- Email: [email protected]
913 SPANISH CONSENSUS GUIDE FOR THE TREATMENT OF SEVERE REFRACTORY SPASTICITY WITH INTRATHECAL BACLOFEN
S258
Poster Sessions / European Journal of Pain 13 (2009) S55–S285
pre-interventional clinical evaluation. In patients developing a headache after dural puncture, Careful clinical evaluation is also needed to differentiate between causative anatomic and functional pathologies, and to stratify for specific interventions, if necessary supplemented by diagnostic procedures. We report a case of acute subdural haematoma triggered by intraspinal analgesia for prostate radioactive seeds implantation for the treatment of prostate carcinoma, in a 65 year old patient with an undiagnosed chronic subdural haematoma after a symptom-free interval of three weeks following a sports accident. Risk factors, clinical features, differential diagnoses, and specific therapeutic strategies are presented and discussed. Though being a rare complication, anaesthetists and pain therapists should include intracerebral haemorrhage in the differential diagnosis of post-dural puncture headache and other central nervous complications. 910 IS A SCREENING FOR EPIDURAL CORTICOSTEROID INJECTIONS USEFUL? K. Lathouwers1 *, M. Puylaert2 , J. Van Zundert, P. Vanelderen, P. Devooght, R. Heylen. 1 Department of Anesthesiology, Intensive care and Pain therapy, Ziekenhuis Oost Limburg, Genk, Belgium; 2 Department of Anesthesiology, Intensive care and Pain therapy, Ziekenhuis Oost Limburg, Genk, Belgium Background: Administration of corticosteroids in the epidural space for pain management remains controversial. Therefore, we introduced 7 years ago a pre-operative screening to evaluate patients referred to our centre for an epidural infiltration. At this assesment the indication was evaluated, the planned intervention explained and informed consent obtained. Methods: Over a 4 month period we reviewed retrospectively 207 files of patients referred to our centre with the request for an epidural infiltration. Results: 64% of the patients were referred by a neurosurgeon, 23% by a GP, 5% by a rheumatologist, 5% by an orthopaedic surgeon and 1% by other specialists. In 72% or 149 patients an epidural infiltration was performed. 28% or 58 patients were referred incorrectly, independent of the basic training of the referring physician: • 48% or 27 patients presented with low back pain which were treated with a facet joint block or a sacroiliacal joint infiltration; • Another drop out of 45% or 26 patients was recognized because of spontaneous pain relief; • Two patients needed further investigation to exclude orthopaedic or oncological problems; • One patient refused therapy after reading the informed consent; • Two patients chose to discuss it with their GP and followed physiotherapy instead. Conclusions: Epidural steroids should be administered only in cases of subacute radicular pain. These results show that in 28% of referrals an infiltration of steroids and the concommitant risks could be avoided. Screening is advised to select the precise indication. 911 SACRAL NEUROPLASTY FOR POSTLAMINECTOMY CHRONIC LOW BACK PAIN G.R. Lauretti *, A.L. Mattos, W. Trevellin, C.C.F. Righeti, C.S. Resende. Faculty of Medicine of Ribeirao Preto, University of S˜ ao Paulo, Ribeirao Preto, Brazil Background and Objectives: This study evaluated the efficacy of caudal neuroplasty with clonidine, lidocaine, hyaluronidase, hypertonic saline and dexamethasone after postlaminectomy pain. Methods: 17 patients with pain VAS8–9 cm were evaluated. All patients were regularly taking 20 mg oral fluoxetine/day and an oral tablet of the cytidine-uridine-hydroxicobalamine complex twice daily during 21 days. Patients were submitted to a caudal:
