eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy
Neoplastic Lumbosacral Plexopathy: Treatment & Medication
Updated: Dec 4, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Rehabilitation Program
Physical Therapy
For physical rehabilitation, the likely progression of neurologic weakness needs to be considered. If the patient is noted to have associated weakness after acute pain has subsided, one may recommend active range-of-motion (AROM) exercises, with advancement to low resistance exercises. Assistive devices, such as a cane, walker, or wheelchair, may be required for ambulation in patients with weakness of the hip extensors, abductors, or quadriceps, with or without loss of joint position sense. Use of an ankle-foot orthosis (AFO) and, in rare cases, a knee-ankle-foot orthosis (KAFO) may be beneficial for mobility.
Occupational Therapy
The occupational therapist should assess activities of daily living (ADL) and prescribe appropriate adaptive equipment. In particular, be aware that standing-transfer safety may be impaired in cases in which involvement is more distal than proximal. With more proximal involvement, sit-to-stand transfers also may be affected. Equipment may be used specifically to facilitate dressing and bathing activities involving the lower extremity.
Medical Issues/Complications
- Medical or surgical treatment of the carcinoma when possible is the first treatment of choice.
- Intra-arterial chemotherapy regionally has limited use in patients with pelvic pain and intractable pain due to plexopathy.
- The most commonly used treatment with such plexopathy involves radiation treatment. Subjective improvement has been noted in 85% of patients with regard to symptoms. Objective improvement, including neurologic improvement and reduction in measurable tumor size, has been noted in 48% of patients. However, the average response duration has been found to be only 4 months.
- Pain management is an important issue and may require an analgesic ladder approach, including agents specifically for the management of neuropathic pain.
- Neuropathic pain may respond to nerve stimulation, antidepressants, and antiepileptics.
- Plexopathy-associated complications, such as contractures, deep venous thrombosis, immobility, and compressive neuropathies, should be anticipated, and early treatment should be provided.
- Lymphedema in the lower extremities may be an issue and can be particularly difficult to treat. Treatment should focus on improving the swelling, thus improving pain and function. Initial intervention may include wrapping with nonelastic wrapping, elevation, appropriate retrograde massage techniques, ROM exercises, and education. With improvement in edema, compressive garments should be considered, although these may have to be of a custom type.
Surgical Intervention
Patients with more severe and recalcitrant pain may respond to the use of epidural catheter drug delivery and/or neurostimulatory/neuroablative surgical approaches. Cordotomies have been reported to have good outcomes in Europe. However, pain relief has been noted to be transient. Such ablative procedures carry the risk of sensory and motor deficits. The mortality rate has been significant at 5%.
Occasional relief of chronic pain has been achieved with plexus dissection and neurolysis.
Consultations
Pain is a significant issue in most patients and studies have shown that pain is often poorly controlled in these patients. A multidisciplinary approach is needed. Consider early consultation with pain service, given the patient's short life expectancy following diagnosis. These patients may benefit from opiate analgesics, continuous infusion pumps, and procedures such as local and regional blocks, sympathectomy, and rhizotomy.
Other Treatment
Nonpharmacologic measures, such as transcutaneous electrical nerve stimulation (TENS) or Anodyne therapy, may be used for neuropathic pain.
Medication
Tricyclic antidepressants, such as amitriptyline (10-100 mg qhs), may be helpful at low doses. Antiepileptics, such as gabapentin (300-3600 mg/d in 3-4 divided doses) also can be tried. Opiates, especially methadone and steroids, can be considered as well. Mexiletine, a class 1b antiarrhythmic, at 200 mg bid, has been used for the management of significant neuropathic pain due to neoplastic plexus infiltration.17 Low- (0.1 g/kg/d) and higher-dose (0.2-2 g/kg/d) intravenous immunoglobulin therapy has, in limited cases, been successfully used for idiopathic brachial and lumbosacral plexopathy. However, its effectiveness in neoplastic plexopathy is unproven. A single dose (500 mg or 1 g) of intravenous magnesium sulfate has been used with success in a small sample of patients with neuropathic pain due to neoplastic plexopathy.18
Tricyclic antidepressants
These agents have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin.
Amitriptyline (Elavil)
Analgesic for certain chronic and neuropathic pain.
Adult
10-100 mg PO qhs
Pediatric
Not established
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine and quinidine) may increase amitriptyline levels; amitriptyline inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; patient has taken MAO inhibitors in past 14 d; has history of seizures, cardiac arrhythmias, glaucoma, and urinary retention
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; avoid using in elderly patients
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties, which are beneficial for patients who experience pain.
