Skip to main content
SpringerLink
Log in

Intrathecal Therapy for Chronic Spine Pain

  • Chapter
  • First Online:
Integrating Pain Treatment into Your Spine Practice

  • 1028 Accesses

Abstract

Intrathecal (IT) analgesic infusions have been used for decades to treat patient with chronic pain. Intrathecal drug delivery systems (IDDSs) are a treatment option for patients who have failed previous conservative measures or have intolerable side effects with oral or transdermal medications. The purpose of this chapter is to review and understand when an IDDS is appropriate, how to manage the device and IT medications, and to be aware of the potential complications associated with IT drug delivery. The focus of this chapter is using IDDSs for chronic noncancer pain originating from the spine.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 79.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 99.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Brown J, et al. Disease-specific and generic health outcomes: a model for the evaluation of long-term intrathecal opioid therapy in noncancer low back pain patients. Clin J Pain. 1999;15(2):122–31.

    Article  CAS  PubMed  Google Scholar 

  2. Deer TR, et al. Polyanalgesic Consensus Conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation. 2012;15(5):436–64. discussion 464–6.

    Article  PubMed  Google Scholar 

  3. Hayek SM, et al. Age-dependent intrathecal opioid escalation in chronic noncancer pain patients. Pain Med. 2011;12(8):1179–89.

    Article  PubMed  Google Scholar 

  4. Rauck RL, et al. Long-term intrathecal opioid therapy with a patient-activated, implanted delivery system for the treatment of refractory cancer pain. J Pain. 2003;4(8):441–7.

    Article  CAS  PubMed  Google Scholar 

  5. Smith TJ, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin Oncol. 2002;20(19):4040–9.

    Article  CAS  PubMed  Google Scholar 

  6. Onofrio BM, Yaksh TL. Long-term pain relief produced by intrathecal morphine infusion in 53 patients. J Neurosurg. 1990;72(2):200–9.

    Article  CAS  PubMed  Google Scholar 

  7. Penn RD, Paice JA. Chronic intrathecal morphine for intractable pain. J Neurosurg. 1987;67(2):182–6.

    Article  CAS  PubMed  Google Scholar 

  8. Atli A, et al. Intrathecal opioid therapy for chronic nonmalignant pain: a retrospective cohort study with 3-year follow-up. Pain Med. 2010;11(7):1010–6.

    Article  PubMed  Google Scholar 

  9. Shaladi A, et al. Continuous intrathecal morphine infusion in patients with vertebral fractures due to osteoporosis. Clin J Pain. 2007;23(6):511–7.

    Article  PubMed  Google Scholar 

  10. Deer T, et al. Intrathecal drug delivery for treatment of chronic low back pain: report from the National Outcomes Registry for Low Back Pain. Pain Med. 2004;5(1):6–13.

    Article  PubMed  Google Scholar 

  11. Rainov NG, Heidecke V, Burkert W. Long-term intrathecal infusion of drug combinations for chronic back and leg pain. J Pain Symptom Manage. 2001;22(4):862–71.

    Article  CAS  PubMed  Google Scholar 

  12. Anderson VC, Burchiel KJ. A prospective study of long-term intrathecal morphine in the management of chronic nonmalignant pain. Neurosurgery. 1999;44(2):289–300. discussion 300–1.

    Article  CAS  PubMed  Google Scholar 

  13. Roberts LJ, et al. Outcome of intrathecal opioids in chronic non-cancer pain. Eur J Pain. 2001;5(4):353–61.

    Article  CAS  PubMed  Google Scholar 

  14. Winkelmuller M, Winkelmuller W. Long-term effects of continuous intrathecal opioid treatment in chronic pain of nonmalignant etiology. J Neurosurg. 1996;85(3):458–67.

    Article  CAS  PubMed  Google Scholar 

  15. Battal B, et al. Cerebrospinal fluid flow imaging by using phase-contrast MR technique. Br J Radiol. 2011;84(1004):758–65.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Greitz D, Franck A, Nordell B. On the pulsatile nature of intracranial and spinal CSF-circulation demonstrated by MR imaging. Acta Radiol. 1993;34(4):321–8.

    Article  CAS  PubMed  Google Scholar 

  17. Enzmann DR, Pelc NJ. Normal flow patterns of intracranial and spinal cerebrospinal fluid defined with phase-contrast cine MR imaging. Radiology. 1991;178(2):467–74.

