High thoracic/low cervical, long-term intrathecal (i.t.) infusion of bupivacaine alleviates "refractory" pain in patients with unstable angina pectoris. Report of 2 cases

Intrathecal cervical analgesia for cancer pain: a 12-year follow-up study in a comprehensive cancer center

BACKGROUND

Intrathecal analgesia plays a key role for patients suffering refractory cancer pain. Nevertheless, intrathecal drug delivery systems (IDDS), requiring a cervical catheter tip implantation, have been poorly described in medical literature.

AIMS

A monocentric retrospective follow-up study was designed to evaluate results of cervical IDDS for cancer pain.

PATIENTS AND METHODS

From January 2010 to December 2022, all intrathecal-treated patients were prescribed a combined intrathecal analgesics regimen through a catheter placed in the cervical vertebral canal. Post-implant assessment of pain was determined using a numeric rating scale (NRS). Patients were followed via day-hospital visits and telephone calls at least monthly. Pain scores were compared using the Wilcoxon's signed rank test.

RESULTS

Ninety-eight patients were included in this study; all received intrathecal treatments. Implanted patients suffered from severe pain (mean presurgical maximum numerical rating score 8.02±0.24 despite a mean 562.56±127.72 mg of oral morphine equivalent daily dose). Mean survival time after intrathecal treatment start was 208.48±67 days. Intrathecal drug delivery systems provided pain relief compared with initial pain score with a significant statistical difference after 1 week, 1 month, 2 and 3 months (p<0.01). A 50% reduction in initial pain level was achieved in 93% of cases during the first week of intrathecal implant.

CONCLUSIONS

Results suggest that long-term intrathecal treatment using a multidrug regimen for cancer-related pain through cervical intrathecal catheters was suitable and safe in our study population. We demonstrated a clinically and statistically significant pain reduction in patients using mainly a percutaneous lumbar approach.

Use of a continuous, local infusion of bupivacaine for postoperative analgesia in dogs undergoing total ear canal ablation

OBJECTIVE

To determine whether addition of a continuous, local infusion of bupivacaine would improve postoperative analgesia in dogs undergoing total ear canal ablation.

DESIGN

Randomized controlled trial.

ANIMALS

16 dogs undergoing total ear canal ablation (12 unilaterally and 4 bilaterally with > 1 month between procedures).

PROCEDURE

Dogs were randomly allocated to receive morphine (0.25 mg/kg [0.11 mg/lb]) at the end of the procedure (10 procedures) or morphine and a continuous, local infusion of bupivacaine (0.13 to 0.21 mg/kg/h [0.06 to 0.1 mg/lb/h]; 10 procedures). Dogs were observed for 48 hours after surgery. Additional doses of morphine were administered up to every 4 hours in dogs with signs of severe pain.

RESULTS

Temperament, sedation, analgesia, and cumulative pain scores were not significantly different between groups any time after surgery. Recovery score was significantly higher for dogs that received bupivacaine than for control dogs 2 hours after extubation but not at any other time. Serum cortisol concentration was not significantly different between groups at any time but, in both groups, was significantly increased at the time of extubation, compared with all other observation times. Total number of additional doses of morphine administered was not significantly different between groups. Bupivacaine was not detected in the plasma of any of the dogs that received the local bupivacaine infusion.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that addition of a continuous, local infusion of bupivacaine did not significantly increase the degree of postoperative analgesia in dogs that underwent total ear canal ablation and were given morphine at the end of surgery.

Microcatheterization of the cervical epidural space via lumbar puncture: technical note

OBJECTIVE

Deposition of opiates, corticosteroids, or local anesthetics into the epidural space is useful for the management of painful maladies of the cervical and thoracic spine. We describe a novel technique for epidural medication delivery via an angiographic microcatheter inserted at or below the conus and advanced cephalad under fluoroscopic guidance. Unlike commercial kits used by anesthesiologists, this method uses a radiopaque catheter that can be precisely targeted to the levels of interest. The hazards of direct puncture, such as "wet tap" or injury to the cervical cord, are minimized.

METHODS

An 18-gauge Tuohy needle is inserted into the lumbar epidural space. A 2.3-French microcatheter and a 0.018-inch steerable guidewire are then introduced through the lumen of the needle. The catheter is fluoroscopically advanced to the cervical epidural space, where Depo-Medrol (Pharmacia & Upjohn, Kalamazoo, MI) is administered. As the catheter is withdrawn, additional corticosteroid can be delivered to the thoracic epidural space, together with long-acting morphine compounds or local anesthetics. Regional pressures within the epidural space and other physiological parameters can be measured, and the local microenvironment can be sampled.

RESULTS

To date, we have performed 16 procedures for 13 patients. All patients reported improvement, of varying extent and duration. There have been no complications.

CONCLUSION

Our system of accessing the epidural space has many advantages, compared with direct puncture and commercially available kits. It provides a safe means of delivering epidural medication to multiple spinal levels and permits measurement of physiological variables that may be useful in the diagnosis and treatment of cervical and thoracic spine disease.