Morphine sulfate (Astramorph, MS Contin, MSIR)
Generally used for short-term, acute pain, moderate to severe in nature, as well as for chronic pain (eg, that associated with cancer). Morphine sulfate is available in immediate (3-4 h duration) and extended-release preparation (12 h). Switch over to long-acting preparations (MS Contin) once the pain is controlled with short-acting preparation (MS IR). Morphine can produce drug dependence and has the potential to be abused. Tolerance may develop with repeat exposure. Abrupt cessation of the drug or a sudden reduction in dose with prolonged use may result in withdrawal symptoms. Physical dependence is not of paramount importance in terminally ill patients.
Adult
30 mg PO q3-4h initial dose in opiate-naive patients (no exposure to opiates) or in those with limited opiate exposure; may be titrated upward by 50% if pain control inadequate after first 24 h; balance between analgesia and adverse effects
Pediatric
Not established
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Methadone (Dolophine)
Used in the management of severe pain. Methadone inhibits ascending pain pathways, diminishing the perception of and response to pain.
Adult
2.5-10 mg PO/IM/SC q3-8h prn; increase to maintenance dose of 5-20 mg q6-8h
Pediatric
Not established
Phenytoin, rifampin, and pentazocine may decrease blood levels of methadone; phenothiazines, tricyclic antidepressants, MAOIs, and CNS depressants may increase toxicity of methadone
Documented hypersensitivity; bronchial asthma or increased intracranial pressure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in severe liver disease; due to its relatively long half-life, titrate dose slowly
Muscle relaxants
These agents inhibit events involved in muscle contraction.
Methocarbamol (Robaxin)
Reduces nerve impulse transmission from the spinal cord to skeletal muscle.
Adult
1.5 g PO qid for 2-3 d and decrease to 4-4.5 g/d in 3-6 divided doses
Pediatric
Administer as in adults
Increases toxicity of CNS depressants
Documented hypersensitivity; renal impairment
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in history of seizures
Antiepileptics
Antiepileptics are used to manage severe muscle spasms and to provide sedation in neuralgia.
Pregabalin (Lyrica)
Structural derivative of GABA. The mechanism of action is unknown. Pregabalin binds with high affinity to the alpha2 -delta site (a calcium channel subunit). In vitro, it reduces the calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. Pregabalin is FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as an adjunctive therapy in partial-onset seizures.
Adult
50 mg PO tid initially; if needed, may increase to 100 mg tid within 1 wk
Pediatric
Not established
May cause additive effects on cognitive and gross motor functioning when coadministered with drugs that cause dizziness or somnolence
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue gradually (over a minimum of 1 wk) to minimize increased seizure frequency in patients with seizure disorders; may cause insomnia, nausea, headache, or diarrhea with abrupt withdrawal; common adverse effects include dizziness, somnolence, blurred vision, weight gain, and peripheral edema; may elevate creatinine kinase level, decrease platelet count, and increase PR interval; doses >300 mg/d associated with higher rate of adverse effects and treatment discontinuation; decrease dose with renal impairment (ie, CrCl <60 mL/min)
Gabapentin (Neurontin)
Has anticonvulsant properties and antineuralgic effects; however, the exact mechanism of action is unknown. Gabapentin is structurally related to GABA but does not interact with GABA receptors.
Adult
300-3600 mg/d PO divided tid/qid
Pediatric
Not established
Antacids may significantly reduce bioavailability of gabapentin (administer at least 2 h following antacids); may increase norethindrone levels significantly
Documented hypersensitivity; antacids may significantly reduce bioavailability of gabapentin (administer at least 2 h following antacids); may increase norethindrone levels significantly; caution in severe renal disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Antacids may significantly reduce bioavailability of gabapentin (administer at least 2 h following antacids); may increase norethindrone levels significantly; caution in severe renal disease
More on Neoplastic Lumbosacral Plexopathy |
| Overview: Neoplastic Lumbosacral Plexopathy |
| Differential Diagnoses & Workup: Neoplastic Lumbosacral Plexopathy |
 Treatment & Medication: Neoplastic Lumbosacral Plexopathy |
| Follow-up: Neoplastic Lumbosacral Plexopathy |
| References |
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Further Reading
Keywords
neoplastic lumbosacral plexopathy, plexus, lumbosacral, breast cancer, sciatic nerve, colorectal cancer, psoas, neoplastic, psoas muscle, femoral nerve, iliopsoas, iliopsoas muscle, ilioinguinal nerve, obturator nerve, abdominal cancer, cervical cancer, pelvic tumor, retroperitoneal tumor, NLP, lumbosacral plexus, lumbosacral plexopathy, proximal lumbosacral plexopathy, malignant psoas syndrome, MPS, malignant lumbosacral plexopathy, lumbosacral carcinomatous, neuropathy tumor-induced lumbosacral plexopathy, tumor, lumbar plexus, sacral plexus
