Summary
Intrathecal delivery of analgesic drugs by implantable pump systems has been recognized as a treatment option for patients with chronic pain of benign or malignant origin that is resistant to oral or parenteral medication. Patients with chronic back and leg pain (CBLP), a benign but severely disabling condition of the lumbar spine with multifactorial genesis, have been demonstrated in a number of retrospective and in some prospective clinical studies to benefit from intrathecal delivery of opioid and/or non-opioid substances, either as single drugs or in combinations. In addition, intrathecal therapy for CBLP has been proven safe and less expensive that conventional medical therapy.
This chapter summarizes the clinical and experimental evidence and the personal experience of the authors with long-term intrathecal infusion therapy for CBLP. It discusses important clinical issues such as drug selection, drug combinations, and side effects and complications of intrathecal infusion. It is concluded that further clinical research is needed in order to provide stronger evidence for the usefulness of a number of drugs currently used for intrathecal therapy on a mostly empirical basis.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
Preview
Unable to display preview. Download preview PDF.
References
Anderson VA, Burchiel KJ (1999) A prospective study of long-term intrathecal morphine in the management of chronic nonmalignant pain. Neurosurgery 44: 289–301
Batra YK, Jain K, Chari P, Dhillon MS, Shaheen B, Reddy GM (1999) Addition of intrathecal midazolam to bupivacaine produces better post-operative analgesia without prolonging recovery. Int J Clin Pharmacol Ther 37: 519–523
Bennett G, Burchiel K, Buchser E, Classen A, Deer T, Du Pen S, Ferrante FM, Hassenbusch SJ, Lou L, Maeyaert J, Penn R, Portenoy RK, Rauck R, Serafini M, Willis KD, Yaksh T (2000) Clinical guidelines for intraspinal infusion: report of an expert panel. Polyanalgesic consensus conference 2000. J Pain Symptom Manage 20: S37–S43
Bennett G, Serafini M, Burchiel K, Buchser E, Classen A, Deer T, Du Pen S, Ferrante FM, Hassenbusch SJ, Lou L, Maeyaert J, Penn R, Portenoy RK, Rauck R, Willis KD, Yaksh T (2000) Evidence-based review of the literature on intrathecal delivery of pain medication. J Pain Symptom Manage 20: S12–S36
Coffey RJ, Burchiel K (2002) Inflammatory mass lesions associated with intrathecal drug infusion catheters: Report and observations on 41 patients. Neurosurgery 50: 78–87
De Lissovoy G, Brown RE, Halpern M, Hassenbusch SJ, Ross E (1997) Cost-effectiveness of long-term intrathecal morphine therapy for pain associated with failed back surgery syndrome. Clin Ther 19: 96–112
Deer T, Chapple I, Classen A, Javery K, Stoker V, Tonder L, Burchiel K (2004) Intrathecal drug delivery for treatment of chronic low back pain: Report from the national outcomes registry for low back pain. Pain Med 5: 6–13
Deer TR, Caraway DL, Kim CK, Dempsey CD, Stewart CD, McNeil KF (2002) Clinical experience with intrathecal bupivacaine in combination with opioid for the treatment of chronic pain related to failed back surgery syndrome and metastatic cancer pain of the spine. Spine J 2: 274–278
Hassenbusch S, Burchiel K, Coffey R, Cousins MJ, Deer T, Hahn MB, Pen SD, Follett KA, Krames E, Rogers JN, Sagher O, Staats PS, Wallace M, Willis KD (2002) Management of intrathecal catheter-tip inflammatory masses: A consensus statement. Pain Med 3: 313–323
Hassenbusch SJ, Gunes S, Wachsman S, Willis KD (2002) Intrathecal clonidine in the treatment of intractable pain: a phase I/II study. Pain Med 3: 85–91
Hassenbusch SJ, Portenoy RK, Cousins M, Buchser E, Deer TR, Du Pen SL, Eisenach J, Follett KA, Hildebrand KR, Krames ES, Levy RM, Palmer PP, Rathmell JP, Rauck RL, Staats PS, Stearns L, Willis KD (2004) Polyanalgesic consensus conference 2003: an update on the management of pain by intraspinal drug delivery — report of an expert panel. J Pain Symptom Manage 27: 540–563
Hassenbusch SJ, Stanton-Hicks M, Covington EC, Walsh JG, Guthrey DS (1995) Long-term intraspinal infusion of opiates in the treatment of neuropathic pain. J Pain Symptom Manage 10: 527–543
