Intrathecal pain management: a team-based approach

Adler, Jeremy A.; N, Lotz

doi:10.2147/jpr.s142147

Cited by 16 publications

(18 citation statements)

References 62 publications

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“…6 Concerns regarding complications impede the further dissemination of IMITPP. 22,27 Although intrathecal morphine infusion therapy reduces the incidence of the adverse advents caused by systemic opioids due to high morphine concentrations at the site of action, several operative and drug-related complications may arise after implantation. 3,4 As compared to intrathecal morphine infusion therapy via an implanted morphine pump, disadvantages of IMITPP in operative complications are infection and the possibility of inadvertent catheter dislodgement or removal, which could be avoided by careful maintenance and was not observed in this study.…”

Section: Discussionmentioning

confidence: 99%

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<p>Intrathecal Morphine Infusion Therapy via a Percutaneous Port for Refractory Cancer Pain in China: An Efficacy, Safety and Cost Utilization Analysis</p>

Qin¹,

Li²,

Liu³

et al. 2020

JPR

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Purpose: Intrathecal morphine infusion therapy via a percutaneous port (IMITPP) has been used widely for its relatively low initial cost. However, there is scarce knowledge about IMITPP. In this study, we sought to evaluate efficacy, complications, and the interval required to achieve the cost equivalence of IMITPP in patients with refractory cancer pain in China. Patients and Methods: A retrospective chart review was conducted on cancer patients who had received IMITPP at our hospital between April 2017 and April 2019. Data from the numeric pain rating scale and Karnofsky performance scores, and complications and costs related to IMITPP were collected from medical records. Daily analgesic costs before and after IMITPP were calculated based on the doses of opioids on admission and at discharge, respectively. The doses of systemic opioids before IMITPP were stratified into very high doses [VHD, oral morphine equivalent dose (OMED) >599 mg/day], high doses (HD, 300 mg/day ≤ OMED ≤ 599 mg/day), and regular doses (RD, OMED < 300 mg/day). Results: Intrathecal morphine infusion therapy via a percutaneous port provided significant pain relief, but impaired activities of daily living in patients with refractory cancer pain. The commonly reported complications included nausea/vomiting and urinary retention, most of which were managed with symptomatic therapies. The median interval required to achieve cost equivalence was 11.44 months. The median intervals of VHD group and HD group were significantly shorter than that of RD group. Conclusion: Intrathecal morphine infusion therapy via a percutaneous port provided effective cancer pain management without causing serious complications. Patients with higher doses of systemic opioids would economically benefit from IMITPP in a shorter time.

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Section: Discussionmentioning

confidence: 99%

“…We considered diarrhea as a gastrointestinal withdrawal symptom associated with systemic opioids withdrawal in the two patients. 27 Additional studies examining factors associated with risks of gastrointestinal withdrawal symptom are required.…”

Section: Discussionmentioning

confidence: 99%

<p>Intrathecal Morphine Infusion Therapy via a Percutaneous Port for Refractory Cancer Pain in China: An Efficacy, Safety and Cost Utilization Analysis</p>

Qin¹,

Li²,

Liu³

et al. 2020

JPR

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“…21,23 Previous observations demonstrate that N-type VDCCs blockers result in analgesia in a range of pain models, 17,31,55 and ziconotide, the first-choice compound among ω-CTX analogues, is in clinical use as an intrathecal medication for chronic pain in the United States. 1,2 Of note, a direct block of N-type Ca 2+ channels, as that achieved by ziconotide or ω-CTXs, is associated with serious side effects (psychological and neuropsychiatric symptoms including depression, cognitive impairment, and hallucinations; anxiety; panic attacks; ataxia; asthenia; headache; and dysesthesia). 35 Interestingly, an "indirect" VDCC modulation as that accomplished by A 3 AR activation could represent a suitable approach to pain control without adverse side effects.…”

Section: Discussionmentioning

confidence: 99%

Adenosine A3 receptor activation inhibits pronociceptive N-type Ca2+ currents and cell excitability in dorsal root ganglion neurons