    Article  CAS  PubMed  Google Scholar 

  18. Greitz D. Cerebrospinal fluid circulation and associated intracranial dynamics. A radiologic investigation using MR imaging and radionuclide cisternography. Acta Radiol Suppl. 1993;386:1–23.

    CAS  PubMed  Google Scholar 

  19. Henry-Feugeas MC, et al. Origin of subarachnoid cerebrospinal fluid pulsations: a phase-contrast MR analysis. Magn Reson Imaging. 2000;18(4):387–95.

    Article  CAS  PubMed  Google Scholar 

  20. Friese S, et al. The influence of pulse and respiration on spinal cerebrospinal fluid pulsation. Invest Radiol. 2004;39(2):120–30.

    Article  PubMed  Google Scholar 

  21. Alperin N, et al. Hemodynamically independent analysis of cerebrospinal fluid and brain motion observed with dynamic phase contrast MRI. Magn Reson Med. 1996;35(5):741–54.

    Article  CAS  PubMed  Google Scholar 

  22. Grider JS, Harned ME, Etscheidt MA. Patient selection and outcomes using a low-dose intrathecal opioid trialing method for chronic nonmalignant pain. Pain Physician. 2011;14(4):343–51.

    PubMed  Google Scholar 

  23. Yamada S, et al. Influence of respiration on cerebrospinal fluid movement using magnetic resonance spin labeling. Fluids Barriers CNS. 2013;10(1):36.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Bernards CM. Cerebrospinal fluid and spinal cord distribution of baclofen and bupivacaine during slow intrathecal infusion in pigs. Anesthesiology. 2006;105(1):169–78.

    Article  PubMed  Google Scholar 

  25. Flack SH, Anderson CM, Bernards C. Morphine distribution in the spinal cord after chronic infusion in pigs. Anesth Analg. 2011;112(2):460–4.

    Article  CAS  PubMed  Google Scholar 

  26. Alperin N, et al. MRI study of cerebral blood flow and CSF flow dynamics in an upright posture: the effect of posture on the intracranial compliance and pressure. Acta Neurochir Suppl. 2005;95:177–81.

    Article  CAS  PubMed  Google Scholar 

  27. Hocking G, Wildsmith JA. Intrathecal drug spread. Br J Anaesth. 2004;93(4):568–78.

    Article  CAS  PubMed  Google Scholar 

  28. Yaksh TL, et al. Analgesia produced by a spinal action of morphine and effects upon parturition in the rat. Anesthesiology. 1979;51(5):386–92.

    Article  CAS  PubMed  Google Scholar 

  29. Krames ES. Intraspinal opioid therapy for chronic nonmalignant pain: current practice and clinical guidelines. J Pain Symptom Manage. 1996;11(6):333–52.

    Article  CAS  PubMed  Google Scholar 

  30. Sylvester RK, Lindsay SM, Schauer C. The conversion challenge: from intrathecal to oral morphine. Am J Hosp Palliat Care. 2004;21(2):143–7.

    Article  PubMed  Google Scholar 

  31. Kroin JS. Intrathecal drug administration. Present use and future trends. Clin Pharmacokinet. 1992;22(5):319–26.

    Article  CAS  PubMed  Google Scholar 

  32. Deer TR. Polyanalgesic Consensus Conference 2012. Neuromodulation. 2012;15(5):418–9.

    Article  PubMed  Google Scholar 

  33. Hamza M, et al. Prospective study of 3-year follow-up of low-dose intrathecal opioids in the management of chronic nonmalignant pain. Pain Med. 2012;13(10):1304–13.

    Article  PubMed  Google Scholar 

  34. Deer TR, et al. Polyanalgesic Consensus Conference–2012: recommendations to reduce morbidity and mortality in intrathecal drug delivery in the treatment of chronic pain. Neuromodulation. 2012;15(5):467–82. discussion 482.

    Article  PubMed  Google Scholar 

  35. Deer TR, et al. Polyanalgesic Consensus Conference–2012: consensus on diagnosis, detection, and treatment of catheter-tip granulomas (inflammatory masses). Neuromodulation. 2012;15(5):483–95. discussion 496.

