Intrathecal therapy (IT pumps)

  • Typically delivered through an intrathecal pump
  • Catheter enters spine into CSF
  • Spinal catheter is tunneled through subcutaneous tissues to drug reservoir pump (typically located in right or left lower quadrant above fascial plane) 
  • Traditionally, intrathecal opioids are 300 times more effective than oral due to increased proximity to dorsal horn
  • Medications do not travel diffusely through CSF, but in more limited dermatomal manner, so regional/dermatomal pain can be addressed with ITP but not “whole body” pain 
  • FDA has only approved monotherapy with baclofen for spasticity, and morphine and ziconitide for pain 
  • *However, de facto therapy includes polypharmacy (for example, combination of opioid with local anesthetic), and these are considered first-line options by the Polyanalgesic Consensus Conference Guidelines (PACC)
Clinical Use: 

Indications, Best uses, Dosing, Applications

  • Cancer and non-cancer pain 
    • Pain arising from primary tumor or metastatic disease
    • Post-laminectomy surgery syndrome 
  • Inadequate pain control on current systemic therapies and/or intolerable side effects 
  • Failed and/or not candidate for other interventions (i.e. epidural steroid injection) 
  • Nociceptive and/or neuropathic pain 
  • Can have mixture of programming options: 
    • Basal (continuous) 
    • Patient controlled intrathecal analgesia (PCITA) 
    • Provider-programmed intermittent boluses (can choose specific doses over specific intervals of time at specific hours)
Special Considerations: 
  • For ITP patients requiring acute pain management (e.g. post-operative), they may require higher doses of systemic therapies for analgesia, but be equally sensitive to side effects such as respiratory depression as patients who are opioid-naïve or on low-dose opioids 
    • If acute pain is in similar dermatomal region as chronic pain, can use PCITA to help manage acute pain as well 
  • Catheters are usually placed with entry site around L1/2, but can be higher or lower.  Catheter can then be advanced as high as C2.  For neuraxial anesthesia, please be aware of the location of the catheter so as not to puncture the intrathecal catheter 
  • Intrathecal pumps are usually placed in the subcutaneous tissues in the lower abdomen.  Please be aware during surgeries that are in the abdominal area that this may interrupt either the pump or the catheter
  • MRI compatibility
    • Prometra Flowonix pump can cause fatal discharge of intrathecal pump medications in MRI (needs to have medications removed prior to MRI scan, and then refilled after) 
    • Medtronic Synchromed II pump (the one used at UCSF), is MRI compatible but will cause a stall during the MRI that will typically recover within an hour or two after the scan, but could take up to 24 hours 
      • If patient has PCITA device (PTM), you can ask them to check whether their pump is functioning again after the MRI

Deer TR, Pope JE, et al.  The Polyanalgesic Consensus Conference (PACC): Recommendations on Intrathecal Drug Infusion Systems Best Practices and Guidelines. Neuromodulation. 2017 Feb;20(2):96-132. doi: 10.1111/ner.12538. Epub 2017 Jan 2. Erratum in: Neuromodulation. 2017 Jun;20(4):405-406. PMID: 28042904.

Hayek, Salim M., and Michael C. Hanes. "Intrathecal therapy for chronic pain: current trends and future needs." Current pain and headache reports 18.1 (2014): 388.