Anesth Analg 2007; 105:1410-1412
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000286169.02429.11
NEUROSURGICAL ANESTHESIOLOGY
Intrathecal Opioids for Control of Chronic Low Back Pain During Deep Brain Stimulation Procedures
Michelle Lotto, MD*, and
Nicholas M. Boulis, MD
From the *Section of Neurological Anesthesia, Cleveland Clinic, and Cleveland Clinic Lerner College of Medicine, Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio.
Address correspondence and reprint requests to Michelle Lotto, MD, Department of General Anesthesiology, E-31, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH 44195. Address e-mail to lottom{at}ccf.org.
Abstract
Patients with chronic low back pain may not be able to endure the supine position required by the lengthy deep brain stimulation procedure. Many neurophysiologists severely restrict the use of opioids and sedative drugs during deep brain stimulation procedures due to the concern for depression of cellular firing frequencies used to map the brain for placement of the stimulator leads. We present two cases in which spinal opioids were used to achieve prolonged pain relief in patients with chronic back pain, without altering cellular firing critical for brain mapping.
Deep brain stimulation (DBS) has been revolutionary in restoring quality of life to patients with refractory Parkinson's disease. Unfortunately, the procedure is lengthy and requires minimal administration of anesthetic medications to avoid interference with the microrecordings used to identify the subthalamic nucleus (STN) during placement of the DBS leads (1–3). The patient must remain capable of cooperating with the neurologic examination so that the therapeutic motor effects and somatic side effects of subcortical stimulation can be assessed. Anesthetics can alter neuronal firing frequency and impair patient assessment, and are avoided during most cases of STN stimulation (1–3). Limitations imposed on the anesthesiologist complicate the care of patients who are unable to tolerate many hours in a single position as required by the procedure. We report the successful use of intrathecal opioids to treat chronic neuromuscular back pain in two patients unable to tolerate the positioning for DBS.
CASE REPORTS
Case 1
A 78-yr-old man with a history of postlaminectomy syndrome presented for bilateral STN DBS for Parkinson's disease refractory to medical management. After placement of the steriotactic head frame, the patient was positioned supine and the head frame was affixed to the bed. Fifteen minutes after positioning, the patient complained of severe low back pain and requested to sit upright. Despite attempts at repositioning, the patient felt he would not be able to tolerate the supine position for the duration of the procedure and considered discontinuing the surgery. Several options were discussed to control the patient's pain and to allow him to continue with the procedure. Administration of IV opioids was discussed and dismissed due to the potential effects of opioids on intracellular firing and neuronal monitoring for DBS lead placement. Neuraxial blockade with local anesthetics was not an option since the motor blockade would interfere with assessment of effectiveness of STN stimulation in treating the lower extremity Parkinsonian symptoms. The patient consented to placement of a subdural catheter and administration of intrathecal opioids before repositioning. The initial dose of 25 µg of fentanyl did not improve the patient's back pain in the supine position. Two subsequent 25 µg doses of fentanyl also did not suppress the pain. Sixty micrograms of preservative-free hydromorphone was administrated. The patient reported an improvement in pain from 9/10 to 2/10 within 10 min of the injection. He was able to tolerate the supine position for the entire length of the procedure (7.25 h) without further dosing of the intrathecal catheter. After surgery, the patient was monitored in the Neurological Stepdown unit. He was very satisfied with his pain control during the procedure and reported excellent pain control throughout the first postoperative night.
Case 2
A 71-yr-old man with a history of Parkinson's disease characterized by progressive lower extremity rigidity, bradykinesia, and gait disturbance presented for bilateral STN DBS. During positioning, the patient raised some concern about his ability to tolerate the lengthy procedure in the supine position. He recounted how he was unable to tolerate his preoperative magnetic resonance imaging due to low back pain after 15 min of laying supine. The patient consented to a single shot intrathecal injection of preservative-free hydromorphone 50 µg. After the spinal injection, the patient was positioned supine and experienced no pain for the duration of the 8-h procedure. Postoperatively, the patient was monitored in the Neurological Stepdown unit.
