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Very-low Dose Of Bupivacaine Boluses In Intrathecal Patient Controlled Analgesia To Treat A Chronic Neurophatic Spinal Cord Pain Patient: A Case Report And Literature Review

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Introduction:

Refractory pain treated with intrathecal drug delivery systems (IDDS) is an effective option for chronic pain patients unresponsive to more conservative therapies (1 ). Bupivacaine continuous  infusion mixed with opioids or alone, is considered an appropriated option for chronic neuropathic pain(2,3 ). New devices for patient controlled intrathecal analgesia (PCIA)  have emerged  to improve results of IDDS. Bupivacaine has a therapeutical  potential,  to improve pharmacokinetic and increase analgesia (4)

Methods:

Clinical case report of a 42 YO male patient with complete spinal cord lesion pain at T12 level, refractory to  medical management , who received IDDS (SynchroMed®8627EL, Medtronic Inc.), tip of  catheter at T11-T12 level. He had adequate analgesic response, with continuous  infusion of hydromorphone 50 microgr/day  + Bupivacaine 3mg/day. After approximately  4 years, he lost pain control and his pain increased. Pump integrity system  was reviewed, and failure ruled out to explain  refractoriness to treatment.  When increasing opioid dose, side effects limited this therapeutic option.

In order to avoid a higher daily dose of Bupivacaine  and maintain acceptable pump refill times, we decided to adapt a device (Medtronic myPTM® Model 8835) to patient pump,  starting with very low doses of Bupivacaine (0.2mg bolus/ 5 boluses on demand/day) , in adittion to his daily  continuous IDDS scheme.   Patient  was instructed in using this device (figure 1).  After 3 days of treatment,   patient reduced his frequency paroxisms and severity of pain NRS = 2/10.

Results:

We observed that  addition of  very low dose boluses of  Bupivacaine on top of the continuous infusion by mean of PCIA   programming modality (4), resulted in  significant pain control, without  adverse effects.  . After 3 months with this new regimen, his previous pump needed replacement due to battery exhaustion,  and we were able to continue  this regimen, maintaining stable his opioid+bupivacaine continuous daily  dose.

 

Conclusions:

Very low dose of bupivacaine pulses (less than 0.5mg), in PCIA, compared to those described previously in literature (5),  may have  potential benefit on pain control for patients with refractory  pain. To the best of our knowledge, such an observation has neither been reported for neuropathic pain in spinal cord injury patient.  Theories such as a “current” effect of pulsatile bupivacaine (6), or a “priming” effect of a continuous  infusion plus boluses, can explain this response (7). This result  may  decrease the risk of bupivacaine taquiphilaxis or haemodynamic effects in this population.