DIFFICULT MANAGEMENT OF PAIN FOLLOWING SACROCOCCYGEAL CHORDOMA - 13 MONTHS OF SUBARACHNOID INFUSION

We report on a patient suffering severe pain following a long-standing sacral chordoma in whom management of therapy and pain was extremely difficult. Because orally administered morphine was observed to be ine ffective in the early stages of treatment, we tried to achieve pain re lief by using epidural morphine. This was also unsatisfactory. Intrath ecal infusion of morphine and bupivacaine through a catheter inserted at the L2-L3 level was also found to be ineffective; only a segment bl ock was observed. A structural anomaly of the spine was suspected and confirmed by myelography, showing metastasis at L3. Pain relief improv ed when an infusion of morphine + bupivacaine was employed through a c atheter placed at the L4-L5 level below the blockage. A major problem which continued throughout the course of the disease was the daily occ urrence of episodes of unbearable sharp pain that required addition of midazolam to the local anesthetic/opioid subarachnoid infusion. The p atient received this mixture through an intrathecal port during the la st 13 months of life, a gradually increasing dose being necessary. Per iods of analgesia were followed by occasional crises of intense sharp pain suggesting incomplete relief. No serious complications or meningi tis occurred. This case emphasizes the difficulty in managing pain in this type of cancer.