DISCUSSION
The use of single-cell microrecordings during DBS lead placement significantly restricts the number of anesthetics that can be delivered to patients undergoing DBS. Retrospective studies have suggested that placement of the STN lead under general anesthesia can reduce the benefit of DBS in Parkinsonian patients compared with placement under local anesthesia (3). Little clinical evidence is available as to the specific effect of opioids on neuronal firing. The choice of drugs and use of opioids during DBS appears to vary among institutions; however, in the authors' institution, as in many others, the neurophysiologists and surgeons are adamant about the avoidance of drugs that might interfere with neuromonitoring or examination of the patient undergoing DBS (1,2). Intrathecal opioids can provide ideal pain relief for patients undergoing DBS because they do not affect voluntary motor activity or alter other sensory modalities used to precisely map the STN during DBS. Intrathecal opioids offer some benefits over epidural administration, such as faster onset and lower systemic spread. Although epidural delivery of opioids can reduce pain without neuroaxial blockade, sampling from serum plasma after epidural administration of opioids demonstrates a rapid increase in systemic drug levels (4). The pain relief achieved from epidural opioids is suggested to be a combination of both systemic and local effects (4,5). To the contrary, very little opioid has been found in the systemic system for up to 2 h after intrathecal injections of hydrophilic opioids such as morphine, providing pain relief with minimal patient sedation (4).
Opioid selection is also important for impacting pain relief. More lipophilic drugs, such as the short-acting synthetic opioids fentanyl and sufentanil, are removed from the cerebrospinal fluid (CSF) rapidly, and therefore will affect fewer spinal levels (6). This variation in opioid spread in the CSF may explain the inadequate pain relief experienced by the patient in the first case after intrathecal fentanyl administration. More hydrophilic drugs, such as morphine and hydromorphone, have a greater rostral spread and a significant effect across multiple spinal levels after a single intrathecal injection. This is best demonstrated by the long-acting pain relief that can be achieved for thoracic incisions after lumbar injections of intrathecal morphine. The duration of pain relief is long and variable, lasting from 12 to 40 h (7). Less research has been conducted on the pharmacokinetics of intrathecal hydromorphone when compared with intrathecal morphine. Hydromorphone has not been approved for spinal use, but several studies have shown it to be safe and effective when administered via intrathecal infusion pumps in patients with chronic pain (8,9). In fact, a national multidisciplinary meeting of pain management advocates has promoted hydromorphone as a first-line drug for intrathecal opioid therapy in chronic pain (10). In this case, hydromorphone was chosen over morphine because of a faster onset time than morphine (11).
It should be noted that spinal opioids will have an eventual rostral spread to the intraventricular CSF. Morphine can be detected in intracranial CSF collected from the cisterna magna within 2 h of subarachnoid administration, with peak concentrations varying from 2 to 9 h after delivery. In both cases presented here, there were no difficulties with neuronal recordings through the duration of the procedures. Again, there is little scientific evidence in the literature for the specific effect of opioids on neuronal firing, and it is possible that there is no significant impact by any route of administration. Rostral spread of opioids in the CSF can lead to the highly undesirable effect of delayed respiratory depression, which has occurred as late as 12 h after administration of intrathecal morphine. Lower opioid doses have been suggested to reduce the risk of high CSF concentrations and may decrease the risk of delayed respiratory depression. Postoperatively, patients require a monitored setting that can provide frequent respiratory assessments for 24 h after administration of long-acting intrathecal opioids (12). The need for additional monitoring creates a potential increase in perioperative costs for patients after administration of spinal opioids. Patients undergoing DBS at our institution are routinely monitored in a stepdown unit for the first postoperative night. If respiratory depression or obtundation does occur postoperatively in a DBS patient, neurologic events should also be excluded. Intracranial hemorrhage (although rarely symptomatic) is the most frequent complication of DBS surgery (13).
In conclusion, we present a useful technique, which allowed patients who would otherwise be unable to tolerate DBS surgery to proceed with the procedure in comfort. It should be noted that elderly Parkinsonian patients are at risk for over-sedation from opioid medications and perioperative delirium, and appropriate monitoring is required after use of intrathecal opioids. Patients should also be informed of the other potential side effects of intrathecal opioids, including nausea or vomiting, generalized pruritus, and urinary retention.
Footnotes
Accepted for publication July 31, 2007.
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