Ultrasound-guided bilateral quadratus lumborum block vs. intrathecal morphine for postoperative analgesia after cesarean section: a randomized controlled trial.

BACKGROUND: Adequate pain control after cesarean section (CS) is crucial for mothers caring for newborns, and early ambulation to avoid thromboembolism and chronic abdominal and pelvic pain. This randomized controlled trial compared the efficacy of quadratus lumborum block (QLB) and intrathecal morphine (ITM) for analgesia after CS. METHODS: Ninety women at ≥ 37 weeks pregnancy scheduled for elective CS were enrolled. All patients received spinal anesthesia and post-operative QLB. They were randomly allocated to Control (anesthesia: 0.1 ml saline, QLB: 24 ml saline), ITM (anesthesia: 0.1 mg morphine, QLB: 24 ml saline), or QLB groups (anesthesia: 0.1 ml saline, QLB: 24 ml 0.375% ropivacaine). Integrated analgesia score (IAS) and numerical rating scale (NRS) scores at rest and during movement, morphine requirements in the first 48 h, time to first morphine dose, and morphine-related side effects were recorded. RESULTS: IASs and NRS scores at rest and during movement were significantly lower in QLB and ITM group than in Control group. Moreover, IASs and NRS scores at rest and during movement were lower in QLB group than in ITM group. Time to first morphine dose was significantly longer in QLB group than in ITM and Control group. Furthermore, morphine requirements in the first 48 h were significantly lower in QLB group than ITM and Control group. Incidence of morphine-related side effects was significantly higher in ITM group than in QLB and Control group. CONCLUSIONS: QLB and ITM are effective analgesic regimens after CS. However, QLB provides better long-lasting analgesia and reduced total postoperative morphine consumption.

Characterization of Effect of Repeated Bolus or Continuous Intrathecal Infusion of Morphine on Spinal Mass Formation in the Dog.

BACKGROUND: We determined whether intrathecally delivering the same daily dose of morphine (MS) at a fixed concentration of 25 mg/mL by periodic boluses versus continuous infusion would reduce intrathecal mass (IMs) formation in dogs. METHODS: Adult dogs (hound cross, n = 32) were implanted with intrathecal catheters connected to SynchroMed II infusion pumps. Animals were randomly assigned to receive infusion of 0.48 mL/day of saline or MS dosing (12 mg/day at 25 mg/mL) as boluses: x1 (q24hour), x2 (q12hour), x4 (q6hour), or x8 (q3hour) given at the rate of 1000 µL/hour, or as a continuous infusion (25 mg/mL/20 µL/hour). RESULTS: With IT saline, minimal pathology was noted. In contrast, animals receiving morphine displayed spinally compressing durally derived masses with the maximal cross-sectional area being greatest near the catheter tip. Histopathology showed that IMs consisted of fibroblasts in a collagen (type 1) matrix comprised of newly formed collagen near the catheter and mature collagen on the periphery of the mass. The rank order of median cross-sectional mass area (mm2 ) was: Saline: 0.7 mm2 ; x2: 1.8 mm2 ; x4: 2.7 mm2 ; x1: 2.7 mm2 ; x8: 4.2 mm2 ; Continuous: 8.1 mm2 , with statistical difference from saline being seen with continuous (p < 0.0001) and x8 (p < 0.05). Bench studies with a 2D diffusion chamber confirmed an increase in dye distribution and lower peak concentrations after bolus delivery versus continuous infusion of dye. CONCLUSIONS: Using multiple bolus dosing, IMs were reduced as compared to continuous infusion, suggesting relevance of bolus delivery in yielding reduced intrathecal masses.

Effect of Long-Term Intrathecal Bupivacaine Infusion on Blood Pressure.

