Interventional Pain Management for Sacroiliac Tumors in the Oncologic Population: A Case Series and Paradigm Approach

Abstract

Introduction: Tumors invading the sacrum and/or ilium often represent incurable metastatic disease, and treatment is targeted toward palliation of symptoms and control of pain. As systemic opioid therapy is frequently inadequate and limited by side effects, a variety of interventional techniques are available to better optimize analgesia. Using six patients as a paradigm for interventional approaches to pain relief, we present a therapeutic algorithm for treating sacroiliac tumor-related pain in the oncologic population.

Methods: We describe the use of ultrasound-guided proximal sacroiliac joint corticosteroid injection, sacroiliac lateral branch radiofrequency ablation, percutaneous sacroplasty, and implantable neuraxial drug delivery devices to treat malignant sacroiliac pain in six patients. Pre- and postprocedure numerical rating scale (NRS) pain scores, duration of pain relief, and postprocedure pain medication requirements were studied for each patient.

Results: Each patient had marked improvement in their pain based on an average postprocedure NRS difference of six points. The average duration of pain relief was eight months. In all cases, opioid requirements decreased after the intervention.

Discussion: Depending on tumor location, burden of disease, and patient preference, patients suffering from metastatic disease to the sacrum may find benefit from use of ultrasound-guided proximal sacroiliac joint corticosteroid injection, sacroiliac lateral branch radiofrequency ablation, percutaneous sacroplasty, dorsal column stimulator leads, and/or implantable neuraxial drug delivery devices. We provide a paradigm for treatment in this patient population.

Figure 1

Axial CT images with bone window illustrating bilateral ileum with posterior lytic lesions (arrows) without cortical erosion.

Figure 2

Axial CT images showing primarily blastic metastasis with sclerosis in the right posterior ileum and sacral ala, including cortical involvement of the joint space (arrow).

Figure 3

Axial CT image with bone window showing large lytic lesion involving the right sacrum (*) and mixed sclerotic lesion in bilateral ileum (arrows).

Figure 4

(A) Axial CT images with bone window showing mixed sclerotic lesions in the right posterior ileum (*) and sacrum with insufficiency fracture partially visualized in this cut (arrow). (B) Axial CT images illustrating percutaneous sacroplasty demonstrating adequate augmentation partially visualized in this cut by evidence of bone cement (arrows) in previous lytic tumor/sacral fracture.

Figure 5

Axial CT image of extensive bilateral sacral and iliac disease involving cortical erosion of joint spaces as well as foraminal compromise.

Figure 6

(A) Axial cut T2 weighted MRI image of the sacrum at the S1 foramen. Patient has black areas of the right sacrum denoting sacroplasty and invasion of the right sacrum with tumor after radiation changes, and (*) denotes enlarged S1 nerve root consistent with a swollen or inflamed nerve. (B) Dorsal column stimulation leads placed at T7. Two leads in staggered formation to cover both low back pain and right posterior thigh pain.

Figure 7

Ultrasound view (1–5 MHz curvilinear probe, GE Logic P9) of the sacroiliac joint at the level of the S2 neuroforamen. The arrow points to the trajectory of the needle into the sacroiliac joint. (A) Ilium. (B) Sacrum. (*) Inferior border of the sacroiliac joint.

Figure 8

Flow chart of interventional procedures based on tumor location and improvement in pain control for patients with sacroiliac joint metastasis. SI = sacroiliac.