Abstract
Implantation of an intrathecal drug delivery system (IDDS) requires a comprehensive knowledge of the process, including selection of appropriate patients and indications for implantation, the method of performing a trial, the surgical procedure of implantation, and the choice of pharmacologic agents. Additionally, knowledge of cerebrospinal fluid (CSF) dynamics plays an important role in determining IDDS success. This chapter addresses the pharmacologic fundamentals of the intrathecal agents that are typically used in an IDDS.
References
Henry-Feugeas MC, Idy-Peretti I, Baledent O, Poncelet-Didon A, Zannoli G, Bittoun J, et al. Origin of subarachnoid cerebrospinal fluid pulsations: a phase-contrast MR analysis. Magn Reson Imaging. 2000;18:387–95.
Friese S, Hamhaber U, Erb M, Kueker W, Klose U. The influence of pulse and respiration on spinal cerebrospinal fluid pulsation. Investig Radiol. 2004;39:120–30.
Alperin N, Vikingstad EM, Gomez-Anson B, Levin DN. Hemodynamically independent analysis of cerebrospinal fluid and brain motion observed with dynamic phase contrast MRI. Magn Reson Med. 1996;35:741–54.
Stockman HW. Effect of anatomical fine structure on the flow of cerebrospinal fluid in the spinal subarachnoid space. J Biochem Eng. 2006;128:106–14.
Degrell I, Nagy E. Concentration gradients for HVA, 5-HIAA, ascorbic acid, and uric acid in cerebrospinal fluid. Biol Psychiatry. 1990;27:891–6.
Bernards CM. Cerebrospinal fluid and spinal cord distribution of baclofen and bupivacaine during slow intrathecal infusion in pigs. Anesthesiology. 2006;105:169–78.
Hettiarachchi HD, Hsu Y, Harris TJ Jr, Penn R, Linninger AA. The effect of pulsatile flow on intrathecal drug delivery in the spinal canal. Ann Biomed Eng. 2011;39:2592–602.
Weisner B, Bernhardt W. Protein fractions of lumbar, cisternal, and ventricular cerebrospinal fluid: separate areas of reference. J Neurol Sci. 1978;37:205–14.
Yaksh TL, Rudy TA. Analgesia mediated by a direct spinal action of narcotics. Science. 1976;192:1357–8.
Basbaum AI, Clanton CH, Fields HL. Opiate and stimulus-produced analgesia: functional anatomy of a medullospinal pathway. Proc Natl Acad Sci. 1976;73:4685–8.
Behar M, Magora F, Olshwang D, Davidson JT. Epidural morphine in treatment of pain. Lancet. 1979;1(8115):527–9.
Wang JK, Nauss LE, Thomas JE. Pain relief by intrathecally applied morphine in man. Anesthesiology. 1979;50:149–51.
Matsuki A. Nothing new under the sun – a Japanese pioneer in the clinical use of intrathecal morphine [editorial]. Anesthesiology. 1983;58:289–90.
Childers SR, Snyder SH. Guanine nucleotides differentiate agonist and antagonist interactions with opiate receptors. Life Sci. 1978;23:759–61.
Childers SR, Creese I, Snowman AM, Synder SH. Opiate receptor binding affected differentially by opiates and opioid peptides. Eur J Pharmacol. 1979;55:11–8.
Al-Hasani R, Bruchas MR. Molecular mechanisms of opioid receptor-dependent signaling and behavior. Anesthesiology. 2011;115:1363–81.
Kroin JS. Intrathecal drug administration: present use and future trends. Clin Pharmacokinet. 1992;22:319–26.
McQuay HJ, Sullivan AF, Smallman K, Dickenson AH. Intrathecal opioids, potency and lipophilicity. Pain. 1989;36:111–5.
Ummenhofer WC, Arends RH, Shen D, Bernards CM. Comparative spinal distribution and clearance kinetics of intrathecally administered morphine, fentanyl, alfentanil, and sufentanil. Anesthesiology. 2000;92:739–53.
Bernards CM, Shen DD, Sterling ES, Adkins JE, Risler L, Phillips B, Ummenhofer W. Epidural, cerebrospinal fluid, and plasma pharmacokinetics of epidural opioids (part 1). Anesthesiology. 2003;99:455–65.
Bernards CM. Understanding the physiology and pharmacology of epidural and intrathecal opioids. Best Pract Res Clin Anaesthesiol. 2002;16:489–505.
Kroin JS, Ali A, York M, Penn RD. The distribution of medication along the spinal canal after chronic intrathecal administration. Neurosurgery. 1993;33:226–30; discussion 230.
Staats P, Whitworth M, Barakat M, Anderson W, Lilienfeld S. The use of implanted programmable infusion pumps in the management of nonmalignant, chronic low-back pain. Neuromodulation. 2007;10:376–80.
Boswell MV, Iacono RP, Guthkelch AN. Sites of action of subarachnoid lidocaine and tetracaine: observations with evoked potential monitoring during spinal cord stimulator implantation. Reg Anesth. 1992;17:37–42.
Jaffe RA, Rowe MA. Differential nerve block. Direct measurements on individual myelinated and unmyelinated dorsal root axons. Anesthesiology. 1996;84:1455–64.