    Article  PubMed  Google Scholar 

  36. Allen JW, et al. Opiate pharmacology of intrathecal granulomas. Anesthesiology. 2006;105(3):590–8.

    Article  CAS  PubMed  Google Scholar 

  37. Veizi IE, et al. Combination of intrathecal opioids with bupivacaine attenuates opioid dose escalation in chronic noncancer pain patients. Pain Med. 2011;12(10):1481–9.

    Article  PubMed  Google Scholar 

  38. De Andres J, et al. Can an intrathecal, catheter-tip-associated inflammatory mass reoccur? Clin J Pain. 2010;26(7):631–4.

    Article  PubMed  Google Scholar 

  39. McGivern JG. Ziconotide: a review of its pharmacology and use in the treatment of pain. Neuropsychiatr Dis Treat. 2007;3(1):69–85.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Jain KK. An evaluation of intrathecal ziconotide for the treatment of chronic pain. Expert Opin Investig Drugs. 2000;9(10):2403–10.

    Article  CAS  PubMed  Google Scholar 

  41. Rauck RL, et al. A randomized, double-blind, placebo-controlled study of intrathecal ziconotide in adults with severe chronic pain. J Pain Symptom Manage. 2006;31(5):393–406.

    Article  CAS  PubMed  Google Scholar 

  42. Wallace MS, et al. Intrathecal ziconotide in the treatment of chronic nonmalignant pain: a randomized, double-blind, placebo-controlled clinical trial. Neuromodulation. 2006;9(2):75–86.

    Article  PubMed  Google Scholar 

  43. Staats PS, et al. Intrathecal ziconotide in the treatment of refractory pain in patients with cancer or AIDS: a randomized controlled trial. JAMA. 2004;291(1):63–70.

    Article  CAS  PubMed  Google Scholar 

  44. Wallace MS, et al. Intrathecal ziconotide for severe chronic pain: safety and tolerability results of an open-label, long-term trial. Anesth Analg. 2008;106(2):628–37, table of contents.

    Article  CAS  PubMed  Google Scholar 

  45. Webster LR, et al. Long-term intrathecal ziconotide for chronic pain: an open-label study. J Pain Symptom Manage. 2009;37(3):363–72.

    Article  CAS  PubMed  Google Scholar 

  46. Kapural L, et al. Intrathecal ziconotide for complex regional pain syndrome: seven case reports. Pain Pract. 2009;9(4):296–303.

    Article  PubMed  Google Scholar 

  47. Rauck RL, et al. Intrathecal ziconotide for neuropathic pain: a review. Pain Pract. 2009;9(5):327–37.

    Article  PubMed  Google Scholar 

  48. Hayek SM, et al. 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(5):397–403.

    Article  PubMed  Google Scholar 

  49. Shields DEP, Aclan JB, Szatkowski AB. Chemical stability of admixtures containing ziconotide 25 mcg/mL and morphine sulfate 10 mg/mL or 20 mg/mL during simulated intrathecal administration. Int J Pharm Compd. 2008;12(6):553–7.

    CAS  Google Scholar 

  50. Butterworth 4th JF, Strichartz GR. Molecular mechanisms of local anesthesia: a review. Anesthesiology. 1990;72(4):711–34.

    Article  CAS  PubMed  Google Scholar 

  51. 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(1):37–42.

    CAS  PubMed  Google Scholar 

  52. Tejwani GA, Rattan AK, McDonald JS. Role of spinal opioid receptors in the antinociceptive interactions between intrathecal morphine and bupivacaine. Anesth Analg. 1992;74(5):726–34.

    Article  CAS  PubMed  Google Scholar 

  53. Penning JP, Yaksh TL. Interaction of intrathecal morphine with bupivacaine and lidocaine in the rat. Anesthesiology. 1992;77(6):1186–2000.

    Article  CAS  PubMed  Google Scholar 

  54. Ortner CM, et al. On the ropivacaine-reducing effect of low-dose sufentanil in intrathecal labor analgesia. Acta Anaesthesiol Scand. 2010;54(8):1000–6.

    Article  CAS  PubMed  Google Scholar 

  55. Parpaglioni R, et al. Adding sufentanil to levobupivacaine or ropivacaine intrathecal anaesthesia affects the minimum local anaesthetic dose required. Acta Anaesthesiol Scand. 2009;53(9):1214–20.

    Article  CAS  PubMed  Google Scholar 

  56. Nitescu P, et al. Continuous infusion of opioid and bupivacaine by externalized intrathecal catheters in long-term treatment of “refractory” nonmalignant pain. Clin J Pain. 1998;14(1):17–28.

