An Intrathecal Pump Misadventure in Two Acts: An Unrecognized Partial Pocket Fill Followed by an Unusual Withdrawal Syndrome Two Months Later.

We present a case of a patient with an intrathecal pump who experienced an unrecognized partial pocket fill, leading to an atypical opioid withdrawal characterized by akathisia. A 57-year-old female with multiple myeloma presented to an emergency department with new-onset akathisia requiring admission. Eight weeks prior, her intrathecal pump was refilled with morphine, bupivacaine, and ziconotide.

The Polyanalgesic Consensus Conference (PACC)®: Updates on Clinical Pharmacology and Comorbidity Management in Intrathecal Drug Delivery for Cancer Pain.

Introduction: The International Neuromodulation Society convened a multispecialty group of physicians based on expertise with international representation to establish evidence-based guidance on using intrathecal drug delivery in chronic pain treatment. This Polyanalgesic Consensus Conference (PACC)® project's scope is to provide evidence-based guidance for clinical pharmacology and best practices for intrathecal drug delivery for cancer pain.

Materials And Methods: Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature.

Optimization of Radiofrequency Needle Placement in Percutaneous Cordotomy Using Electromyography in the Deeply Sedated Patient.

Background And Objectives: Cordotomy, the selective disconnection of the nociceptive fibers in the spinothalamic tract, is used to provide pain palliation to oncological patients suffering from intractable cancer-related pain. Cordotomies are commonly performed using a cervical (C1-2) percutaneous approach under imaging guidance and require patients' cooperation to functionally localize the spinothalamic tract. This can be challenging in patients suffering from extreme pain.

Antiplatelet and Wound Healing Implications of Immunotherapy and Targeted Cancer Therapies in the Perioperative Period.

The traditional paradigm of oncologic treatment centered on cytotoxic chemotherapy has undergone tremendous advancement during the last 15 yr with the advent of immunotherapy and targeted cancer therapies. These agents, including small molecule inhibitors, monoclonal antibodies, and immune-checkpoint inhibitors, are highly specific to individual tumor characteristics and can prevent cell growth and tumorigenesis by inhibiting specific molecular targets or single oncogenes. While generally better tolerated than traditional chemotherapy, these therapies are associated with unique constellations of adverse effects.

Controversies in intrathecal drug delivery for cancer pain.

Pain and suffering related to cancer are challenging issues that continue to deserve consideration for treatment optimization. Advances in analgesic management and control of the underlying cancer have improved symptom management, yet many patients still suffer from uncontrolled pain. Intrathecal drug delivery has an established role in the management of refractory cancer pain, but there are significant knowledge gaps in our understanding and application of this therapy.

Dorsal Versus Ventral Intrathecal Catheter Tip Location and Effect on Dose Escalation and Opioid Use in Patients With Cancer Pain.

Objectives: In the practice of intrathecal drug delivery, consensus exists regarding the cephalad to caudad location of the catheter tip relative to dermatomal distribution of pain. However, data are lacking on the importance of dorsal vs ventral tip location relative to the spinal cord. We hypothesize that a dorsally placed catheter tip improves efficacy because of closer proximity to nociceptive pathways.

Management of Cancer-Related Pain With Intrathecal Drug Delivery: A Systematic Review and Meta-Analysis of Clinical Studies.

Background: Despite increased attention paid to assessment and management, pain continues to be a prevalent and undertreated symptom in patients with cancer. Intrathecal drug delivery (IDD) is a therapeutic option that allows targeted delivery of analgesics to the intrathecal space.

Objective: The aim of this review was to examine the efficacy of managing cancer-related pain with IDD.

Initial Intrathecal Dose Titration and Predictors of Early Dose Escalation in Patients With Cancer Using a 100:1 Oral to Intrathecal Morphine Conversion Ratio.

Objective: Pain is common in patients with advanced cancer, and intrathecal drug delivery (IDD) has been successfully used for recalcitrant pain. We report on our experience using a 100:1 oral-to-intrathecal morphine conversion ratio for initial dosing and factors predictive of early dose escalation.

Materials And Methods: Retrospective review of an intrathecal drug delivery system (IDDS) data base at the Huntsman Cancer Institute-University of Utah in cancer patients initiated on IDD with morphine or hydromorphone.

The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain.

Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data.

Quantitative Assessment of the Incidence of Persistent Orthostatic Hemodynamic Changes After Celiac Plexus Neurolysis: A Prospective Case Series.

Celiac plexus neurolysis has been associated with orthostatic hypotension but has not been quantified prospectively or evaluated for persistence after the immediate postprocedural period. Our objective was to quantify persistent hemodynamic changes induced by celiac plexus neurolysis. In this case series of 16 patients with cancer, 8 (50%) had orthostatic hypotension alone, 3 (18.

Dye-Sensitized Nonstoichiometric Strontium Titanate Core-Shell Photocathodes for Photoelectrosynthesis Applications.

A core-shell approach that utilizes a high-surface-area conducting core and an outer semiconductor shell is exploited here to prepare p-type dye-sensitized solar energy cells that operate with a minimal applied bias. Photocathodes were prepared by coating thin films of nanocrystalline indium tin oxide with a 0.8 nm AlO seeding layer, followed by the chemical growth of nonstoichiometric strontium titanate.

The Effect of Measured Radiotherapy Dose on Intrathecal Drug Delivery System Function.

