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Long Term Intrathecal Infusion of Opiates for Treatment of Failed Back Surgery Syndrome

  • Nilton Alves LaraJr.
  • Manoel J. Teixeira
  • Erich T. Fonoff
Chapter
Part of the Acta Neurochirurgica Supplementum book series (NEUROCHIRURGICA, volume 108)

Abstract

Failed Back Surgery Syndrome (FBSS) is a multidimensional painful condition and its treatment remains a challenge for the surgeons. Prolonged intrathecal infusion of opiates for treatment of noncancer pain also remains a controversial issue. The authors present a prospective study about the long-term treatment of 30 patients with nonmalignant pain treated with intrathecal infusion of morphine from February, 1996 to May, 2004. Self-administration pumps were implanted in 18 patients and constant-flow pumps in 12. The mean intensity of pain reduced from 9.5 to 4.6 according to the visual analogue scale (p < 0.001); the mean daily dose of morphine necessary for pain control became constant after the sixth month of treatment. No difference was observed in the results between patients treated with bolus or constant infusion. Side effects were more frequent at the beginning and became tolerable after the first month of treatment. There was improvement of the quality of life measured by SF-36 (30.8–49.6) and in all dimensions of the Treatment of Pain Survey, except for working capacity. The follow-up period ranged from 18 to 98 months (mean = 46.7 months). It was concluded that intrathecal infusion of morphine is a useful and safe tool for long-term treatment of chronic nonmalignant pain.

Keywords

Failed back surgery pain Implantable pumps Intractable pain Opiates Treatment of pain 

Notes

Conflict of interest statementWe declare that we have no conflict of interest.

