This page contains a Flash digital edition of a book.
Pain


Table 2: Outcomes of Prospective Studies Evaluating Intrathecal Medications for Neuropathic Pain Study


Medication


Kumar et al., Morphine, 200192


infusion


Anderson and Morphine, Burchiel, 199993


Angel et al., 199894


Morphine, infusion


Hassenbusch Morphine, et al., 199595


sufentanil, infusion


Dureja et al., Midazolam, 201030


bolus with or without epidural Borg and


Krijnen, 199631 Van Hilten


et al., 200038


Taira et al., 199541


methylprednisolone Midazolam, bolus


Prospective, observational, 4 Baclofen, bolus Prospective, comparative, 7 Baclofen, bolus Prospective, observational, 9


Herman et al., Baclofen, bolus Prospective, 199240


Nitescu et al., Bupivacaine with Prospective, 199849


morphine, infusion


or without morphine, infusion


Staats et al., 200456


Ziconotide, bolus Prospective,


Webster et al., Ziconotide, 200996


infusion or without


comparative, 111 Prospective,


observational, 78


Siddall et al., Clonidine with Prospective, 200070


morphine, bolus


Eisenach et al., Clonidine, bolus Prospective, 199871


<0.2 comparative, 16 35 NP


Higher doses demonstrated both better analgesia and more stable hemodynamics


CRPS = complex regional pain syndrome; DA = deafferentation; FBSS = failed back surgery syndrome; MS = multiple sclerosis; NO = nociceptive; NP = neuropathic; PHN = post herpetic neuralgia; SCI = spinal cord injury; TMy = transverse myelitis.


Staats and colleagues56 conducted a multicenter, double-blind,


placebo-controlled study to assess the efficacy of ziconotide in patients with either malignant or AIDS-related pain. One hundred and eleven patients were enrolled and randomized to receive either ziconotide or placebo. Ziconotide dosing and titration were altered during the study from a starting dose of 0.4 µg/hour to less than 0.1 µg/hour to decrease the incidence of adverse effects; the maximum dose was maintained at 2.4 µg/hour. Overall, significantly better pain relief was observed with ziconotide than placebo (53.0 versus 17.5 %) over a two-week time course. Serious adverse effects were reported in 30.6 % of the treatment group, with the most common complaints being dizziness, confusion, and urinary retention.


158 A subsequent study by Rauck et al.57 was designed to determine


whether the prevalence of adverse effects could be decreased by using a lower maximum dose and slower titration schedule. Two hundred and twenty patients with refractory non-malignant pain were randomized to either placebo or ziconotide. The most prevalent diagnosis was FBSS consisting of mixed neuropathic and somatic pain. Ziconotide was started at a dose of 0.1 µg/hour and titration was slowly achieved over a three-week period in increments of 0.05–0.1 µg/hour, to a mean dose of 0.29 µg/hour. The study demonstrated superior pain relief in the treatment group (14.7 versus 7.2 %) with a similar rate of adverse effects between the two groups. A total of 12 % of patients in the treatment group experienced serious adverse effects,


US NEUROLOGY <0.2 comparative, 15 17 NP <0.2 3 53 22–36 NP, AIDS, PHN NP, NO cohort, 90


Krames et al., Bupivacaine with Prospective, 199350


1–2.5 observational, 16 60–80 NP, NO, mixed


Bupivacaine improved analgesia in 8 of 10 patients with a pure or mixed neuropathic component to their pain


25 % increase in incidence of adverse events compared with placebo


Required ziconotide dose remained stable


throughout treatment period, suggesting no development of tolerance


Clonidine shown to augment intrathecal morphine analgesia


<0.2 observational 0.2 60–100 NP, mixed 80 MS, SCI, TMy <0.2 0.5–3


Functionality studied


>50 CRPS Stroke, SCI 0.2–0.5 75–90 NP


Study Type, n


Prospective,


observational, 16 Prospective,


hydromorphone, observational, 30 infusion


Prospective, comparative, 18 Prospective, comparative, 150 0.2 60 PHN 0.5–3.0


observational, 11 (mean 2.3) Prospective,


0.8–4.7 Follow-up Relief of Pain, (Mean in Years) n %


1–4 (mean 1.5) NO 57, FBSS 61, NO, mixed (FBSS), DA 75


DA 2.0


50 % with >25 % Mixed (FBSS), pain relief


NO, DA, NP 73 61


The best long-term results were seen with deafferentation and mixed pain


Adverse effects managed by dose reduction, addition of bupivacaine, or replacement of morphine with hydromorphone


Mixed (FBSS), NP 2 patients experienced bladder dysfunction requiring pump removal


NP


33 % re-operation rate; edema resolved in 3 patients after switching to sufentanil


Combination therapy with midazolam and epidural methylprednisolone resulted in longer-duration analgesia


Patients studied had pain refractory to conventional analgesics


3 patients regained normal hand function, and


2 of these 3 women regained the ability to walk


Relief of pain, allodynia, and hyperalgesia


appeared 1–2 hours after the injection and persisted for 10–24 hours


Temporal dissociation regarding the


action on dysesthetic pain and spasticity-related pain


Sedative consumption was cut in half Condition(s) Studied Comments and Complications


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76  |  Page 77  |  Page 78  |  Page 79  |  Page 80  |  Page 81  |  Page 82  |  Page 83  |  Page 84  |  Page 85  |  Page 86  |  Page 87  |  Page 88  |  Page 89  |  Page 90  |  Page 91  |  Page 92  |  Page 93  |  Page 94  |  Page 95  |  Page 96  |  Page 97  |  Page 98  |  Page 99  |  Page 100  |  Page 101  |  Page 102  |  Page 103  |  Page 104  |  Page 105  |  Page 106  |  Page 107  |  Page 108