Hodgson PS, Neal JM, Pollock JE, Liu SS (1999) The neurotoxicity of drugs given intrathecally (spinal). Anesth Analg 88: 797–809
Kanoff RB (1994) Intraspinal delivery of opiates by an implantable, programmable pump in patients with chronic, intractable pain of nonmalignant origin. J Am Osteopath Assoc 94: 487–493
Krames ES (1999) Practical issues when using neuraxial infusion. Oncology 13[Suppl] 2: 37–44
Kumar K, Hunter G, Demeria DD (2002) Treatment of chronic pain by using intrathecal drug therapy compared with conventional pain therapies: a cost-effectiveness analysis. J Neurosurg 97: 803–810
Kumar K, Kelly M, Pirlot T (2001) Continuous intrathecal morphine treatment for chronic pain of nonmalignant etiology: Long-term benefits and efficacy. Surg Neurol 55: 79–88
Mironer YE, Haasis JC, Chapple I, Brown C, Satterthwaite JR (2002) Efficacy and safety of intrathecal opioid/bupivacaine mixture in chronic nonmalig-nant pain: A double blind, randomized, crossover, multicenter study by the national forum of independent pain clinicians (NFIPC). Neuromodulation 5: 208–213
Nguyen H, Garber JE, Hassenbusch SJ (2003) Spinal analgesics. Anesthesiol Clin N Am 21: 805–816
Onesti ST (2004) Failed back syndrome. Neurologist 10: 259–264
Paice JA, Penn RD, Shott S (1996) Intraspinal morphine for chronic pain: a retrospective, multicenter study. J Pain Symptom Manage 11: 71–80
Penn RD, Paice JA (1987) Chronic intrathecal morphine for intractable pain. J Neurosurg 67: 182–186
Penn RD (2003) Intrathecal medication delivery. Neurosurg Clin N Am 14: 381–387
Phillips FM, Cunningham B (2002) Managing chronic pain of spinal origin after lumbar surgery: the role of decompressive surgery. Spine 27: 2547–2554
Portenoy RK (1996) Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage 11: 203–217
Porter J, Jick H (1980) Addiction rare in patients treated with narcotics. N Engl J Med 302: 123
Rainov NG, Buchser E (2002) Making a case for programmable pumps over fixed rate pumps for the management of fluctuations in chronic pain and spasticity. Neuromodulation 5: 89–99
Rainov NG, Heidecke V, Burkert W (2001) Long-term intrathecal infusion of drug combinations for chronic back and leg pain. J Pain Symptom Manage 22: 862–871
Roberts LJ, Finch PM, Goucke CR, Price LM (2001) Outcome of intrathecal opioids in chronic non-cancer pain. Eur J Pain 5: 353–361
Serrao JM, Marks RL, Morley SJ, Goodchild CS (1992) Intrathecal midazolam for the treatment of chronic mechanical low back pain: a controlled comparison with epidural steroid in a pilot study. Pain 48: 5–12
Slipman CW, Shin CH, Patel RK, Isaac Z, Huston CW, Lipetz JS, Lenrow DA, Braverman DL, Vresilovic EJ Jr (2002) Etiologies of failed back surgery syndrome. Pain Med 3: 200–217
Thimineur MA, Kravitz E, Vodapally MS (2004) Intrathecal opioid treatment for chronic non-malignant pain: a 3-year prospective study. Pain 109: 242–249
Waguespack A, Schofferman J, Slosar P, Reynolds J (2002) Etiology of long-term failures of lumbar spine surgery. Pain Med 3: 18–22
Winkelmüller M, Winkelmüller WE (1996) Long-term effects of continuous intrathecal opioid treatment in chronic pain of nonmalignant etiology. J Neurosurg 85: 458–467
Wulf H, Gleim M, Mignat C (1994) The stability of mixtures of morphine hydrochloride bupivacaine hydrochloride and clonidine hydrochloride in portable pump reservoirs for the management of chronic pain syndromes. J Pain Symptom Manage 9: 308–311
Yaksh TL, Hassenbusch S, Burchiel K, Hildebrand KR, Page LM, Coffey RJ (2002) Inflammatory masses associated with intrathecal drug infusion: A review of preclinical evidence and human data. Pain Med 3: 300–312
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2007 Springer-Verlag
About this chapter
Cite this chapter
Rainov, N.G., Heidecke1, V. (2007). Management of chronic back and leg pain by intrathecal drug delivery. In: Sakas, D.E., Simpson, B.A., Krames, E.S. (eds) Operative Neuromodulation. Acta Neurochirurgica Supplements, vol 97/1. Springer, Vienna. https://doi.org/10.1007/978-3-211-33079-1_6
Download citation
DOI: https://doi.org/10.1007/978-3-211-33079-1_6
Publisher Name: Springer, Vienna
Print ISBN: 978-3-211-33078-4
Online ISBN: 978-3-211-33079-1
eBook Packages: MedicineMedicine (R0)