PALLIATIVE STRATEGIES FOR PAIN MANAGEMENT IN METASTATIC SPINAL TUMORS

Metastatic spinal tumors are a significant cause of morbidity in cancer patients, leading to severe pain and substantial impairment in quality of life. Pain may result from the direct effect of the tumor, mechanical compression from metastasis, osteolytic activity, or nerve compression. Patients have no-ciceptive, neuropathic, or mixed types of pain that include both.Effective pain management in spinal metastatic tumors requires a multidisciplinary approach involving pain specialists, oncologists, neu-rosurgeons, radiation oncologists, physiatrists, and palliative care teams. Performance status, tumour burden, systemic disease and life expectancy should be considered in treatment planning. Pain man-agement needs to be planned individually.Pharmacological management is guided by the World Health Organization’s analgesic ladder. Mild pain is treated with nonsteroidal anti-inflammatory drugs and acetaminophen; moderate pain with weak opioids; and severe pain with strong opioids. With the update of this step system, Step 2 is no longer a mandatory transition step; moderately monitored, managed, low-dose strong opioids can be started directly. The ladder is now bi-directional, allowing both upward and downward transitions based on pain control, adverse effects, and patient-specific factors. Pro-longed administration of opioids can result in tolerance; therefore, opioid rotation is recommended as a management strategy. İnterventional procedures is emphasized for refractory pain, potentially before Step 3 in appropriate cases. Adjuvant agents such as anticonvulsants, antidepressants, corticosteroids, and bone-targeting drugs can enhance analgesic effects. Interventional procedures are considered for cases resistant to pharmacological therapy. The importance of interventional treatments is increasing due to the side effects of opioids, opioid dependence, and tolerance to abuse. Options include verte-bral augmentation, radiofrequency or cryoablation, transforaminal epidural steroid injections, selective nerve root blocks, neurolytic blocks, intrathecal drug delivery systems, and spinal cord stimulation .