OBJECTIVES: The local anesthetic bupivacaine is a common analgesic adjuvant medication used in combination with opioids in intrathecal drug delivery systems (IDDSs). While the acute effects of spinal bupivacaine injection on blood pressure (BP) have been studied, there is a dearth of data regarding long-term effects of continuous intrathecal bupivacaine infusion. MATERIALS AND METHODS: A retrospective review of all noncancer pain patients receiving bupivacaine through IDDSs from January 2013 to November 2017 was performed. Blood pressure values before implantation, and after implant at the 1-week, 3-month, 6-month and 1-year time points are recorded as well as corresponding bupivacaine and opioid doses in the IDDS. RESULTS: Eighty-two patients were included in the study; median patient age was 64 years and intrathecal catheter tips were located predominantly in the lower thoracic spine. Significant decreases in systolic blood pressure (SBP) and mean arterial pressure (MAP) relative to baseline occurred in patients receiving chronic lower thoracic intrathecal bupivacaine delivery at 3, 6, and 12 months post-implant (-12.96 ± 18.21; p < 0.001 and - 6.38 ± 12.04; p < 0.001, respectively). The only significant decrease in DBP was observed at 1 year post-implant (-3.09 ± 11.76; p < 0.05). Similar decreases in BP values occurred in patients with or without hypertension. CONCLUSIONS: Long-term thoracic intrathecal infusion of bupivacaine likely exerts a lowering effect on BP, primarily because of a significant decrease in SBP. This effect is likely due to efferent sympathetic blockade by bupivacaine.

Conversion of Intrathecal Opioids to Fentanyl in Chronic Pain Patients With Implantable Pain Pumps: A Retrospective Study.

OBJECTIVES: Conversion between routes such as intravenous (IV), epidural (EP), and intrathecal (IT) routes for morphine is well established. Conversion ratios for IV:EP:IT fentanyl and conversion from IT morphine/hydromorphone to IT fentanyl have been challenging given the lipophilic nature of fentanyl. Our study reviews the outcomes and conversion ratios reached after converting IT opioids from morphine/hydromorphone to fentanyl in patients with IT pumps. METHODS: After Institutional Review Board approval at Henry Ford Health System, a chart review was performed on all patients who had Synchromed II IT pumps implanted 2009-2016 and were converted from morphine/hydromorphone to fentanyl. The chart review included the initial fentanyl dose and fentanyl IV:IT conversion ratio, eventual IT fentanyl dose, and IV:IT conversion ratio reached to give superior VAS from previous IT opioid. Wilcoxon non-paired signed rank test was used to examine the change in fentanyl dosage and IV:IT conversion ratio. RESULTS: The mean IT morphine equivalent dose at initial conversion was 15.8 mg/day, and the mean fentanyl IT starting dose was 0.73 mg/day (SD = 1.37 mg). The mean fentanyl dose at the end of titration was 0.94 mg/day (SD = 2.05 mg) which represented a significant 25.1% mean dose increase (P = 0.004). The initial mean IV:IT fentanyl conversion ratio was 38.7:1 (SD = 33.01), but the mean IV:IT fentanyl conversion ratio at end of titration with better analgesia was significantly lower at 32.9:1 (SD = 27.1) (P = 0.016). CONCLUSIONS: Given the pharmacokinetics of lipophilic fentanyl compared to hydrophilic morphine/hydromorphone, the current conversion ratio of IV fentanyl to IT fentanyl and IV morphine to IT fentanyl appears to be conservative.

The Development and Validation of a Quality Assessment and Rating of Technique for Injections of the Spine (AQUARIUS).

