A Cancer Pain Tutorial

A Comprehensive Visual Short Course
on Cancer Pain Management

Metastatic Bone Disease

Invasion of bone is the most common cause of pain in both adults and children with cancer. The mechanism of bone pain from metastatic tumor involvement is poorly understood .

Growth of metastatic tumor in bone is associated with two processes. Active bone destruction and new bone formation.

Bone pain seems to be related to the process of rapid bone resorption through osteolytic activity plus bone replacement by the activity of osteoblasts. The pain mechanism is nociceptive. It is dull, aching, throbbing in nature.

Skullbases Metastases
Pain Type : Neuropathic
Cause: Direct Infiltration or Compression Upon the Nerve By Tumor or Metastasis
Effects: Constant Throbbing Headache or Earache Deep in the Head

Clinical Signs:
Pain, Neurological Signs

Associated Cancers: Nasopharyngeal Tumors
Diagnosis : CT or MRI used to Document Disease

Metastases to the skullbase is most common in patients with nasopharyngeal tumors, but may occur with any tumor that metastasizes to bone. Pain is often the earliest complaint, proceeding neurological signs by several weeks.

Documentation by plain X-ray is difficult; computerized tomography or magnetic resonance imaging is usually necessary to document disease. Once the neurological signs of have developed they are usually irreversible. The pain is usually described as a constant throbbing headache or earache deep in the head.

Jugular Foramen
animation of jugular foramen
Pain Type : Neuropathic
Cause: Invasion of Bone By Tumor or Metastasis
Effects: Neurological Signs

Clinical Signs:
Occipital Pain Referred to the Vertex of the head and Ipsilateral Shoulder and Arm Pain, Exacerbated by Head Movement, Horner's Syndrome, (ptosis, miosis, anhidrosis)

The most common early presenting symptom is occipital pain referred to the vertex of the head and ipsilateral shoulder and arm pain, exacerbated by head movement.

Presence of neurological signs are associated with lesions of the 9th, 10th, 11th, and 12th cranial nerves. Horner's syndrome is seen because of the proximity of the cervical sympathetic chain to the jugular foramen.

Clivus Metastasis
anaimation of clivus metastasis
Pain Type : Nociceptive Neuropathic Psychogenic
Cause: Invasion of Bone By Tumor or Metastasis
Effects: Unilateral Cranial Nerve Dysfunction Progressing to Bilateral Involvement

Clinical Signs:
Vertex Headache Exacerbated by Neck Flexion

Vertex headache exacerbated by neck flexion is the most common pain presentation for clivus metastasis.

Unilateral cranial nerve dysfunction (6 to 12) progressing to bilateral involvement can be seen.

Sphenoid Sinus Metastasis
Pain Type : Neuropathic
Cause: Invasion of Bone By Tumor or Metastasis
Effects: Diplopia

Clinical Signs:
Severe Bifrontal Headache Radiating to Both Temples, Intermittent Retro-orbital Pain

Sphenoid sinus metastases presents with severe bifrontal headache, radiating to both temples and intermittent retroorbital pain.

Diplopia is a result of cranial nerve involvement (VI) as the tumor invades the cavernous sinus.

Odontoid Fracture
animation of odontoid fracture
Pain Type: Neuropathic
Cause: Invasion of Bone By Tumor or Metastasis
Effects: Pain radiates from the Occipital Area of Skull to the Vertex and is Exacerbated by Neck Movement

Clinical Signs:
Severe Neck Pain and Neck Stiffness Without Signs of Spinal Cord Compression

Diagnosis : CT Scan to Confirm Diagnosis

Odontoid fractures are usually seen secondary to destruction of the atlas.

Severe neck pain and neck stiffness without signs of spinal cord compression occur. Pain radiates from the occipital area of the skull to the vertex and is exacerbated by neck movement. Spinal cord compression may occur and cause neurological signs.

CT scanning confirms the diagnosis. Early diagnosis prevents irreversible neurologic loss that may result in quadriplegia or paraplegia.