You perform the block, and he has immediate pain relief and goes home. A week later George is back to see you. He is in severe pain. He would like to try something which will give him long-term pain relief.
What could be done to help George?
Obviously, the pain relief from the block was short-lived. The alternate option now is to consider intrathecal drug delivery after careful evaluation of its feasibility. An
MRI should be done to rule out intraspinal metastasis or areas of tumor that could interfere with percutaneous placement into the L1-L2 or L2-L3 interspace. A percutaneous intrathecal catheter would be most likely, but if he were still fairly functional and independent, a permanent implanted device would provide more flexibility and portability in his final months.
Is there a role for epidural analgesia?
The epidural route is commonly selected for delivering pharmacological agents if the patient is unlikely to survive more than 3 months. The intrathecal route is preferred if long-term survival is likely as drugs can be delivered by implanted pumps. The dose requirement of spinal infusion is significantly less, and refill intervals are much longer than epidural infusions. In addition, the intrathecal route provides analgesia that is more predictable.
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