BACKGROUND AND OBJECTIVES: Systematic reviews evaluate the utility of procedural interventions of the spine, including epidural steroid injections (ESIs). However, existing quality assessment tools either fail to account for proper technical quality and patient selection or are not validated. We developed and validated a simple scale for ESIs to provide a quality assessment and rating of technique for injections of the spine (AQUARIUS). METHODS: Seven experts generated items iteratively based on prior ESI technique studies and professional judgment. Following testing for face and content validity, a 17-item instrument was used by 8 raters from 2 different backgrounds to assess 12 randomized controlled trials, selected from 3 different categories. Using frequency of assessment, a 12-item instrument was also generated. Both instruments underwent reliability (intraclass correlation coefficient), validity (ability to distinguish "low," "random," and "high" study categories), and diagnostic accuracy (receiver operating characteristics) testing. RESULTS: Both 17- and 12-item instruments were scored consistently by raters regardless of background, with overall intraclass correlation coefficients of 0.72 (95% confidence interval [CI], 0.53-0.89) and 0.71 (95% CI, 0.51-0.89), respectively. Both instruments discriminated between clinical trials from all 3 categories. Diagnostic accuracy was similar for the 2 instruments, with areas under receiver operating characteristic curves of 0.89 (95% CI, 0.82-0.96) and 0.90 (95% CI, 0.82-0.97), respectively. CONCLUSIONS: The instrument in both 17- and 12-item formats demonstrates good reliability and diagnostic accuracy in rating ESI studies. As a complement to other tools that assess bias, the instrument may improve the ability to evaluate evidence for systematic reviews and improve clinical trial design.

Manejo de la deprivación de altas dosis de morfina intratecal en el postoperatorio de paciente sometido a retirada de sistema intratecal por infección. Propuesta de manejo / No disponible

Los pacientes afectos de dolor crónico, portadores de sistemas de liberación de fármacos intratecales, actualmente plantean un desafío de manejo, cuando por razones perioperatorias, nos vemos obligados a interrumpir de forma brusca la administración de dichos fármacos, como el caso clínico que exponemos. en el mismo se aborda la problemática de contrarrestar los efectos de la deprivación de morfina a altas dosis intratecales en un paciente sometido a retirada del sistema intratecal, con una propuesta de manejo y los resultados clínicos observados (AU)

Patients with chronic pain disease, bearers of intrathecal dru release systems, currently pose a challenge of handling, when in the perioperative period, we are forced to discontinue the administration of such drugs, as the clinical case set out sharply. It addresses the problem of countering the effects of the deprivation of high dose of intrathecal morphine in a patient undergoing withdrawal of the intrathecal system, with a proposal for management and clinical outcomes observed (AU)

Management patterns in acute low back pain: the role of physical therapy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To evaluate the relationship between early physical therapy (PT) for acute low back pain and subsequent use of lumbosacral injections, lumbar surgery, and frequent physician office visits for low back pain. SUMMARY OF BACKGROUND DATA: Wide practice variations exist in the treatment of acute low back pain. PT has been advocated as an effective treatment in this setting although disagreement exists regarding its purported benefits. METHODS: A national 20% sample of the Centers for Medicare and Medicaid Services physician outpatient billing claims was analyzed. Patients were selected who received treatment for low back pain between 2003 and 2004 (n = 439,195). To exclude chronic low back conditions, patients were excluded if they had a prior visit for back pain, lumbosacral injection, or lumbar surgery within the previous year. Main outcome measures were rates of lumbar surgery, lumbosacral injections, and frequent physician office visits for low back pain during the following year. RESULTS: Based on logistic regression analysis, the adjusted odds ratio for undergoing surgery in the group of enrollees that received PT in the acute phase (<4 weeks) compared to those receiving PT in the chronic phase (>3 months) was 0.38 (95% confidence interval [CI], 0.360.41), adjusting for age, sex, diagnosis, treating physician specialty, and comorbidity. The adjusted odds ratio for receiving a lumbosacral injection in the group receiving PT in the acute phase was 0.46 (95% CI, 0.44-0.49), and the adjusted odds ratio for frequent physician office usage in the group receiving PT in the acute phase was 0.47 (95% CI, 0.44-0.50). CONCLUSION: There was a lower risk of subsequent medical service usage among patients who received PT early after an episode of acute low back pain relative to those who received PT at later times. Medical specialty variations exist regarding early use of PT, with potential underutilization among generalist specialties.

Intrathecal therapy for cancer and non-cancer pain.

