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Neuraxial Drug Administration

A Review of Treatment Options for Anaesthesia and Analgesia

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Abstract

Neuraxial drug administration describes techniques that deliver drugs in close proximity to the spinal cord, i.e. intrathecally into the CSF or epidurally into the fatty tissues surrounding the dura, by injection or infusion. This approach was initially developed in the form of spinal anaesthesia over 100 years ago. Since then, neuraxial drug administration has evolved and now includes a wide range of techniques to administer a large number of different drugs to provide anaesthesia, but also analgesia and treatment of spasticity in a variety of acute and chronic settings.

This review concentrates on the pharmacological agents used and the clinical basis behind currently utilised approaches to neuraxial drug administration. With regard to local anaesthetics, the main focus is on the development of the enantiomer-specific compounds ropivacaine and levobupivacaine, which provide similar efficacy to bupivacaine with a reduced risk of severe cardiotoxicity. Opioids are the other group of drugs widely used neuraxially, in particular to provide analgesia alone or more commonly in combination with other agents. The physicochemical properties of the various opioids explain the main differences in efficacy and safety between these drugs when used intrathecally, of which morphine, fentanyl and sufentanil are most commonly used. Another group of drugs including clonidine, dexmedetomidine and epinephrine (adrenaline) provide neuraxial analgesia via α-adrenergic receptors and are used mainly as adjuvants to local anaesthetics and opioids. Furthermore, intrathecal baclofen is in routine clinical use to treat spasticity in a number of neurological conditions.

Beside these established approaches, a wide range of other drugs have been assessed for neuraxial administration to provide analgesia; however, most are in various early stages of investigation and are not used routinely. These drugs include neostigmine, ketamine, midazolam and adenosine, and the conotoxin ziconotide. The latter is possibly the most unusual compound here; it has recently gained registration for intrathecal use in specific chronic pain conditions.

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Acknowledgements

The authors did not receive any funding to assist in the preparation of this review. The only potential conflicts of interest that may be relevant to the contents of this review are that Stephen Schug and Michael Paech are or were acting in the past as consultants for Mayne Pharma, Xenome Pty Ltd, AstraZeneca and Abbott Laboratories.

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Authors and Affiliations

  1. Pharmacology Unit, School of Medicine and Pharmacology, UWA Anaesthesia, University of Western Australia, Perth, Western Australia, Australia

    Stephan A. Schug & Michael J. Paech

  2. Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, Perth, Western Australia, Australia

    Stephan A. Schug, David Saunders, Irina Kurowski & Michael J. Paech

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  1. Stephan A. Schug
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Correspondence to Stephan A. Schug.

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Schug, S.A., Saunders, D., Kurowski, I. et al. Neuraxial Drug Administration. CNS Drugs 20, 917–933 (2006). https://doi.org/10.2165/00023210-200620110-00005

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