This page contains a Flash digital edition of a book.
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of polyethylene glycol extracted from vials of steroid by an average of 85 % without decreasing the amount of steroid withdrawn.91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.


Conclusions


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,


1. Dieleman JP, Kerklaan J, Huygen FJ, et al., Incidence rates and treatment of neuropathic pain conditions in the general population, Pain, 2008;137:681–8.


2. Corning JL, Spinal anesthesia and local medication of the cord, New York Journal of Medicine, 1885;42:483–5.


3. Calthorpe N, The history of spinal needles: getting to the point, Anaesthesia, 2004;59:1231–41.


4. Bier A, Versuche uber cocainisirung des ruckenmarkes, Deutsche Zeitschrift fur Chirurgie, 1899;51:361–9.


5. Pert CB, Snyder SH, Opiate receptor: demonstration in nervous tissue, Science, 1973;179:1011–4.


6. Simon EJ, Hiller JM, Edelman I, Stereospecific binding of the potent narcotic analgesic (3H) etorphine to rat-brain homogenate, Proc Natl Acad Sci U S A, 1973;70:1947–9.


7. Terenius L, Stereospecific interaction between narcotic analgesics and a synaptic plasm a membrane fraction of rat cerebral cortex, Acta Pharmacol Toxicol, 1973;32:317–20.


8. Yaksh TL, Rudy TA, Analgesia mediated by a direct spinal action of narcotics, Science, 1976;192:1357–8.


9. Wang JK, Nauss LA, Thomas JE, Pain relief by intrathecally applied morphine in man, Anesthesiology, 1979;50:149–51.


10. Reisine T, Opiate receptors, Neuropharmacology, 1995;34:463–72. 11. Ocana M, Cendan CM, Cobos EJ, et al., Potassium channels and pain: present realities and future opportunities, Eur J Pharmacol, 2004;500:203–19.


12. Payne R, Inturrisi CE, CSF distribution of morphine, methadone and sucrose after intrathecal injection, Life Sci, 1985;37:1137–44.


13. Smith TJ, Staats PS, Deer T, et al., Implantable Drug Delivery Systems Study Group, 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;20:4040–9.


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


15. Paice JA, Penn RD, Shott S, Intraspinal morphine for chronic pain: a retrospective, multicenter study, J Pain Symptom Manage, 1996;11:71–80.


16. Winkelmüller M, Winkelmüller W, Long-term effects of continuous intrathecal opioid treatment in chronic pain of nonmalignant etiology, J Neurosurg, 1996;85:458–67.


17. Roberts LJ, Finch PM, Goucke CR, et al., Outcome of intrathecal opioids in chronic non-cancer pain, Eur J Pain, 2001;5:353–61.


18. Doleys DM, Coleton M, Tutak U, Use of intraspinal infusion therapy with non-cancer pain patients: follow up and comparison of workers compensation vs. non-workers compensation patients, Neuromodulation, 1998;1:149–59.


19. Tutak U,Doleys DM, Intrathecal infusion systems for treatment of chronic low back and leg pain of noncancer origin, South Med J, 1996;89:295–300.


20. Becker WJ, Ablett DP, Harris CJ, et al., Long term treatment of intractable reflex sympathetic dystrophy with intrathecal morphine, Can J Neurol Sci, 1995;22:153–9.


21. Goodman RR, Brisman R, Treatment of lower extremity reflex sympathetic dystrophy with continuous intrathecal morphine infusion, Appl Neurophysiol, 1987;50:425–6.


22. Thimineur MA, Kravitz E, Vodapally MS, Intrathecal opioid treatment for chronic non-malignant pain: a 3-year prospective study, Pain, 2004;109:242–9.


US NEUROLOGY


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


23. Allen JW, Horais KA, Tozier NA, et al., Opiate pharmacology of intrathecal granulomas, Anesthesiology, 2006;105:590–8.


24. Duarte RV, Raphael JH, Southall JL, et al., Intrathecal inflammatory masses: is the yearly opioid dose increase an early indicator?, Neuromodulation, 2010;13:109–13.


25. Yaksh TL, Hassenbusch S, Burchiel K, et al., Inflammatory masses associated with intrathecal drug infusion: a review of preclinical evidence and human data, Pain Med, 2002;3:300–12.


26. Bowery NG, GABAB receptor pharmacology, Annu Rev Pharmacol Toxicol, 1993;33:109–47.


27. Olsen RW, Sieghart W, International Union of Pharmacology. LXX. Subtypes of gamma-aminobutyric acid(A) receptors: classification on the basis of subunit composition, pharmacology, and function. Update, Pharmacol Rev, 2008;60:243–60.


28. Hassenbusch SJ, Portenoy RK, Cousins M, et al., Polyanalgesic Consensus Conference 2003: an update on the management of pain by intraspinal drug delivery-report of an expert panel, J Pain Symptom Manage, 2004;27:540–63.


29. Lim J, Lim G, Sung B, et al., Intrathecal midazolam regulates spinal AMPA receptor expression and function after nerve injury in rats, Brain Res, 2006;1123:80–8.


30. Dureja GP, Usmani H, Khan M, et al., Efficacy of intrathecal midazolam with or without epidural methylprednisolone for management of post-herpetic neuralgia involving lumbosacral dermatomes, Pain Physician, 2010;13:213–21.


31. Borg PA, Krijnen JH, Long-term intrathecal administration of midazolam and clonidine, Clin J Pain, 1996;12:63–8.


32. Shih A, Miletic V, Miletic G, et al., Midazolam administration reverses thermal hyperalgesia and prevents gamma- aminobutyric acid transporter loss in a rodent model of neuropathic pain, Anesth Analg, 2008;106:1296–302.


