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Home Intrathecal analgesia: a targeted approach to the management of chronic pain

Intrathecal analgesia: a targeted approach to the management of chronic pain

The management of chronic and refractory pain is a major medical challenge. When conventional treatments show their limitations, certain more targeted approaches offer interesting alternatives. Intrathecal analgesia is based on the continuous administration of analgesics directly into the cerebrospinal fluid, using a pump implanted under the skin.
This technique is particularly indicated for chronic pain linked to cancer, as well as for certain types of pain that are resistant to conventional treatments. By enabling lower doses to be administered while maintaining optimal efficacy, it reduces the side effects of analgesics and improves pain relief.
Origins and progress of intrathecal analgesia

Pain information is conveyed by the sensory nerves, which converge on the spinal cord before being relayed to the brain centres responsible for analysing and perceiving it. When a drug is administered orally, dermally or through the bloodstream, it is distributed throughout the body, with only a fraction of the active substance reaching the receptors in the spinal cord. Alternatively, when intrathecal analgesia is used, the drug is delivered directly into the cerebrospinal fluid, enabling a targeted action with a much lower dose than that used in other routes of administration. This localised concentration maximises efficacy while reducing the side effects associated with systemic analgesics.

The first studies on this approach date back to the 1980s, when researchers discovered the existence of opioid receptors in the spinal cord. This was the starting point for an in-depth exploration of pain modulation pathways and the therapeutic potential of intrathecal treatments. Today, this method is an essential tool in the arsenal for treating chronic pain, particularly in oncology.

Functioning of the intrathecal pump

The implant of an intrathecal pump is a surgical procedure performed under local or a general anaesthetic. The device includes a tank, located under the skin at the abdominal level, connected to a catheter that delivers the medication directly into the subarachnoid space. Once in place, the pump continuously releases a precise amount of medication, adjusted according to the patient's needs. The frequency of follow-up consultations depends on the dose administered and may require regular visits. These are used to optimise the treatment, refill the pump and adjust the dosage to ensure optimum pain relief. When the pump is refilled, the reservoir is emptied and refilled using a needle inserted through the skin, a quick and painless procedure.

Benefits of targeted administration

This method of administration means that effective concentrations can be achieved with much lower doses than those required for systemic administration. The result is a reduction in the undesirable effects of opioids, such as drowsiness and digestive problems. In addition, this approach offers the possibility of administering certain analgesics that can only be delivered by this route, thereby broadening the therapeutic options for patients suffering from refractory chronic pain.

 

Indications and patient selection

Who can benefit from intrathecal analgesia?
Intrathecal analgesia is primarily intended for patients suffering from severe chronic pain resistant to conventional treatments, particularly in oncology. It is also considered for certain neuropathic pains or complex pain syndromes.

Pre-implantation test
In some cases, a preliminary test, normally in the form of a single injection into the intrathecal space, is proposed prior to implantation. This step enables the potential efficacy of the treatment to be assessed, and ensures that the patient will benefit from implantation of the pump. However, this test is not always necessary, particularly in cancer patients.

Efficiency and benefits of intrathecal analgesia

Improved comfort and quality of life

Studies have shown a clear improvement in the comfort of patients suffering from cancer pain, with a reduction in the need for systemic analgesics. In the case of non-malignant pain, the results are more variable but often show a reduction in pain intensity. Better pain management enables patients to regain a degree of autonomy and improve their general well-being.

 

Comparison with systemic treatments

Intrathecal administration allows for more efficient absorption of the drug, requiring a dose up to 300 times lower than the oral route and 100 times lower than the intravenous route. This optimisation reduces side effects such as nausea, vomiting, constipation, respiratory depression, cardiovascular problems, sedation and, more rarely, excitation. It also reduces the risk of opioid tolerance.

Conclusion: an effective treatment

Intrathecal analgesia is an effective and well-tolerated treatment option for the management of refractory chronic pain. By directly targeting the central nervous system, it optimises pain management while minimising the adverse effects of systemic treatments. Although its use must be chosen with discretion, it is a relevant solution for patients suffering from incapacitating pain.

Insight of Pain Clinic

Qui peut bénéficier d’une pompe intrathécale ?

Cette technique s’adresse aux patients souffrant de douleurs chroniques sévères réfractaires aux traitements conventionnels ou présentant des effets indésirables invalidants liés aux antalgiques. Elle est indiquée aussi bien pour les douleurs associées au cancer que pour certaines douleurs chroniques non cancéreuses ne répondant pas aux autres approches thérapeutiques.
 

Comment se déroule la procédure ?

L’intervention, réalisée sous anesthésie locale, locorégionale ou générale, requiert généralement une hospitalisation de courte durée.

Quels sont les médicaments administrés par voie intrathécale ?

Les opioïdes comme la morphine ou l’hydromorphone, les anesthésiques locaux et des alternatives comme le ziconotide peuvent être utilisés.

Combien de temps dure une pompe intrathécale ?

La batterie d’une pompe a une durée de vie moyenne de 7 ans et peut être remplacée si nécessaire.

Quels sont les risques de cette technique ?

Les principaux risques incluent les infections, les céphalées post-ponction durale, les complications mécaniques liées au dispositif ainsi que les effets secondaires des médicaments administrés.

Who should I see about these symptoms?

We recommend that you see the following health professional(s) :
Dr. med.
Matthieu Cachemaille
Anesthesiologist
Hôpital de La Tour
Dr.
Maria Luz Padilla del Rey
Anesthesiologist
Hôpital de La Tour
PD Dr. med.
Christophe Perruchoud
Anesthesiologist
Hôpital de La Tour
Dr. med.
Blaise Rutschmann
Anesthesiologist
Hôpital de La Tour

Specialties involved

The Pain Clinic