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INTRODUCTION

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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

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INDICATIONS

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  • 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

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AVAILABLE MEDICATIONS

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  • 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)

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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)
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RELEVANT ANATOMY

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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).

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Figure 68-1.

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

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Basic Prerequisites

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  • Patient has tried and failed maximal systemic pain control

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