33. Asiedu M, Ossipov MH, Kaila K, et al., Acetazolamide and midazolam act synergistically to inhibit neuropathic pain, Pain, 2010;148:302–8.


34. Yaksk TL, Allen JW, The use of intrathecal midazolam in humans: a case study of process, Anesth Analg, 2004;98:1536–45.


35. Ugur B, Basalogu K, Yurtseven T, et al., Neurotoxicity with a single dose of intrathecal midazolam administration, Eur J Anaesthesiol, 2005;22:907–12.


36. Bahar M, Cohen ML, Grinshpon Y, et al., Spinal anaesthesia with midazolam in the rat, Can J Anaesth, 1997;44:208–15.


37. Tucker AP, Lai C, Nadeson R, et al., Intrathecal midazolam. I. A cohort study investigating safety, Anesth Analg, 2004;98:1512–20.


38. van Hilten BJ, van de Beek WT, Hoff JI, et al., Intrathecal baclofen for treatment of dystonia in patients with reflex sympathetic dystrophy, N Engl J Med, 2000;343:625–30.


39. Zuniga RE, Perera S, Abram SE, Intrathecal baclofen: a useful agent in the treatment of well-established complex regional pain syndrome, Reg Anesth Pain Med, 2002;27:90–3.


40. Herman RM, D’Luzansky SC, Ippolito R, Intrathecal baclofen suppresses central pain in patients with spinal lesions. A pilot study, Clin J Pain, 1992;8:338–45.


41. Taira T, Kawamura H, Tanikawa T, et al., A new approach to control central deafferentation pain: spinal intrathecal baclofen, Stereotact Funct Neurosurg, 1995;65:101–5.


42. Zuniga RE, Schlicht CR, Abram SE, Intrathecal baclofen is analgesic in patients with chronic pain, Anesthesiology, 2000;92:876–80.


43. Lind G, Meyerson BA, Winter J, et al., Intrathecal baclofen as adjuvant therapy to enhance the effect of spinal cord stimulation in neuropathic pain: a pilot study, Eur J Pain, 2004;8:377–83.


44. Schrechtmann G, Lind G, Winter J, Intrathecal clonidine and baclofen enhance the pain-relieving effect of spinal cord stimulation: a comparative placebo-controlled, randomized trial, Neurosurgery, 2010;67:173–81.


45. Denys P, Mane M, Azouvi P, Side effects of chronic intrathecal baclofen on erection and ejaculation in patients with spinal cord lesions, Arch Phys Med Rehabil, 1998;79:494–6.


46. Krames ES, Gershow J, Glassberg A, et al., Continuous infusion of spinally administered narcotics for the relief of pain due to malignant disorders, Cancer, 1985;56:696–702.


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


48. Osenbach R, Intrathecal drug delivery in the management of pain. In: Fishman S (ed.), Bonica’s Management of Pain, 4th ed, Philladelphia, PA, US: Lippincott Williams and Wilkins, 2010:1437–58.


49. Nitescu P, Dahm P, Appelgren L, Continuous infusion of opiod and bupivacaine by externalized intrathecal catheters in long-term treatment of “refractory” nonmalignant pain, Clin J Pain, 1998;14:17–28.


50. Krames ES, Lanning RM, Intrathecal infusion analgesia for nonmalignant pain: analgesic efficacy of intrathecal opiod with or without bupivacaine, J Pain Symptom Manage, 1993;8:539–48.


51. Deer TR, Caraway DL, Kim CK, et al., Clinical experience with intrathecal bupivacaine in combination with opiod for the treatment of chronic pain related to failed back surgery syndrome and metastatic cancer pain of the spine, Spine J, 2002;2:274–8.


52. Vanegas H, Schaible H, Effects of antagonists to high-threshold calcium channels upon spinal mechanisms of pain, hyperalgesia and allodynia, Pain, 2000;85:9–18.


53. McGivern JG, Targeting N-type and T-type calcium channels for the treatment of pain, Drug Discov Today, 2006;11:245–53.


54. Takasusuki T, Yaksh T, Regulation of spinal substance p release by intrathecal calcium channel blockade, Anesthesiology, 2011;115:153–64.


55. Rauck RL, Wallace MS, Burton AW, et al., Intrathecal ziconotide for neuropathic pain: a review, Pain Practice, 2009;9:327–37.


56. Staats PS, Yearwood T, Charapata SG, et al., Intrathecal zico notide in the treatment of refractory pain in patients with cancer or AIDS: a randomized controlled trial, JAMA, 2004;291:63–70.


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


58. Raffaeli W, Sarti D, Demartini L, et al., Italian registry on long- term intrathecal ziconotide treatment, Pain Physician, 2011;14:15–24.


59. Wallace MS, Kosek PS, Staats P, et al., Phase II, open-label, multicenter study of combined intrathecal morphine and ziconotide: addition of ziconotide in patients receiving intrathecal morphine for severe chronic pain, Pain Medicine, 2008;9:271–81.


60. Michiels WB, McGlthlen GL, Platt BJ, et al., Trigeminal neuralgia relief with intrathecal ziconotide, Clin J Pain, 2011;27:352–4.


61. Lux EA, Rasche D, Experience in treatment of patients with neuropathic facial pain using ziconotide, Schmerz, 2011;25:434–9.


62. Lux EA, Case report: successful treatment of a patient with trigeminal neuropathy using ziconotide, Anesth Analg, 2010;110:1195–7.


63. Kamibayashi T, Maze M, Clinical use of alpha 2-adrenergic 161


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