References

  1. 1.
    Krames ES. (1996) Intraspinal opioid therapy for chronic non-malignant pain: current practice and clinical guidelines. J Pain Symptom Manage. 11:333–52.Google Scholar
  2. 2.
    Anderson SR. (2000) A rationale for the treatment algorithm of failed back surgery syndrome. Curr Rev Pain. 4(5):395–406.PubMedCrossRefGoogle Scholar
  3. 3.
    Krames ES, Gershow J, Glassberg A. (1985) Continuous infusion of spinally administered narcotics for the relief of pain due to malignant disorders. Cancer. 56(3): 696–702.PubMedCrossRefGoogle Scholar
  4. 4.
    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(4):300–12.PubMedCrossRefGoogle Scholar
  5. 5.
    Spaziante R, Cappabianca P, Ferone A, Craus W, de' Santi MS, de Divitiis E. (1985) Treatment of chronic cancer pain by means of continuous intrathecal low dose morphine administration with a totally implantable subcutaneous pump. Case report. J Neurosurg Sci. 29(2):143–51.PubMedGoogle Scholar
  6. 6.
    Coombs DW, Saunders RL, Gaylor M, Pageau MG. (1982) Epidural narcotic infusion reservoir: implantation technique and efficacy. Anesthesiology. 56(6):469–73.PubMedCrossRefGoogle Scholar
  7. 7.
    Coombs DW,Saunders RL, Gaylor MS, Block AR, Colton T, Harbaugh R, Pageau MG, Mroz W. (1983) Relief of continuous chronic pain by intraspinal narcotics infusion via an implanted reservoir. JAMA. 250(17):2336–9.PubMedCrossRefGoogle Scholar
  8. 8.
    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(6):487–93.PubMedGoogle Scholar
  9. 9.
    Melzack R. (1975) The McGill Pain Questionnaire: Major properties and scoring methods. Pain. 1(3):277–99.PubMedCrossRefGoogle Scholar
  10. 10.
    Onofrio BM, Yaksh TL, Amold PG. (1981) Continuous low-dose intrathecalmorphine administration in the treatment of chronic pain of malignant origin. Mayo Clin Proc. 56(8):516–20.PubMedGoogle Scholar
  11. 11.
    Peng PW, Fedoroff I, Jacques L, Kumar K. (2007) Survey of the practice of spinal cord stimulators and intrathecal analgesic delivery implants for management of pain in Canada. Pain Res Manag. 12(4):281–5. LPubMedGoogle Scholar
  12. 12.
    Penn RD, Paice JA. (1987) Chronic intrathecal morphine for intractable pain. Neurosurg. 67(2):182–6.CrossRefGoogle Scholar
  13. 13.
    Auld AW, Maki-Jokela A, Murdoch DM. (1985) Intraspinal narcotic analgesia in the treatment of chronic pain. Spine. 10(8):777–81.PubMedCrossRefGoogle Scholar
  14. 14.
    Brazenor GA. (1987) Long term intrathecal administration of morphine: a comparison of bolus injection via reservoir with continuous infusion by 15 implanted pump. Neurosurgery. 21(4):484–91.PubMedCrossRefGoogle Scholar
  15. 15.
    Anderson VC, Burchiel KJ. (1999) A prospective study of long-term intrathecal morphine in the management of chronic nonmalignant pain. Neurosurgery. 44(2):289–300.PubMedCrossRefGoogle Scholar
  16. 16.
    Dahm P, Nitescu P, Appelgren L. (1998) Efficacy and technical complications of long-term continuous intraspinal infusions of opioid and or bupivacaine in refractory nonmalignant pain: a comparison between the epidural and the intrathecal approach with externalized or implanted catheters and infusion pumps. Clin J Pain. 14(1):4–16.PubMedCrossRefGoogle Scholar
  17. 17.
    Harbaugh RE, Coombs DW, Saunders RL, Gaylor M, Pageau M. (1982) Implanted continuous epidural morphine infusion system. Preliminary report. J Neurosurg. 56(6):803–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Schultheiss R, Schramm J, Neidhardt J. (1992) Dose changes in long- and medium-term intrathecal morphine therapy of cancer pain. Neurosurgery. 31(4):664–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Wang JK, Nauss LA, Thomas JE. (1979) Pain relief by intrathecally applied morphine in man. Anesthesiology. 50(2):149–512.PubMedCrossRefGoogle Scholar
  20. 20.
    Whitehurst WR, Doleys DM, Friday N, Murray JB, Marullo DS, Haile JM. (1993) Effects of long term chronic spinal opiate therapy in 27 noncancer pain patients. In Proceedings of the AANS National Meeting; April; Boston.Google Scholar
  21. 21.
    Angel IF, Gould HJ, Carey ME. (1998) Intrathecal morphine pump as a treatment option in chronic pain of nonmalignant origin. Surg Neurol. 49(1):92–8.PubMedCrossRefGoogle Scholar
  22. 22.
    Hassenbusch SJ, Stanton-Hicks M, Covington EC, Walsh JG, Guthrey DS. (1995) Long-term intraspinal infusions of opioids mu the treatment of neuropathic pain. J Pain Symptom Manage. 10(7):527–43.PubMedCrossRefGoogle Scholar
  23. 23.
    Penn RD, Paice JA, Gottschalk W, Ivankovich AD. (1984) Cancer pain relief using chronic morphine infusion: Early experience with a programmable implanted drug pump. J Neurosurg. 61920:302–6.Google Scholar
  24. 24.
    Mavrocordatos P, Cahana A. (2006) Minimally invasive procedures for the treatment of failed back surgery syndrome. Adv Tech Stand Neurosurg. 31:221–52.PubMedCrossRefGoogle Scholar
  25. 25.
    Portenoy RK, Foley KM. (1986) Chonic use of opioid analgesics in nonmalignant pain: report of 38 cases. Pain. 25(2):171–86.PubMedCrossRefGoogle Scholar
  26. 26.
    Cionelli RM. (1997) Tradução para o português e validação do questionário genérico de avaliação de qualidade de vida do Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) [Tese]. São Paulo: Escola Paulistade Medicina – UNIFESP.Google Scholar
  27. 27.
    Wang JK. (1985) Intrathecal morphine for intractable pain secondary to cancer of pelvic organs. Pain. 21(1):99–102.PubMedCrossRefGoogle Scholar
  28. 28.
    Onofrio BM, Yaksh TL. (1990) Long-term pain relief produced by intrathecal morphine infusion in 53 patients. J Neurosurg. 72(2):200–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Kames LD, Naliboff BD, Heinrich RL, Schag CC. (1984) The chronic illness problem inventory: problem-oriented psychosocial assessment of patients with chronic illness. Int J Psychiatry Med. 14(1):65–75.PubMedCrossRefGoogle Scholar
  30. 30.
    Rogers WH, Wittink H, Wagner A, Cynn D, Carr DB. (2000) Assessing individual outcomes during outpatient, multidisciplinary chronic pain treatment by means of an augmented SF-36. Pain Med. 1(1):44–54.PubMedCrossRefGoogle Scholar
  31. 31.
    Winkelmuller M. (1996) Long-term effects of continuous intrathecal opioid treatment in chronic pain of nonmalignant etiology. J Neurosurg. 85(3):458–67.PubMedCrossRefGoogle Scholar
  32. 32.
    Yaksh TL, Onofrio HM. (1987) Retrospective consideration of the doses given intrathecally by chronic infusion in 163 patients by 19 phisicians. Pain. 31(2):211–23.PubMedCrossRefGoogle Scholar
  33. 33.
    Gourlay GK, Plummer JL, Cherry DA, Onley MM, Parish KA, Wood MM, Cousins MJ. (1991) Comparison of intermittent bolus with continuous infusion of epidural morphine in the treatment of severe cancer pain. Pain. 47(2):135–40.PubMedCrossRefGoogle Scholar
  34. 34.
    Coffey RJ, Burchiel K. (2002) Inflammatory mass lesions associated with intrathecal drug infusion catheters: report and observations on 41 patients. Neurosurgery. 50(1):78–86.PubMedGoogle Scholar
  35. 35.
    France RD, Urban BJ, Keefe FJ. (1984) Long-term use of narcotic analgesics in chronic pain. Soc Sci Med. 19(12):1379–82.PubMedCrossRefGoogle Scholar
  36. 36.
    Poletti CE, Cohen AM, Todd DP, Quemann RG, Sweet WH, Zervas NT. (1981) Cancer pain relieved by long-term epidural morphine with permanent indweiling systems for self-administration. J Neurosurg. 55(4):581–4.PubMedCrossRefGoogle Scholar
  37. 37.
    Kamran S, Wright B. (2001) Complications of intrathecal drug delivery systems. Neuromodulation. 4(3):111PubMedCrossRefGoogle Scholar
  38. 38.
    Long DM. (1991) Failed back surgery syndrome. Neurosurg Clin N Am. 2:899.PubMedGoogle Scholar
  39. 39.
    Shetter AG, Hadiey MN, Wilkinson E. (1986) Administration of intraspinal morphine sulfate for the treatment of intractable cancer pain. Neurosurgery. 18(6):740–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Zenz M, Strumpf M, Tryba M. (1992) Long term oral opioid therapy in patients with chronic nonmalignant pain. J Pain Symptom Manage. 7:69–77.PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag/Wien 2011

Authors and Affiliations

  • Nilton Alves LaraJr.
    • 1
  • Manoel J. Teixeira
    • 1
  • Erich T. Fonoff
    • 1
  1. 1.Division of NeurosurgeryUniversity Of São PauloSão PauloBrazil

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