Fink BR. Mechanisms of differential axial blockade in epidural and subarachnoid anesthesia. Anesthesiology. 1989;70:851–8.
Raymond SA. Subblocking concentrations of local anesthetics: effects on impulse generation and conduction in single myelinated sciatic nerve axons in frog. Anesth Analg. 1992;75:906–21.
Jaffe RA, Rowe MA. Subanesthetic concentrations of lidocaine selectively inhibit a nociceptive response in the isolated rat spinal cord. Pain. 1995;60:167–74.
Burm AG. Clinical pharmacokinetics of epidural and spinal anaesthesia. Clin Pharmacokinet. 1989;16:283–311.
Covino BG, Scott DB, Lambert DH. Handbook of spinal anesthesia and analgesia. Philadelphia, PA: WB Saunders; 1994.
Datta S, Kodali BS, Segal S. Obstetric anesthesia handbook. 5th ed. New York, NY: Springer; 2010.
Hayek SM, Hanes MC. Intrathecal therapy for chronic pain: current trends and future needs. Curr Pain Headache Rep. 2014;18:388.
Veizi IE, Hayek SM, Narouze S, Pope JE, Mekhail N. Combination of intrathecal opioids with bupivacaine attenuates opioid dose escalation in chronic noncancer pain patients. Pain Med. 2011;12:1481–9.
Mironer YE, Haasis JC, Chapple I, Brown C, Satterthwaite JR. Efficacy and safety of intrathecal opioid/bupivacaine mixture in chronic nonmalignant pain: a double blind, randomized, crossover, multicenter study by the National Forum of Independent Pain Clinicians (NFIPC). Neuromodulation. 2002;5:208–13.
Deer TR, Caraway DL, Kim CK, Dempsey CD, Stewart CD, McNeil KF. 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. 2002;2:274–8.
Hayek SM, Veizi E, Hanes M. Intrathecal hydromorphone and bupivacaine combination therapy for post-laminectomy syndrome optimized with patient-activated bolus device. Pain Med. 2015;17(3):561–71.
McGivern JG. Ziconotide: a review of its pharmacology and use in the treatment of pain. Neuropsychiatr Dis Treat. 2007;3:69–85.
Wermeling D, Drass M, Ellis D, Mayo M, McGuire D, O'Connell D, et al. Pharmacokinetics and pharmacodynamics of intrathecal ziconotide in chronic pain patients. J Clin Pharmacol. 2003;43:624–36.
Yaksh TL, de Kater A, Dean R, Best BM, Miljanich GP. Pharmacokinetic analysis of ziconotide (SNX-111), an intrathecal N-type calcium channel blocking analgesic, delivered by bolus and infusion in the dog. Neuromodulation. 2012;15:508–19; discussion 519.
Westenbroek RE, Hoskins L, Catterall WA. Localization of Ca2+ channel subtypes on rat spinal motor neurons, interneurons, and nerve terminals. J Neurosci. 1998;18:6319–30.
Hayek SM, Hanes MC, Wang C, Veizi IE. Ziconotide combination intrathecal therapy for noncancer pain is limited secondary to delayed adverse effects: a case series with a 24-month follow-up. Neuromodulation. 2015;18:397–403.
Sierralta F, Naquira D, Pinardi G, Miranda HF. α-Adrenoceptor and opioid receptor modulation of clonidine-induced antinociception. Br J Pharmacol. 1996;119:551–4.
Feng X, Zhang F, Dong R, Li W, Liu J, Zhao X, et al. Intrathecal administration of clonidine attenuates spinal neuroimmune activation in a rat model of neuropathic pain with existing hyperalgesia. Eur J Pharmacol. 2009;614:38–43.
Hassenbusch SJ, Gunes S, Wachsman S, Willis KD. Intrathecal clonidine in the treatment of intractable pain: a phase I/II study. Pain Med. 2002;3:85–91.
Rauck RL, North J, Eisenach JC. Intrathecal clonidine and adenosine: effects on pain and sensory processing in patients with chronic regional pain syndrome. Pain. 2015;156:88–95.
Hayek SM, Mekhail NA. Complex regional pain syndrome: redefining reflex sympathetic dystrophy and causalgia. Phys Sportsmed. 2004;32:18–25.
Deer TR, Pope JE, Hayek SM, Lamer TJ, Veizi IE, Erdek M, et al. The polyanalgesic consensus conference (PACC): recommendations for intrathecal drug delivery: guidance for improving safety and mitigating risks. Neuromodulation. 2017;20:155–76.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2018 Springer International Publishing AG, part of Springer Nature
About this chapter
Cite this chapter
Choi, K.S., Hayek, S.M. (2018). Intrathecal Drug Delivery: Pharmacokinetics and Dynamics. In: Diwan, S., Deer, T. (eds) Advanced Procedures for Pain Management. Springer, Cham. https://doi.org/10.1007/978-3-319-68841-1_29
Download citation
DOI: https://doi.org/10.1007/978-3-319-68841-1_29
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-68839-8
Online ISBN: 978-3-319-68841-1
eBook Packages: MedicineMedicine (R0)