The guiding light of all approaches to
analgesia should lead to the goal of pain relief with functional
restitution. As soon as conventional treatment with opioids and
adjuvant drugs is found to be unsuccessful for a patient with chronic
pain, and side effects have been treated or avoided through opioid
sequential trials, then alternative delivery sources should be
considered. Neuraxial analgesia (comprising both epidural and
intrathecal drug delivery), with either a single agent or a
combination of drugs, may allow the patient to achieve relief from
intractable pain where opioid analgesia alone has its limits.
The discovery of the analgesic effects
of neuraxial opioids, alkaloids, and peptides has led to the expanded
use of regional anesthesia in long-term analgesic delivery systems.
Today the choices of analgesic agents include opioids,
alpha-2-agonists, intrathecal (IT) SNX-111, and local anesthetic
agents; additional agents will certainly be added in the future. In
this context, the clinician will always be faced with a decision of
who, when, what, and how to manage the patient with intractable
noncancer pain. Patient selection, device selection, and route of
delivery are and will likely continue to be the key questions.
This Clinical Update will describe
the options for neuraxial analgesia for patients with intractable
pain. We will include discussions of drug choices and pharmacology,
patient selection, and optimization of conservative therapy. We will
explore issues of delivery routes and device selection and provide
insights into identification and treatment of side effects and
complications. We will present off-label uses of various agents that
have undergone animal spinal cord toxicity studies, and discuss the
literature supporting the use of these agents in the neuraxial spaces.
