You should suspect that pain is of bony origin if there are known bone metastases or a cancer which commonly spreads to bone e.g. breast, lung, renal, prostate.
Bone pain can be extremely debilitating because it affects function in so many ways. The treatment priorities are first getting pain relieved to allow sleep, then when sitting up and finally when moving about.
Red flags
The two things to bear in mind are:
- Cord compression from worsening vertebral metastases. Symptoms are worsening pain or heavy legs.
- Risk of pathological fracture in a long bone. Symptoms are sudden worse pain on weight bearing.
Consider urgent scanning for rapidly changing pain.
Clinical features
Bone pain is usually well localised, might be worse on weight bearing (depending on site) and may be tender to touch. Often throbs at night.
An initial approach to treatment
- Apply hot or cold packs
- Paracetamol and NSAIDs - alongside a PPI.
- A COX-2 inhibitor such as Celecoxib may be a good option
- Titration of a strong opioid - e.g. titrate oral Morphine solution from 2.5mgs 4 hourly
- A prn dose of analgesia before planned activity may help e.g. before a walk
- Consider a trial of Lidocaine 5% plaster if the bone pain is very superficial e.g. a rib metastasis
- Urgent control for severe bone pain - Dexamethasone 6mg a day for 5 days and then review (a good response to steroids may be an indication to refer for radiotherapy)
Specialist care
- Radiotherapy is always considered for persistent metastatic bone pain. Often a single fraction is used. May cause a pain flare initially - cover with steroids.
- Bisphosphonates intravenously (eg Zometa) to reduce skeletal events due to bone metastases, but can also help pain. There may be a role for oral bisphosphonates.
- Denosumab is a subcutaneous option that oncologists may recommend instead of bisphosphonates, but is much more costly
- Prophylactic surgery can be dramatically helpful to prevent a pathological fracture and help pain