Intrathecal Drug Delivery for Neuropathic Pain
longer-lasting analgesia than the other two groups. For all treatments, the maximum benefit was observed between one and three weeks.30
The potential risk of adhesive arachnoiditis must be taken into account when opting to pursue intrathecal steroid administration. Preservative-free methylprednisolone formulations are not commercially available, but a recent report by Candido et al. described a technique by which they were able to decrease the amount of polyethylene glycol extracted from vials of steroid by an average of 85 % without decreasing the amount of steroid withdrawn.91
However, as the precise causative agent remains unclear, it is prudent to reserve this treatment for those who have failed safer and more conventional treatments, and to limit the number of intrathecal injections to four.
Since its introduction more than 30 years ago, the use of intrathecal therapy to provide analgesia has grown steadily. Significant advances have been made with regard to delivery systems, selection criteria,
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and the discovery of new drugs that act via non-opioid receptor sites. Opioids remain the most commonly used intrathecal analgesics, and the evidence supporting their use in cancer-related pain remains strong. For neuropathic pain, intrathecal opioids may provide long-term benefit in carefully selected individuals, but this must be weighed against the cumulative risks of long-term intrathecal opioid therapy, including hyperalgesia and endocrine dysfunction. There is very strong evidence to support the use of baclofen as a treatment for spasticity-related pain, and moderate evidence to support its use for neuropathic pain. Although limited by its narrow therapeutic index and high cost, there is good evidence that ziconotide is effective for neuropathic pain. Bupivacaine has a long history of safe use as a spinal analgesic and may provide significant benefit to individuals as an adjunct agent. Because of its opioid-sparing properties and ability to attenuate the sympathetic response, clonidine may be especially useful in patients with neuropathic pain. Future studies should focus on cost-effectiveness, better identification of phenotypes that may respond to intrathecal treatment, and methods to reduce adverse effects and complications. n
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