Coppi

Cherchi

Fusco

et al. 2019

Pain

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Recently, studies have focused on the antihyperalgesic activity of the A 3 adenosine receptor (A 3 AR) in several chronic pain models, but the cellular and molecular basis of this effect is still unknown. Here, we investigated the expression and functional effects of A 3 AR on the excitability of small-to medium-sized, capsaicin-sensitive, dorsal root ganglion (DRG) neurons isolated from 3-to 4-week-old rats. Real-time quantitative polymerase chain reaction experiments and immunofluorescence analysis revealed A 3 AR expression in DRG neurons. Patch-clamp experiments demonstrated that 2 distinct A 3 AR agonists, Cl-IB-MECA and the highly selective MRS5980, inhibited Ca 2+ -activated K + (K Ca ) currents evoked by a voltage-ramp protocol. This effect was dependent on a reduction in Ca 2+ influx via N-type voltage-dependent Ca 2+ channels, as Cl-IB-MECA-induced inhibition was sensitive to the N-type blocker PD173212 but not to the L-type blocker, lacidipine. The endogenous agonist adenosine also reduced N-type Ca 2+ currents, and its effect was inhibited by 56% in the presence of A 3 AR antagonist MRS1523, demonstrating that the majority of adenosine's effect is mediated by this receptor subtype. Current-clamp recordings demonstrated that neuronal firing of rat DRG neurons was also significantly reduced by *

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“…Other clinical factors that have been reported to influence outcomes include duration of symptoms (duration less than 3 months is associated with better outcomes), present functional status, socio-economic status, psychological factors like depression and anxiety, and sleep quality. 19,70,71 Kanna et al 36 reported that clinical factors including significant sensory symptoms, high mean pre-injection ODI score, high mean post-injection score at 3 weeks, and white-collar employment were associated with poor outcomes following SNRB.…”

Section: Prognostic Indicatorsmentioning

confidence: 99%

Role of transforaminal epidural injections or selective nerve root blocks in the management of lumbar radicular syndrome - A narrative, evidence-based review

Viswanathan

Kanna

Farhadi

2020

Journal of Clinical Orthopaedics and Trauma

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Objective: Lumbar radicular Syndrome (LRS) is a common spinal pathology and is attributed to complex interplay of mechanical, inflammatory and immunological processes. Epidural injection of steroids has a significant therapeutic role in mitigating the inflammatory component of LRS. Trans-foraminal approach under image guidance enables a targeted drug delivery. The current narrative review discusses the various aspects related to lumbar trans-foraminal epidural injection of steroid (LTFIS). Methods: An elaborate search on PubMed, Google and Medline databases was made using keywords "lumbar selective nerve root block", "lumbar trans-foraminal epidural steroid injection", "selective nerve root block in lumbar disc prolapse", "trans-foraminal epidural steroid injection in lumbar prolapse", "selective nerve root block in lumbar radiculopathy", and "trans-foraminal epidural steroid injection in lumbar radiculopathy" The articles were selected based on specific inclusion criteria. Results: Our search identified 539 articles. All articles discussing alternate procedures, LTFIS in other pathologies, diagnostic roles of LTFIS, not pertaining to concerned questions, in non-English language and duplicate articles were excluded. Review articles, randomised controlled trials or level 1 studies were given preference. Overall, 108 articles were included. Being a focussed narrative review, further screening [Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) or Methodological Index for non-randomized studies (MINORS) criteria] was not performed to select articles. Based on the evidence, LTFIS is an effective and useful treatment modality. It is offered to patients with lumbar disc herniation (LDH) presenting with persistent, unilateral, radiculopathy after a course of conservative measures for around 6 weeks' duration. It has been reported to yield better results than caudal or interlaminar epidural injections. The anti-inflammatory and nociceptive signal stabilization actions of steroids, as well as mechanical effects of washout of inflammatory mediators and neural lysis contribute to its efficacy. The three different approaches include sub-pedicular, retro-neural and retro-discal. The procedure is performed under image guidance using a water-soluble contrast under fluoroscopy. The four described radiculogram patterns include "arm", "arrow", "linear" and "splash". Computerised tomography, ultrasonography and magnetic resonance imaging are other modalities, which may be helpful in performing LTFIS. The use of particulate versus non-particulate steroids is controversial. Conclusion:The overall success rate of SNRB is reported to be 76e88%. The majority of benefits are observed during immediate and early post-injection period. Clinical factors including duration and severity of symptoms, and radiological factors like presence of osteophytes, location, size and type of disc prolapse influence outcomes. The radiculogram "splash" pattern is associated with poor outcomes.

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Intrathecal pain management: a team-based approach

Cited by 16 publications

References 62 publications

<p>Intrathecal Morphine Infusion Therapy via a Percutaneous Port for Refractory Cancer Pain in China: An Efficacy, Safety and Cost Utilization Analysis</p>

<p>Intrathecal Morphine Infusion Therapy via a Percutaneous Port for Refractory Cancer Pain in China: An Efficacy, Safety and Cost Utilization Analysis</p>

Adenosine A3 receptor activation inhibits pronociceptive N-type Ca2+ currents and cell excitability in dorsal root ganglion neurons

Role of transforaminal epidural injections or selective nerve root blocks in the management of lumbar radicular syndrome - A narrative, evidence-based review

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