Post-lumbar Puncture Oncology-Specifi c Pain

adverse effect of LP is a post-procedure headache. Typically occurring within 72 h of the procedure, symptoms of post-LP headache include throbbing pain in the bilateral occipital and frontal regions that is exacerbated by vertical position and Valsalva and palliated by lying fl at. Most head- aches resolve within 7 days, but some last for sev- eral weeks. The headache is thought to be caused by leakage of cerebrospinal fl uid CSF and sub- sequent loss of CSF pressure. It is theorized that loss of CSF pressure leads to traction on pain- sensitive intracranial structures or an increase in cerebrovascular blood volume with resultant vasodilation, either of which could cause head- ache Turnbull and Shepherd 2003 . In children, the incidence of post-LP headache has been reported to be between 6 and 15 and has been shown to occur in even young children although is much more common in adolescents Kokki et al. 1999 ; Lee et al. 2007 ; Crock et al. 2014 . Various methods have been proposed to reduce the occurrence of post-LP headache. General guidelines suggest that LP performed with cutting needles should have the beveled edge oriented parallel to the dural fi bers, which run longitudi- nally Janssens et al. 2003 . Post- procedure bed rest has been suggested, but not found to be help- ful Lee et al. 2007 . Studies investigating the use of smaller gauge needles have not found signifi - cant differences in incidence Ebinger et al. 2004 ; Crock et al. 2014 . Use of an atraumatic, or “pen- cil-tip,” needle i.e., Whitacre, has been shown to signifi cantly reduce the incidence of post-LP headache although one study found no difference Kokki et al. 1999 ; Thomas et al. 2000 ; Apiliogullari et al. 2010 . When a post-LP headache occurs, various methods have been employed to treat pain not responsive to NSAIDs or opioids. Oral and IV caffeine has been most widely studied in adults and shown to reduce pain when compared to placebo Sechzer and Abel 1978 ; Camann et al. 1990 . It is hypothesized that caffeine causes relief by decreasing cerebrospinal pressure via cerebrovascular vasoconstriction Janssens et al. 2003 . Dosing of caffeine ranges from 300 to 500 mg in adult studies Lee et al. 2007 ; Basurto Ona et al. 2011 . The effectiveness of caffeine has not been reported in pediatrics, but dosing has been suggested at 100 mg for chil- dren aged 6–10 years and 200 mg for children 10 years McGhee et al. 2011 . In studies with small sample sizes, gabapentin and the combi- nation of caffeine and ergotamine have been shown to reduce pain measured on a visual ana- log scale when compared with placebo Dogan 2006 ; Erol 2011 . Hydration, although men- tioned in supportive care for post-LP headache, has not demonstrated effectiveness when stud- ied Janssens et al. 2003 ; Lee et al. 2007 . A Cochrane review concluded that there is no evi- dence that sumatriptans are effective Basurto Ona et al. 2011 . Severe post-LP headache refractory to medi- cal management can be treated with an epidural blood patch EBP. The procedure involves obtaining access to the epidural space in the area of the previous LP. The patient’s peripheral blood, obtained under sterile technique, is then inserted into the epidural space. The purpose of the procedure is to create pressure to seal the dural tear and prevent further CSF leakage Turnbull and Shepherd 2003 . Kokki and col- leagues 2012 reviewed 41 cases of EBP proce- dures in children and found that 90 had immediate and complete pain relief, with 85 noting permanent relief. In pediatric oncology, blood patches should be considered cautiously given infectious risks for immunosuppressed patients and the theoretical risk of introduction of tumor cells into the CSF.

9.8.4 Mucositis Pain

Pathogenesis and management of mucositis is discussed in Chap. 11 . General pain practices described here are necessary interventions for patients experiencing oral mucositis.

9.9 Summary

The large majority of pediatric oncology patients will suffer from pain at some point during their treatment course secondary to the underlying malignancy; surgical procedures including tumor resection, central venous catheter placement, lumbar puncture and bone marrow aspirate biopsy; and as side effects from chemotherapy including specifi c drug effects such as vincristine- associated neuropathy and general effects such as oral mucositis. Appropriate assessment of pain is the vital fi rst step in appropriate pain manage- ment. Patients who are assessed as having pain should be treated according to the WHO pain lad- der with the appropriate analgesic chosen based on the level of pain, expected course of pain, as well as with consideration to the individual patient’s pain history. Appropriate pain manage- ment requires frequent reassessment to determine if pain control is adequate and side effects are tolerable. The pediatric oncology practitioner must also be aware of the potential for develop- ment of refractory pain or neuropathic pain not well controlled with the use of opioids. In these situations, an interdisciplinary team approach is ideal, utilizing the expertise of a pain service if available as well as alternative and complemen- tary therapies to assist in treatment of the pain experience. Generally, recommendations for pain control are based on expert opinion and consen- sus guidelines, as fi rm evidence is lacking in pediatric patients. References Akbayram S, Akgun C, Dogan M et al 2010 Use of pyri- doxine and pyridostigmine in children with vincristine- induced neuropathy. Indian J Pediatr 77:681–683 Alimi D, Rubino C, Pichard-Leandri E et al 2003 Analgesic effect of auricular acupuncture for cancer pain: a randomized, blinded, controlled trial. J Clin Oncol 21:4120–4126 Anderson BJ 2013 Is it farewell to codeine? 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