Key Learning Points

• Spinal administration refers to the delivery of drugs to the intrathecal or epidural space.

• The principle of spinal administration is to deliver drugs directly to the intrathecal or epidural space so that therapeutic concentrations can be achieved at the dorsal horn of the spinal cord, which cannot be achieved by systemic administration or only with extremely high systemic doses.

• Enhanced therapeutic effects can thereby be achieved, and as smaller doses are needed than for systemic administration there is sparing of side effects.

• The epidural route has in the past been used more commonly than the intrathecal route. The intrathecal route is physiologically preferable, offers improved pain control, and a better side-effect profile. Now that technically the intrathecal route can confidently be used, it is the technique of preference.

• Intrathecal drug delivery (ITDD) is widely used for the management of cancer pain, chronic nonmalignant pain (CNMP) and painful spasticity; there is a supportive evidence base.

• The drugs used are opioids, membrane stabilizers, alpha-2 adrenergic agonists, gamma aminobutyric acid (GABA) agonists and more recently ziconotide, an N-type calcium channel blocker.

• ITDD should be delivered in a multiprofessional, carefully planned, and well-resourced context; patient selection is important and previous and alternative treatments should be considered1 (see also Chapter 31, Intrathecal drug delivery in the Practice and Procedures volume of this series).

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