Objectives: Radiation therapy (RT) and intrathecal drug delivery systems (IDDS) are often used concurrently to optimize pain management in patients with cancer. Concern remains among clinicians regarding the potential for IDDS malfunction in the setting of RT. Here we assessed the frequency of IDDS malfunction in a large cohort of patients treated with RT.

Initiation of Intrathecal Drug Delivery Dramatically Reduces Systemic Opioid Use in Patients With Advanced Cancer.

Objectives: Pain is common in cancer, affecting more than 70% of patients with advanced disease. Intrathecal drug delivery systems (IDDS) are a well-established treatment for patients with refractory cancer pain, improving pain control and reducing associated side effects. To date, details of systemic opioid use before and after IDDS implant have not been reported.

The Rate of Infectious Complications After Intrathecal Drug Delivery System Implant for Cancer-Related Pain Is Low Despite Frequent Concurrent Anticancer Treatment or Leukopenia.

Background: The efficacy of intrathecal drug delivery (IDD) for cancer-related pain is well established. Cancer therapies are often associated with immunosuppression and increased risk of infection, and the rate of infection after intrathecal drug delivery system (IDDS) implant in cancer patients has been reported as 2.4%-6.

Prospective Association of Serum Opioid Levels and Clinical Outcomes in Patients With Cancer Pain Treated With Intrathecal Opioid Therapy.

Background: Opioids remain the mainstay of cancer pain management but are associated with systemic toxicity. In refractory cancer pain, intrathecal therapy (ITT) is associated with improved pain control, reduced systemic side effects, and improved survival. It has been assumed that ITT decreases systemic serum opioid levels and their associated toxicity, but there are limited data to support this assumption.

Pain therapeutics from cone snail venoms: From Ziconotide to novel non-opioid pathways.

There have been numerous attempts to develop non-opioid drugs for severe pain, but the vast majority of these efforts have failed. A notable exception is Ziconotide (Prialt®), approved by the FDA in 2004. In this review, we summarize the present status of Ziconotide as a therapeutic drug and introduce a wider framework: the potential of venom peptides from cone snails as a resource providing a continuous pipeline for the discovery of non-opioid pain therapeutics.

Tertiary Care Clinical Experience with Intravenous Lidocaine Infusions for the Treatment of Chronic Pain.

Objective: To evaluate the safety of and long-term pain relief due to intravenous lidocaine infusion for the treatment of chronic pain in a tertiary pain management clinic.

Design: Retrospective chart review.

Methods: Medical records were reviewed from 233 adult chronic pain patients who underwent one to three lidocaine infusions.

Interventional Treatments of Cancer Pain.

Pain is a significant burden for patients with cancer and is particularly prevalent among those with advanced cancer. Appropriate interventional cancer pain therapies complement conventional pain management by reducing the need for systemic opioid therapy and its associated toxicity; however, these therapies are often underutilized. This article reviews techniques, indications, complications, and outcomes of the most common interventional approaches for the management of cancer-related pain.

Prospective Observational Study of Patient-Controlled Intrathecal Analgesia: Impact on Cancer-Associated Symptoms, Breakthrough Pain Control, and Patient Satisfaction.

Background And Objectives: Although data exist for the efficacy of intrathecal therapy (ITT), there are no prospective data on patient-controlled intrathecal analgesia (PCIA) in refractory cancer pain. This study examines the effect of PCIA on cancer symptom scores, patient satisfaction, and analgesic efficacy with an emphasis on breakthrough pain (BTP).

Methods: Ninety-eight patients with refractory cancer pain prospectively completed questionnaires including the MD Anderson Symptom Inventory and a BTP survey before and after the implantation of an intrathecal pump.

A cost utilization analysis of intrathecal therapy for refractory cancer pain: identifying factors associated with cost benefit.

Objective: Intrathecal therapy (ITT) for cancer pain is characterized by high initial cost followed by low maintenance costs. Non-ITT pain management is associated with steadily increasing cumulative cost that can equal the cost of ITT over time. The intent of this modeling project is to identify factors associated with relatively rapid achievement of cost-benefit with ITT.

Patient-controlled intrathecal analgesia for the management of breakthrough cancer pain: a retrospective review and commentary.

Objective:   Intrathecal therapy (ITT) via an implanted pump has become an accepted practice for the treatment of refractory cancer pain by infusing opioids and adjuncts directly to the neuraxis. Until recently, only a programmed basal rate of infusion could be delivered, and therefore, breakthrough pain required ongoing use of oral or transmucosal opioids. Recently, an implanted pump manufacturer has introduced a handheld device to bolus additional medication for breakthrough pain.

Interventional therapies for the management of cancer pain.

Timely interventional cancer pain therapies complement conventional pain management by reducing the need for high-dose opioid therapy and its associated toxicity. All patients with upper abdominal visceral pain should be considered for celiac plexus neurolysis soon after diagnosis. Intrathecal therapy should be considered in any patient with moderate-to-severe pain despite a reasonable therapeutic trial of opioid pharmacotherapy or in any patient intolerant of opioid therapy.

Intrathecal therapy for the management of cancer pain.

Inadequately managed cancer pain continues to be a significant problem despite increased awareness, improved knowledge and understanding of pain pathophysiology, and standardized treatment guidelines of this distressing and debilitating symptom complex. Small subsets of patients who are refractory to optimal medical management because of drug toxicity or unsatisfactory analgesia may be candidates for exteriorized or implantable intrathecal drug delivery systems. By delivering opioids and other agents directly to the central nervous system, intrathecal drug administration can offer superior pain relief with less toxicity at a fraction of the systemic dose.