BACKGROUND: Intrathecal drug infusion therapy is usually considered when spinal-acting analgesics or antispasmodics administered via the oral or transdermal routes fail to control patients' pain or are associated with unacceptable side effects. The intrathecal administration of centrally acting agents bypasses the blood-brain-barrier resulting in much higher cerebrospinal fluid (CSF) concentrations while using reduced amounts of medication to achieve equipotent doses. The intrathecal approach is associated with higher rates of satisfactory pain relief and lower rates of treatment failures and technical complications compared to the epidural route. A paucity of randomized controlled trials (RCTs) has led to concern regarding proper use, selection criteria, and safety of these devices. Cost effectiveness and comparative therapies have now also become a focus of discussion. OBJECTIVE: The purpose of this systematic review is to evaluate and update the available evidence for the efficacy and safety of intrathecal infusions used in long-term management (> 6 months) of chronic pain. This paper will not focus on intrathecal administration for spasticity or movement disorders. STUDY DESIGN: A systematic review of intrathecal infusion through implanted drug delivery devices for chronic pain. METHODS: Literature search through EMBASE, Medline, Cochrane databases, and systematic reviews as well as peer-reviewed non-indexed journals from 1980 to December 2010. Studies are assessed using the Agency for Healthcare Research and Quality (AHRQ) criteria for observational studies and the Cochrane Musculoskeletal Review Group criteria for randomized trials. The level of evidence was determined using 5 levels of evidence, ranging from Level I to III with 3 subcategories in Level II, based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). OUTCOME MEASURES: The primary outcome measure for chronic non-cancer is pain relief (short-term relief ≤ one-year and long-term > one-year), whereas it is 3 months for cancer. Secondary outcome measures of improvement in functional status, psychological status, return to work, and reduction in opioid intake. RESULTS: The level of evidence for this systematic review of non-cancer pain studies meeting the inclusion criteria of continuous use of an intrathecal drug delivery system (IDDS) for at least 12 months duration with at least 25 patients in the cohort, is Level II-3 based on USPSTF criteria. The level of evidence for this systemic review for cancer-related pain studies meeting the inclusion criteria of continuous use of IDDS for at least 3 months duration with at least 25 patients in the cohort is Level II-2 based on USPSTF criteria. CONCLUSION: Based on the available evidence, the recommendation for intrathecal infusion systems for cancer-related pain is moderate recommendation based on the high quality of evidence and the recommendation is limited to moderate based on the moderate quality of evidence from non-randomized studies for non-cancer related pain.

Administración de fármacos por vía intratecal, ¿un método seguro? / No disponible

No disponible

Evidence-based radiology (part 1): Is there sufficient research to support the use of therapeutic injections for the spine and sacroiliac joints?

INTRODUCTION: This review article addresses the best evidence currently available for therapeutic injection therapy for conditions targeting the spine and sacroiliac joints. The article is presented by spinal region. Controversies and areas of interest for further studies are identified. DISCUSSION: There is conclusive evidence supporting the effectiveness of the caudal approach for the administration of epidural steroid injections for patients with low back pain from a variety of causes. In general, there is moderate-to-strong evidence supporting the use of transforaminal therapeutic epidural injections for lumbar nerve-root compression and facet injections for joint pain arising from these joints in the cervical, thoracic and lumbar spine, but further subgroup analysis is needed to help predict which specific patients may receive the most benefit from these procedures. CONCLUSION: No randomized controlled trials, meta-analyses or systematic reviews addressing the effectiveness of therapeutic sacroiliac joint injections have been found. For some injections, corticosteroids may not provide better outcomes compared to local anesthetic injections alone.

Intrathecal therapy: what has changed with the introduction of ziconotide.

