Narrative review of intrathecal drug delivery (IDD): indications, devices and potential complications

Abstract

The management of chronic refractory pain (non-neoplastic and cancer-related pain) remains a therapeutic challenge. The continuous intrathecal (IT) administration of drugs may play an important role in the possible management options. Intrathecal drug delivery devices (IDDDs) may be effective for patients with refractory chronic pain. Therefore, they may be adopted for non-oncologic pain in patients with compression fractures, spondylolisthesis, spondylosis, back surgery failure syndrome and spinal stenosis.Oncologic patients can benefit from these treatments in a variable way according to tumor characteristics, prognosis, periprocedural imaging and risk of disease progression. In this review, we describe the most commonly used drugs (opioids and non-opioids), their pharmacokinetic and pharmacodynamic features and indications of use. The most used drugs are morphine, hydromorphone, fentanyl, methadone, bupivacaine, clonidine, and ketamine. Patient evaluation before the device implantation should be based on clinical examination, medical records assessment and psychometric evaluation. The infusion pumps available on the market are both non-programmable (with continuous IT deliver of drugs) and programmable (with variable deliver of drugs according to their flow rate). Moreover, we describe the procedure of implantation and the potential complications of IT drug delivery (such as bleeding, infection, loss of cerebrospinal fluid, wound seroma, loss of catheter pump propellant).

Ion elemental-optimized layered double hydroxide nanoparticles promote chondrogenic differentiation and intervertebral disc regeneration of mesenchymal stem cells through focal adhesion signaling pathway

“…Current treatments for disc degeneration can be divided into conservative treatment and surgery. When conservative treatment methods, such as physical therapy, drug treatment, and epidural steroid injection fail, surgical intervention involving vertebral fusion is needed to reduce pain and other symptoms by limiting the movement of the diseased segment of the vertebral body [ 8 , 10 ]. However, the decreased activity of the vertebral body will accelerate the degenerative changes of the adjacent disc [ 9 , 41 ].…”

“…Clinically, low back pain and symptoms of nerve root compression caused by IDD seriously affects the quality of life in patients, which affected 80% people at least once in their life [ 6 , 7 ]. Current IDD therapeutic strategies include artificial IVD replacement and transplantation of autologous and allogeneic materials transplantation, while neither of these strategies could reverse the pathological state of IDD [ [8] , [9] , [10] ].…”

Hemodynamic molecular imaging of tumor-associated enzyme activity in the living brain

“…Here, we used an intra-CSF infusion method that permits relatively low injected doses of the contrast agent to spread over wide fields of view inside the rat brain, but not the periphery. This mode of delivery is similar to clinically applied intrathecal injection methods ( Capozza et al, 2021 ; Fowler et al, 2020 ), and with optimization would not require cranial surgery. In the future, even less invasive delivery routes could also be accessible, however, for instance by conjugating FAPVap to blood–brain barrier-permeating carrier proteins such as anti-transferrin receptor antibodies and then injecting the conjugates intravascularly ( Pardridge, 2017 ).…”

Best Practices for Minimally Invasive Lumbar Spinal Stenosis Treatment 2.0 (MIST): Consensus Guidance from the American Society of Pain and Neuroscience (ASPN)

“… 110 Similar to spinal cord stimulation, IDDS is specifically recommended for patients who are experiencing moderate-to-severe pain of the trunk and limbs after other modalities of pain treatment have failed. 111 While neuromodulation has replaced IDDS in the algorithm for the treatment of many complex pain conditions, the following disease conditions are currently recognized as indications: nonsurgical axial spine pain, postlaminectomy syndrome, abdominal/pelvic pain, extremity pain, complex regional pain syndrome type I and II, thoracic neuropathic/trunk pain, cancer pain, and pain where successful treatment by systemic opioids is limited by side effects. 109 While patients with chronic malignant pain have been more extensively studied, recent evidence demonstrates efficacy for patients with nonmalignant pain conditions.…”