    Article  CAS  PubMed  Google Scholar 

  57. Chestnut DH, et al. Continuous infusion epidural analgesia during labor: a randomized, double-blind comparison of 0.0625 % bupivacaine/0.0002 % fentanyl versus 0.125 % bupivacaine. Anesthesiology. 1988;68(5):754–9.

    Article  CAS  PubMed  Google Scholar 

  58. van Dongen RT, Crul BJ, van Egmond J. Intrathecal coadministration of bupivacaine diminishes morphine dose progression during long-term intrathecal infusion in cancer patients. Clin J Pain. 1999;15(3):166–72.

    Article  PubMed  Google Scholar 

  59. Mironer YE, et al. 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(4):208–13.

    Article  PubMed  Google Scholar 

  60. Deer TR, et al. 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(4):274–8.

    Article  PubMed  Google Scholar 

  61. Kroin JS, et al. The effect of chronic subarachnoid bupivacaine infusion in dogs. Anesthesiology. 1987;66(6):737–42.

    Article  CAS  PubMed  Google Scholar 

  62. Li DF, et al. Neurological toxicity of the subarachnoid infusion of bupivacaine, lignocaine or 2-chloroprocaine in the rat. Br J Anaesth. 1985;57(4):424–9.

    Article  CAS  PubMed  Google Scholar 

  63. Zhong Z, et al. Repeated intrathecal administration of ropivacaine causes neurotoxicity in rats. Anaesth Intensive Care. 2009;37(6):929–36.

    CAS  PubMed  Google Scholar 

  64. Yang SH, Guo QL, Wang YC. Alterations of myelin basic protein concentration in the plasma and ultrastructure in the spinal cord after continuous intrathecal ropivacaine injection in rats. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2008;33(6):527–32.

    CAS  PubMed  Google Scholar 

  65. Yamashita A, et al. A comparison of the neurotoxic effects on the spinal cord of tetracaine, lidocaine, bupivacaine, and ropivacaine administered intrathecally in rabbits. Anesth Analg. 2003;97(2):512–9, table of contents.

    Article  CAS  PubMed  Google Scholar 

  66. Lundborg C, et al. Clinical experience using intrathecal (IT) bupivacaine infusion in three patients with complex regional pain syndrome type I (CRPS-I). Acta Anaesthesiol Scand. 1999;43(6):667–78.

    Article  CAS  PubMed  Google Scholar 

  67. Feng 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(1–3):38–43.

    Article  CAS  PubMed  Google Scholar 

  68. Eisenach JC, Hood DD, Curry R. Intrathecal, but not intravenous, clonidine reduces experimental thermal or capsaicin-induced pain and hyperalgesia in normal volunteers. Anesth Analg. 1998;87(3):591–6.

    CAS  PubMed  Google Scholar 

  69. Uhle EI, et al. Continuous intrathecal clonidine administration for the treatment of neuropathic pain. Stereotact Funct Neurosurg. 2000;75(4):167–75.

    Article  CAS  PubMed  Google Scholar 

  70. Siddall PJ, et al. Intrathecal morphine and clonidine in the management of spinal cord injury pain: a case report. Pain. 1994;59(1):147–8.

    Article  CAS  PubMed  Google Scholar 

  71. Sites BD, et al. Intrathecal clonidine added to a bupivacaine-morphine spinal anesthetic improves postoperative analgesia for total knee arthroplasty. Anesth Analg. 2003;96(4):1083–8, table of contents.

    Article  CAS  PubMed  Google Scholar 

  72. Mogensen T, et al. Epidural clonidine enhances postoperative analgesia from a combined low-dose epidural bupivacaine and morphine regimen. Anesth Analg. 1992;75(4):607–10.

    Article  CAS  PubMed  Google Scholar 

  73. Capogna G, et al. Addition of clonidine to epidural morphine enhances postoperative analgesia after cesarean delivery. Reg Anesth. 1995;20(1):57–61.

    CAS  PubMed  Google Scholar 

  74. Hao JX, et al. Effects of intrathecal vs. systemic clonidine in treating chronic allodynia-like response in spinally injured rats. Brain Res. 1996;736(1–2):28–34.

    Article  CAS  PubMed  Google Scholar 

  75. Bevacqua BK, Fattouh M, Backonja M. Depression, night terrors, and insomnia associated with long-term intrathecal clonidine therapy. Pain Pract. 2007;7(1):36–8.

