INTRODUCTION
Chronic pain is a complex condition that affects individuals across diverse populations. It significantly impairs physical functioning and social participation, and compromises psycho-emotional balance and quality of life[1]. Chronic pain may characterize different clinical conditions, including oncological diseases, either as a consequence of cancer itself or as a result of cancer-related treatments[2]. Indeed, pain emerges as one of the main clinical factors that impact the quality of life of cancer patients[3]. Despite the availability of new pharmacological and non-pharmacological treatment options, achieving effective pain control remains difficult to achieve in a significant proportion of patients, largely due to the heterogeneous and multifactorial nature of cancer pain[4]. Indeed, the peer-reviewed published scientific literature reports a high prevalence of inadequate pain management, as standard pharmacological treatments may fail to provide adequate long-term analgesia. Moreover, these should be used with caution, given their potential side effects and treatment-related adverse events[5-7]. In this context, the surgical implantation of spinal cord stimulation (SCS) represents a promising therapeutic option for cancer-related pain, particularly in patients who are refractory to other treatments[8,9]. However, despite evidence of clinical benefit, the physiological mechanism of action of SCS remains not fully understood[10]. Specifically, uncertainties persist regarding its specific neuronal and cellular targets, and multiple theories have been proposed over the years to explain the device’s functioning and efficacy. This ambiguity has significant implications for the development and refinement of targeted therapies[10-12]. This lack of mechanistic clarity may complicate the standardization of targeted therapies, a challenge further intensified by the heterogeneity of individual characteristics that uniquely shape pain perception. In this context, the patient’s individual profile, disease history, and psychological characteristics should be carefully considered, given their potential impact on treatment response and outcomes[13,14]. Indeed, the literature reports that psychosocial factors can influence SCS outcomes, suggesting that pre-implant evaluation may be crucial for treatment planning[15]. Consequently, an integrated, patient-centred approach may be essential for capturing the patient’s overall profile and needs, thereby supporting a successful treatment outcome[16,17]. Accordingly, this study presents a structured multidisciplinary approach, that combines clinical, biomedical engineering, nursing, and psychological interventions to optimize SCS monitoring and management in a patient with cancer-related chronic pain.
CASE PRESENTATION
Chief complaints
A 37-year-old male patient with persistent neuropathic cancer-related pain in the left foot was referred to the European Institute of Oncology IRCCS (Milan, Italy) for comprehensive assessment and targeted treatment.
History of present illness
The patient had experienced chronic cancer-related neuropathic pain for five years, which had progressively compromised both his physical mobility and his psychosocial functioning. At the time of admission to the IEO centre, in addition to medical assessment, psychological interventions and assessments through validated questionnaires were conducted by a trained psycho-oncology psychotherapist and a research psychologist respectively. The patient’s pain subjective experience of pain and its impact on everyday life, were assessed using the Brief Pain Inventory (BPI). The assessment showed a moderate pain severity score (5, score ranging from 1 to 10) alongside a severe interference score (7.86, score ranging from 1 to 10), with a particularly high impact on working capacity[18]. Other psychometric testing measures revealed a high level of pain catastrophizing (defined as a negative cognitive-affective response to anticipated or actual pain), assessed through the Pain Catastrophizing Scale (PCS = 20, score ranging from 0 to 52)[19], and a good pain resilience measured by the Pain Resilience Scale (PRS = 35, score ranging from 0 to 56)[20]. Additionally, the baseline psychological evaluation identified mild trait anxiety via the State-Trait Anxiety Inventory Form-Y (STAI-Y2 = 44, score ranging from 20 to 80), non-pathological state anxiety (STAI-Y1 = 37, score ranging from 20 to 80)[21] and mild depressive symptoms using the Beck Depression Inventory-Second Edition (BDI-II = 15, score ranging from 0 to 63)[22].
History of past illness
The patient’s oncological history began in 2017 with a diagnosis of undifferentiated pleomorphic sarcoma of the left thigh, which was treated with chemotherapy and major surgical resection. Following the diagnosis of a plurifocal relapse in June 2019, the patient underwent radiotherapy and wide surgical resection of the posteromedial compartment of the left thigh, which included the en bloc sacrifice of the sciatic nerve. This intervention resulted in residual neuropathic pain localized to the left plantar region, which eventually transitioned into a chronic, refractory condition, as subsequent medical treatments did not provide definitive relief. The patient underwent several years of intensive pharmacological management, with various therapeutic regimens; however, these consistently resulted in insufficient analgesic efficacy.
The psycho-cognitive evaluation revealed a history of traumatic and stressful life events that had required psychotherapeutic interventions, which had been completed before the current study, to address persistent depressive symptoms. Beyond the immediate oncological and nociceptive burden, the patient reported a protracted history of social isolation, representing a cumulative stressor in his clinical condition. This psychological impairment had deeply impacted his self-esteem and shaped a fragile self-perception over time. Finally, during the clinical consultation, the patient reported treatment-related brain fog.
Personal and family history
Due to his extensive medical history and the cumulative side effects of long-term pharmacotherapy, the patient reported chronic fatigue and irritability over the years. The patient’s narrative shed light on the profound impact of the aforementioned treatments on his daily life, identity and personal values. Indeed, these symptoms had a profound effect on his social interactions and activities of daily living, resulting in significant challenges in organizing daily activities and maintaining individual well-being.
Physical examination
Upon admission, physical examination showed a body weight of 63 kg and a height of 180 cm. The left leg was not painful on palpation; no superficial allodynia was observed, although mild hypoesthesia was present in the left plantar region where the patient reported pain. The pain was described as intense, constant tingling with occasional sharp, lightning-like sensations. A preoperative anaesthesiology consultation was obtained.
Laboratory examinations
In accordance with standard clinical practice, a complete haematological profile was obtained. Blood compatibility testing was also performed according to institutional protocols in view of potential transfusion.
Imaging examinations
Imaging examinations included two-view chest radiography and an electrocardiography. A functional magnetic resonance imaging of the lumbosacral region, performed within the previous six months, was required and provided by the patient to assess proper device positioning.
FINAL DIAGNOSIS
Chronic cancer-related neuropathic pain of the left plantar region, status post-resection of a left thigh sarcoma, complicated by a history of well-differentiated angiosarcoma of the left abdominal wall. The patient also presented with mild depressive symptoms and mild trait anxiety, likely exacerbated by a history of trauma and chronic medical stress.
TREATMENT
The patient underwent surgical implantation of SCS device, progressing from a temporary one-month lead trial to a definitive implantation. He received comprehensive clinical instructions for effective device management, specifically addressing battery maintenance, recharging protocols, and care of the skin surrounding the surgical site. Medical consultations enabled specialized biomedical engineers to manage lead stimulation settings, which were adjusted from an initial configuration of 3+ 4- 5+, 2 mA, 90 μs, 1200 Hrz, to a final setting of 5+ 6- 7+, 2 mA, 100 μs, 1000 Hz. These modifications were specifically implemented to manage foot paresthesia at the six-month follow-up after definitive implantation. Pharmacological management had been maintained since the initial diagnosis of chronic pain, with ongoing modulation tailored to the patient’s evolving pain trajectory. At the six-month follow-up, the clinical team strategically reduced the pharmacological regimen in response to the patient’s evolving pain profile. Specifically, dosages were reduced as follows: Pregabalin (from 550 mg/die to 400 mg/die), Rivotril (from 10-13 to 7 drops daily), and Bediol (from 60 to 50 drops daily). Bedrolite (32 drops daily) and topical therapy (galenic cream, applied twice daily) remained stable. This surgical and medical pathway was supported by a parallel multidisciplinary approach, including integrated psychological consultations delivered by a trained psycho-oncology psychotherapist. In accordance with institutional protocol, all patients who are candidates for SCS implantation undergo a psychological consultation on the day of pre-admission. Structured psychological interventions were embedded in the care pathway to reinforce the patient’s emotional stability and coping strategies through emotional supportive counselling. These interventions aimed to help the patient actively manage his daily life and mental well-being during a particularly challenging period. In accordance with the patient’s socio-emotional history, psychological treatment was structured around the themes that emerged from the very first consultation, as well as the patient’s adaptation to device implantation. Within the psychological setting the patient had the opportunity to explore aspects related to his identity, reflecting on and reinterpreting personal values, beliefs and past experiences. This process aimed to address the long history of socio-emotional pain experienced by the patient over many years and to adapt to the new condition. In addition, by creating an emotionally-safe setting, substantial effort was directed towards enhancing self-esteem and promoting more adaptive behaviours, with the gradual reduction of social isolation.
