Intrathecal therapy (IT) to administer analgesic agents can be most effective in patients with chronic pain, particularly those whose pain cannot be adequately treated using conventional medical management. Guidelines from the literature are scant, but those that do exist invariably call for a trial of IT therapy to determine whether one should proceed with an implant of a permanent pump and IT catheter. Theoretically, a trial prior to permanent placement of an infusion device increases the likelihood the eventual treatment will be both safe and effective. However, surprisingly little evidence supports the supposition that a successful trial predicts successful IT therapy. It may even be true that IT trials invite more risk then benefit and should be abandoned.
Consider the following personal example: A middle-age man suffering from severe spinal pain experienced dose-limiting side effects from oral and transdermal medications. The patient met the criteria to receive an implantable pump to administer IT opioids and other medications in an effort to minimize the side effects of systemic medications and provide better pain control. The insurance company required a trial, so the patient was hospitalized for a planned 24 to 72 hours to be administered a trial of medications via a percutaneous IT catheter. Within 8 hours of having the catheter placed, the patient showed signs of meningitis. The catheter was removed, and the patient was immediately treated with antibiotic therapy. Unfortunately, he became critically ill and nearly died. The patient recovered but sustained a hearing loss from the antibiotic treatment all the more devastating because this gentleman was in charge of managing the sound in a live theater. His ability to perform at the same level would never be the same. This sad occurrence raises several questions, among them, How did a trial protect this patient from harm? and Are the risks of a temporary catheter equal to, or even greater than, those of a permanent implant? The literature offers little assistance in answering questions like these.
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