    Article  PubMed  Google Scholar 

  76. Fitzgibbon D, et al. Rebound hypertension and withdrawal associated with discontinuation of an infusion of epidural clonidine. Anesthesiology. 1996;84(3):729–31.

    Article  CAS  PubMed  Google Scholar 

  77. Deer TR, et al. Polyanalgesic Consensus Conference–2012: recommendations on trialing for intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation. 2012;15(5):420–35. discussion 435.

    Article  PubMed  Google Scholar 

  78. Ahmed SU, Martin NM, Chang Y. Patient selection and trial methods for intraspinal drug delivery for chronic pain: a national survey. Neuromodulation. 2005;8(2):112–20.

    Article  PubMed  Google Scholar 

  79. Anderson VC, Burchiel KJ, Cooke B. A prospective, randomized trial of intrathecal injection vs. epidural infusion in the selection of patients for continuous intrathecal opioid therapy. Neuromodulation. 2003;6(3):142–52.

    Article  PubMed  Google Scholar 

  80. Doleys DM, Brown JL, Ness T. Multidimensional outcomes analysis of intrathecal, oral opioid, and behavioral-functional restoration therapy for failed back surgery syndrome: a retrospective study with 4 years’ follow-up. Neuromodulation. 2006;9(4):270–83.

    Article  PubMed  Google Scholar 

  81. Ilias W, et al. Patient-controlled analgesia in chronic pain patients: experience with a new device designed to be used with implanted programmable pumps. Pain Pract. 2008;8(3):164–70.

    Article  PubMed  Google Scholar 

  82. Kamran S, Wright BD. Complications of intrathecal drug delivery systems. Neuromodulation. 2001;4(3):111–5.

    Article  CAS  PubMed  Google Scholar 

  83. Jones RL, Rawlins PK. The diagnosis of intrathecal infusion pump system failure. Pain Physician. 2005;8(3):291–6.

    PubMed  Google Scholar 

  84. Follett KA, Naumann CP. A prospective study of catheter-related complications of intrathecal drug delivery systems. J Pain Symptom Manage. 2000;19(3):209–15.

    Article  CAS  PubMed  Google Scholar 

  85. Fluckiger B, et al. Device-related complications of long-term intrathecal drug therapy via implanted pumps. Spinal Cord. 2008;46(9):639–43.

    Article  CAS  PubMed  Google Scholar 

  86. Kallen AJ, Wilson CT, Larson RJ. Perioperative intranasal mupirocin for the prevention of surgical-site infections: systematic review of the literature and meta-analysis. Infect Control Hosp Epidemiol. 2005;26(12):916–22.

    Article  PubMed  Google Scholar 

  87. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2015;2, CD004985.

    PubMed  Google Scholar 

  88. Peerdeman SM, de Groot V, Feller RE. In situ treatment of an infected intrathecal baclofen pump implant with gentamicin-impregnated collagen fleece. J Neurosurg. 2010;112(6):1308–10.

    Article  PubMed  Google Scholar 

  89. Diefenbeck M, Muckley T, Hofmann GO. Prophylaxis and treatment of implant-related infections by local application of antibiotics. Injury. 2006;37 Suppl 2:S95–104.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Division of Pain Medicine, Case Western Reserve University, University Hospitals Case Medical Center, 11100 Euclid Ave., Cleveland, OH, 44106, USA

    Melinda M. Lawrence M.D. & Salim M. Hayek M.D., Ph.D.

Authors
  1. Melinda M. Lawrence M.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Salim M. Hayek M.D., Ph.D.
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Melinda M. Lawrence M.D. .

Editor information

Editors and Affiliations

  1. St. Luke’s University Health Network, Neurosurgery, Bethlehem, Pennsylvania, USA

    Steven M. Falowski

  2. Summit Pain Alliance, Santa Rosa, California, USA

    Jason E. Pope

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Lawrence, M.M., Hayek, S.M. (2016). Intrathecal Therapy for Chronic Spine Pain. In: Falowski, S., Pope, J. (eds) Integrating Pain Treatment into Your Spine Practice. Springer, Cham. https://doi.org/10.1007/978-3-319-27796-7_14

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-27796-7_14

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-27794-3

  • Online ISBN: 978-3-319-27796-7

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation