Abstract Title: Intrathecal analgesia for refractory pain

Authors: Mohammed Alhujairi, MD, FRCPC, Verdun, Quebec
Gerard Huni, MDCM, Montreal , Qc; David Bracco, MD, Montreal , Qc; Juan Francisco Asenjo, MD, Montreal , Qc

ABSTRACT BODY

Introduction:The WHO ladder for pain management in cancer is the corner stone in treating this symptom in oncology patients. Between 10 and 15% of them will experience significant side effects or will not achieve comfort with WHO-level III and coadjuvants. Interventional measures are required in this case to alleviate this group or to control their intolerable side effects. Intrathecal pain techniques are part of the armamentarium to conquer pain control. We report here our experience with intrathecal analgesia over the last five years.

Method:The charts from all patients that received prolonged intrathecal analgesia over the last five years (June 2004 to December 2009) were reviewed and the data was collected. Demographic and medical information pertinent to the implant of an intrathecal device was examined.We focused our interest in pain control, decrease in opioid requirements and their side effect, quality of life and complications of intrathecal catheter placement or its infusion solution, immediately post implant, 2-4 weeks, 6-8 weeks and 20-24 weeks after the procedure

Results:Between 2004 and 2009, 2173 pain procedures were done by a senior author, of those procedures 51 cases had an intrathecal catheter or pump placed. 49 cases were related to advanced cancer, one for a phantom limb pain and another for failed back surgery syndrome
All catheters were successfully implanted without complications related to the procedure. No catheter/reservoir related complication was recorded during the period in use. In the first 24 hours intrathecal therapy improved pain scores by 5 to 10 points (VAS 0-10) in 76% of the patients. At 6-8 weeks follow-up, 40% had total pain relief and an additional 52% had 5 points or more improvement. Only one patient out of 51 did not improve following intrathecal analgesic administration. In all other patients the pain decreased from 7 to 10 before the intervention to 5 or less at 6-8 weeks or last follow-up. 46% of patients had a quality of life improvement of 100% and another 48% of patients improved by 50% or more at 2-4 weeks. At 2-4 weeks the opioid requirement decreased by a median of 80%. At 2-4 weeks, 82% were opioid side-effects free. Side effects of intrathecal medication were transient lasting 1 to 3 days. Only one patient exhibit an unclear lower limb weakness, lasting 3 months possibly due to a combination of disease related deconditioning and local anesthetic effect

Discussion
Refractory pain in palliative patients can be well controlled with intrathecal medication. This route significantly improved quality of life, decreased narcotic consumption and it’s related side effects. Intrathecal medication side effects were uncommon and transient in this series.
Since the advent of implantable IT drug delivery systems over 25 years
ago, numerous advances have been made with regard to system technology,pharmacology, and patient selection. Whereas strong evidence exists for the use of IT therapy for cancer pain, the evidence supporting long-term efficacy in noncancer pain is less convincing. However, in carefully selected patients
The results presented here are encouraging and the palliative care team in our institution have been very interested and supportive of collaborating with us.

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Reg Anesth Pain Med 2010; 48