Administering drugs into the intrathecal space is becoming more popular in the treatment of patients with intractable pain or intolerable side effects of systemic analgesic treatments. Although morphine and ziconotide are the only intrathecal analgesics currently approved by regulatory authorities in the U.S. (Food and Drug Administration) and Europe (national-level approval by individual countries for morphine and European Agency for the Evaluation of Medicinal Products approval for ziconotide), a wide variety of opioid and non-opioid drugs are being used in this way. There is no official guidance concerning the selection of these drugs or their use in combinations and a paucity of efficacy and safety data from randomized controlled trials. The polyanalgesic initiative aims to summarize the current knowledge and to facilitate rational choices of intrathecal drug and drug combinations for the management of chronic pain. The most recent polyanalgesic consensus recommendations were published in 2007. In this review, we shall examine these recommendations, which are tailored toward those practicing intrathecal analgesia in the U.S., and discuss how they should be implemented in Europe, where the healthcare systems and regulations of the medical authorities are different.

Actualización en anestesia y analgesia epidural y subaracnoidea enadultos / Epidural and subarachnoid anesthesia and analgesia in adults: an update

Se presenta una puesta al día actualizada de los últimosavances en manejo clínico e imágenes de las técnicasneuroaxiales más utilizadas en la actualidad: anestesiay analgesia epidural, subaracnoidea y la combinadaespinal-epidural (AU)

We present an update of the latest advances in clinicalmanagement and images of the most commonly usedneuraxial techniques in epidural, subarachnoid, andcombined spinal-epidural anesthesia and analgesia (AU)

[Injection therapy of the spine without imaging]. / Injektionstherapie an der Wirbelsäule ohne Bildsteuerung.

Nerve root blocks and epidural perineural injections are main part in the conservative treatment of degenerative spine diseases. These injections should be done without imaging because degenerative spine diseases - discogenic oder spinal stenotic - tend to recurrence and danger arises from too many imaging with cumulative ionizing radiation over the years, especially in younger people. After certain training it is possible to perform spinal injections without imaging only considering topographic anatomical landmarks like in any other local anesthesia for surgical reasons. Repetitive periradicular injections desensitize the nerve root by local anesthetics and reduce its inflammatory swelling by steroids. The decompensated symptomatic deformity turns back into an asymptomatic compensated status.

Intrathecal chemotherapy for patients with meningeal carcinomatosis.

BACKGROUND: Meningeal carcinomatosis (MC) is increasing, and these patients have a poor prognosis. We analyzed the effects of intrathecal (IT) chemotherapy for these patients. METHODS: Patients received both methotrexate (MTX) (15 mg/m(2)) and prednisolone (10 mg/m(2)) 6 times in 2 weeks by Ommaya reservoir, along with cytosine arabinoside (10 mg/m(2)) for 4 doses of MTX. A cycle consisted of a 2-week period during which patients received these drugs and then 2 weeks off. Treatments were repeated 3 to 6 cycles depending on the clinical status. Cerebrospinal fluid (CSF) samples were also analyzed for cytology and a few markers. RESULTS: Of the 58 patients treated the most common tumor was lymphoma (30 patients), followed by lung and breast. Elevated soluble IL-2 receptor levels were observed in 23 of 30 patients with lymphomatous meningitis. Median survival of MC patients with malignant lymphoma, lung cancer, and breast cancer was 32.8 +/- 9.8, 13.0 +/- 4.1, and 18.4 +/- 7.4 months, respectively. Thus, the patients with lymphoma responded best, both by clearing the CSF and clinically. CONCLUSIONS: Our treatment regimen can improve the neurologic status of patients with MC. In particular, early IT chemotherapy can be effective for patients with lymphoma.

Intrathecal drug delivery 2002.

BACKGROUND: Intrathecal drug delivery has been used clinically since the 1970's. Significant clinical advances have been made combining new technology with pharmacology and surgery. Continuous infusion of medication for both analgesia and spasticity has become a part of the armamentarium for specialists in these areas. Significant recent advances in technology promise further enhancements and improvements for intrathecal therapy. METHODS: A review of the literature combined with 20 years personal experience with intrathecal drug delivery. FINDINGS/DISCUSSION: Intrathecal therapy has established a role in the treatment of malignant pain, benign pain and severe spasticity. Significant literature and the current state of practice in the United States are reviewed. Recent therapeutic enhancements are discussed, and a wish list of future technological enhancements presented.