Combined neurogenic and nociceptive pain in a patient with Pancoast tumor managed by epidural hydromorphone and oral carbamazepine

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Abstract
A 43-year-old male with a Pancoast syndrome suffered severe unrelieved pain for approximately 10 months after diagnosis. The results of administration and cessation of lidocaine and carbamazepine strongly suggest that a neurogenic component contributed to the severity of this patient''s pain. This was also supported by a long period of previous sensory and motor loss in the upper limb and upper chest wall. Initially pain relief was attainable with a combination of oral carbamazepine and oral hydromorphone. However, as the patient''s condition worsened, this combination produced only partial pain relief. Complete relief of the patient''s pain was then attained only with a combination of epidural hydromorphone and oral carbamazepine. Hydromorphone was administered via an implanted, externalized silastic epidural catheter and infused by a miniaturized battery-operated pump which permitted a background infusion and the administration of patient and family-delivered boli. With this combination of oral carbamezepine and epidural hydromorphone, the patient was able to obtain complete pain relief for a period of 3 months until the time of death.