrates infiltration around the nerve root T6/7 on the left side, reaching the spinal canal without infiltrating the dural sac. There is also mesothelioma infiltration around the sympathetic chain and into the left pedicle of T6.The patient was given a transforaminal epidural injection of a mixture of 1 cc bupivacaine 0.5% and 20 mg of depomedrone at the level of T6/7 on the left side. This test treatment completely removed his pain for 48 hours. This strongly suggests that the infiltration of tumour at this level produces the pain.
The patient is presently undergoing radiotherapy directed at the spine in an attempt to reduce the radicular pain. If this treatment is ineffective we will proceed to implant a pump system delivering bupivacaine intrathecally. If this implantation is done, the catheter tip will be placed at T5, if possible on the left side to ensure appropriate anesthesia at the spinal emergence of the T6/7 root
We will keep you informed about the evolution in subsequent messages.
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