OUTCOME AND FOLLOW-UP
The clinical pathway incorporated pain management evaluations conducted by medical professionals, nursing interventions to manage the surgical site and provide guidance on mobility and self-medication protocols, and specialized engineering interventions to optimise neuromodulation. Concurrently, emotional supportive counselling was provided at different time-points according to the patient’s clinical visits (Figure 1), reflecting a structured follow-up model that integrated the administration of targeted psychometric questionnaires with continuous clinical support. Six one-hour psychological sessions were conducted over an eight-month period, beginning two weeks before pre-surgical admission for the temporary device trial and continuing until six months after permanent SCS implantation. During the first psychological consultation, the patient’s history of chronic pain and its psychological and social implications were explored. The patient had the opportunity to reflect on his disease condition and how it had affected his daily life over the preceding months, thereby developing a more integrated perception of his current clinical condition and recognizing the behaviours he had already adopted for pain management. Concurrently, expectations regarding pain intensity reduction, future planning and unmet needs were also explored in depth to personalise psychological counselling and enhance individual coping strategies. Based on the themes that emerged, follow-up consultations aimed to gather information on the patient’s functional and clinical recovery, while also evaluating his resilience and adaptation to both the temporary and permanent SCS devices.
Figure 1 Timeline of psychological assessment and consultations.
SCS: Spinal cord stimulation; BPI: Brief pain inventory; PCS: Pain catastrophizing scale; STAI-Y: State-Trait Anxiety Inventory-Form Y; BDI-II: Beck Depression Inventory-II; PRS: Pain Resilience Scale; PGIC: Clinical Global Impression of Change.
Regarding medical outcomes, the patient had an optimal and uneventful post-operative recovery, reporting only minor localized burning and tingling sensations in the left foot after temporary device implantation. He also demonstrated effective self-management of the neurostimulation system. Clinical evaluation confirmed that the surgical scar at the left lumbar site was healing well. Device diagnostics further indicated that electrode impedances remained within normal parameters, reflecting a stable clinical course and physiological status. At the six-month follow-up, pain severity scores had decreased from moderate to mild pain levels (3.25), while the pain interference score had decreased from severe (7.86) to moderate (6.43), indicating a clinically significant reduction in pain perception and impact. Finally, the patient demonstrated a high level of adaptation to the neurostimulation system and to changes in his physical condition, showing proactive coping strategies. With regard to daily functioning, the patient maintained active management of his routines, sustained meaningful social relationships, and pursued several personal interests. These behaviors may be interpreted as reflecting successful long-term integration of the SCS device into the patient’s lifestyle. The intervention resulted in a slightly positive perceived satisfactory global impression of change (= 4 on a 10-point Likert Scale, where 0 = much better and 10 = much worse), reflecting a slight perceived reduction in pain intensity. The combination of emotional supportive counselling and SCS implantation was associated with progressive overall improvement in the evaluation of pain interference across key functional dimensions. Specifically, BPI scores showed a reduced interference with mood (from 8 to 7), interpersonal relationships (from 8 to 7), and enjoyment of life (from 8 to 6). Furthermore, the multidisciplinary approach was associated with changes the patient’s affective state and cognitive functioning. Depressive symptoms remained clinically stable throughout the process (BDI = 14), and the patient reported a reduction in subjective negative thoughts related to the pain experience (PCS = 16). In contrast to the cognitive dimension, the patient’s emotional status showed an increase in anxiety symptoms from baseline (STAI-Y1 = 37) to the last follow-up (STAI-Y1 = 48). This was accompanied by a marginal decrease in pain resilience (PRS = 27). The non-judgemental clinical environment provided the necessary containment for the patient to safely articulate his emotions, ultimately facilitating the integration of previously unexpressed feelings of loneliness and distress. Finally, the psychological intervention fostered the patient’s re-engagement in well-being-focused activities that had been gradually suppressed because of the debilitating nature of his chronic pain experience.
DISCUSSION
The present work details an integrated multidisciplinary approach focused on enhancing the clinical monitoring and management of the implanted SCS device in a patient suffering from longstanding cancer-related chronic pain. Consistent with the existing literature, the patient’s chronic disease history significantly impacted his overall well-being and quality of life, as evidenced by the baseline assessment[1]. Specifically, the patient reported elevated pain severity and interference, alongside mild trait anxiety and moderate depressive symptoms. A one-month trial period was implemented to verify the device’s efficacy, recognizing that initial patient approval and enthusiasm are not always definitive predictors of long-term clinical success[23]. Indeed, SCS outcomes vary significantly among patients, as they are intrinsically linked to a complex interplay of individual physical characteristics, psychological traits, and the unique nuances of personal pain perception[15]. Furthermore, chronic pain is recognized as being associated with emotional features[24,25]. This relationship appears to be bidirectional: Pain perception and emotional states may negatively affect each other, thus highlighting the importance of considering both dimensions[1,25]. Accordingly, the multifaceted and intra-individual nature of chronic pain perception makes it considerably challenging to fully address individual patient needs and structure tailored care plans[26,27]. A multidisciplinary approach therefore proved essential for this patient. This case study may serve as an example of effective therapeutic cooperation addressing the comprehensive individual profile by incorporating physical characteristics, psycho-emotional features, and the social dimension, thereby ensuring structured continuity of care. Indeed, according to the published literature, such an approach enables the simultaneous management of each individual component by leveraging the specialized expertise of various healthcare professionals[28,29]. Furthermore, this framework allows healthcare professionals to apply the cross-disciplinary skills required to promote effective interprofessional communication, combining proactive care monitoring with decision support[30,31].
