Skip to Main Content




The use of intrathecal opioids dates back to August 16, 1898, when August Bier and his assistant Hildebrandt performed “cocainization of the spinal cord” on each other. Unfortunately, Bier was also the first to describe the complication of postdural puncture headache from his personal experience. The mechanism of opioids on the spinal cord was later confirmed in a rat model.1 Subsequently, intrathecal medication has been widely utilized for both anesthesia and analgesia. The use of implantable intrathecal drug delivery systems began in the early 1980s and is now indicated for use in patients with persistent chronic pain of malignant and nonmalignant origin that are either refractory to maximal medical therapy or dose limited due to significant side effects, and has been demonstrated to have a better side effect profile than systemic opiates alone.2 In addition, non-narcotic medications that can have minimal analgesia when administered systemically can be very effective when administered intrathecally.3




  • Chronic intractable pain

  • Malignant and nonmalignant in origin

  • Refractory pain to maximal systemic medical therapy

  • Dose limiting side effect to systemic medical therapy

  • Intractable spasticity




  • Medications may be compounded to suit individual needs

  • Medications may be used individually or compounded in combination therapy

  • FDA approved and off-label medications (Table 68-1)

Table Graphic Jump Location
TABLE 68-1.List of Medications Used in Intrathecal Pumps. Currently the Only Three FDA Approved Medications are: Morphine, Baclofen, and Ziconotide. These Medications Can be Delivered Individually or Compounded for Combination Therapy (Deer et al, 2012)



The preferred catheter insertion site is below the conus medullaris, usually located at vertebral levels L1-L2 (Figure 68-1A). The catheter is anchored to the lumbodorsal fascia to prevent migration. The pump is usually placed in the left or right lower quadrant of the abdomen in the subcutaneous fat between the inferior costal margin and iliac crest. One may consider placing the pump in the subfacial space between the external and internal abdominal oblique muscles in the young and/or thin patients for decreased risk of wound breakdown and improved cosmesis (Figure 68-1B).

Figure 68-1.

(A) Anatomy for needle insertion. (B) Diagram illustrating the location of IT pump.

Graphic Jump Location Graphic Jump Location

Basic Prerequisites


  • Patient has tried and failed maximal systemic pain control


Want remote access to your institution's subscription?

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.


About MyAccess

If your institution subscribes to this resource, and you don't have a MyAccess profile, please contact your library's reference desk for information on how to gain access to this resource from off-campus.

Subscription Options

AccessAnesthesiology Full Site: One-Year Subscription

Connect to the full suite of AccessAnesthesiology content and resources including procedural videos, interactive self-assessment, real-life cases, 20+ textbooks, and more

$995 USD
Buy Now

Pay Per View: Timed Access to all of AccessAnesthesiology

24 Hour Subscription $34.95

Buy Now

48 Hour Subscription $54.95

Buy Now

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.