Considering the complexity of the presented case, we may speculate that the multidisciplinary approach helped prevent the possibility of device removal, thereby limiting additional hospital and financial burden. Indeed, psychological sequelae, such as depression and anxiety symptoms, have been reported as critical predictors of poor SCS outcomes, with depression specifically identified as a predictive factor for SCS explantation[15,30]. While the exact incidence of SCS explantation remains difficult to define, device removal is widely recognised as a substantial burden for both healthcare facilities and patients, in terms of higher post-implantation care costs and several adverse individual consequences[31]. Furthermore, although generally safe, SCS treatment is associated with potential device or surgery-related complications, such as electrode fracture, or lead migration, which may be prevented through appropriate, structured care management[15]. The outcomes reported here suggest that the implemented structured intervention improved overall pain perception, fostering a sense of individual change in the patient. Assessment outcomes at the six-month follow-up indicate that, despite significant psychological challenges, the integrated psychological interventions played a crucial role in modulating the patient’s emotional and cognitive responses to perceived pain and related difficulties. Indeed, the literature further supports the view that professional emotional support may facilitate the psychological processing of highly invasive or reconstructive surgeries[32]. The combination of clinical work and surgical intervention facilitated recovery in the patient’s personal life, leading to greater well-being and a reduced perception of pain. Accordingly, the pain resilience score decreased, most likely because of lower pain perception scores and, therefore, a reduced need for resilience-related coping abilities. This multidisciplinary approach also facilitated a shift in the patient’s self-concept, transitioning from a self-perception defined solely by illness and chronic pain to an awareness of himself as an individual whose identity extends beyond his medical journey. The regained social openness allowed the patient to refocus on his social dimension, potentially worsening his state anxiety because of renewed social exposure. Furthermore, the patient’s anxiety could also be explained by the conclusion of counselling sessions, which had provided essential support to the patient but were limited to the hospital care pathway. Finally, this approach enabled the management of a wide range of potential side effects that could have occurred in such a complex case, allowing the patient to undergo this crucial intervention, while maintaining an overall relatively stable emotional balance. The structured intervention informs practice by suggesting that care should not be limited to surgical or pharmacological interventions, but should instead actively integrate the expertise of multiple healthcare professionals and incorporate a more comprehensive patient assessment[16,17]. While care costs, logistical barriers, and the difficulty of reconciling divergent professional perspectives may hinder standardization, successful implementations such as this should serve as foundational references for patient-centred, multiprofessional frameworks. Although the single-case design may limit the generalizability of the findings, the descriptive nature of this report may offer valuable evidence to inform future interventions and tailored strategies.
CONCLUSION
A multidisciplinary approach facilitated the successful implementation and management of the neurostimulation intervention. This collaborative framework proved essential in guiding the clinical pathway of a patient whose physical and emotional well-being had been significantly compromised by a history of trauma and longstanding chronic symptoms. The present case highlights the importance of maintaining a comprehensive understanding of the patient’s needs throughout the surgical and pharmacological process. It also supports the value of a shared model of evaluation and intervention, in which medical and psychological expertise are seamlessly integrated to promote continuity of care, strengthen clinical decision-making, and optimize patient outcomes.
ACKNOWLEDGEMENTS
We sincerely thank Federico Borgogni is a PhD student in Medical Humanities within the European School of Molecular Medicine (SEMM) at the University of Milan, Italy.
Peer review: Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Medicine, research and experimental
Country of origin: Italy
Peer-review report’s classification
Scientific quality: Grade B, Grade B, Grade C
Novelty: Grade A, Grade B, Grade B
Creativity or innovation: Grade A, Grade B, Grade B
Scientific significance: Grade A, Grade B, Grade B
P-Reviewer: Abbasi S, Pakistan; Sengel N, Assistant Professor, Türkiye S-Editor: Liu H L-Editor: A P-Editor: Wang WB