1) 60 mg lidocaine followed by 2) 5 ml 10% hypertonic saline; and 3) 30 mg clonidine combined with 10 mg dexamethasone, 666 UI hyaluronidase and 30 mg lidocaine. The caudal block was done at days 1, 14 and 28. Patients were evaluated at days 49 and 84. Results: The pain VAS (cm) at day 1 was 8.6±1.2. The pain VAS (cm) at days 14, 28, 49 and 84 were: 4.7±1; 3.4±1.1; 2.7±0.8 and 3.5±1.3. There was improvement in pain since day 14 (p < 0.0005). Eleven patients referred decrease in pain intensity, less consumption of oral pain killers and better sleep pattern. The others 6 patients were in bed at the time of first evaluation. Two of them restarted to walk after the treatment, while the other could keep seated, instead of lying down all day. The other three patients described 40–60% improvement in pain intensity. The intake of oral ketoprofeno changed from 10 to 3 tablets/week after the treatment (p < 0.005). Conclusions: There was a decrease in pain intensity, and increase in the quality of life with the proposed treatment in the population evaluated. 912 THE COMBINATION OF EPIDURAL METHADONE AND DEXAMETHASONE FOR CANCER PAIN C.C. Rizzo, G.R. Lauretti *, A.L. Mattos. Faculty of Medicine of Ribeirao Preto, University of S˜ ao Paulo, Ribeirao Preto, Brazil Background and Objectives: Patients suffering from severe cancer pain may become resistant to epidural morphine. Methadone is still regarded as a second line opioid for patients suffering from severe cancer pain, probably due to its long plasma half-life that could lead to accumulation and toxicity. However, epidural methadome may be advantageous for those patients. Methods: 32 patients with intractable cancer pain were divided into 4 groups. Group M-2.5 received 2.5 mg epidural methadone diluted in 60 mg lidocaine. Group M-5 received 5 mg methadone diluted in 60 mg lidocaine, Group M-7.5 received 7.5 mg methadone diluted in 60 mg lidocaine. Finally, Group M-D received 7.5 mg methadone combined with 60 mg liodocaine and 10 mg dexamethasone. Analgesia end side effects were evaluated weekly. All patients were taking oral 25 mg amitriptyline at bed time. Results: Epidural methadone resulted in analgesia varying from 1±1 day to the Group M-2.5, 3±1 days to the Group M-5 and 5±2 days for group M-7.5. The association of epidural 10 mg dexamethasone resulted in 11±3 days of analgesia. One patient from group M-5 showed mild sedation for two hours. Conclusions: Epidural methadone was an effective analgesic in patients refractory to epidural morphine, resulting in dosedependent analgesia, which was further improved by the association of epidural dexamethasone, reflecting a good option for pain control in this population. 913 SPANISH CONSENSUS GUIDE FOR THE TREATMENT OF SEVERE REFRACTORY SPASTICITY WITH INTRATHECAL BACLOFEN J.M. Lopez-Millan Infantes1 *, G. Cerda´ Olmedo2 , M.L. Franco 6 Gay3 , J. Insausti4 , M.D. Lopez ´ Alarcon ´ 5 , S. Moliner Velazquez ´ , V. Monsalve Dolz7 , J. Perez ´ Cajaraville8 , M. Tio´ Felip9 , E. Uriarte10 . 1 Hospital Universitario Virgen Macarena, Sevilla, Spain; 2 Hospital General Universitario de Valencia, Valencia, Spain; 3 Hospital Universitario de Cruces, Bilbao, Spain; 4 Hospital de Legan´es, Madrid, Spain; 5 Hospital General Universitario de Valencia, Valencia, Spain; 6 Hospital General Universitario de Valencia, Valencia, Spain; 7 Hospital General Universitario de Valencia, Valencia, Spain; 8 Cl´ınica Universitaria de Navarra, Pamplona, Spain; 9 Hospital Cl´ınico de Barcelona, Barcelona, Spain; 10 Hospital de Legan´es, Madrid, Spain Introduction: The SGNM was created and the supported by ESRASpain to promote the knowledge and to standard the indications of the neuromodulation procedures in our country. In this issue SGNM approches to the standard management of chronic severe refractory spasticity with intrathecal baclofen (ITB). Spasticity is a
Poster Sessions / European Journal of Pain 13 (2009) S55–S285
motor disorder characterized by ‘tight’ or ‘stiff’ muscles that may interfere with voluntary muscle movements and affect a patient’s ability to function. There are no Spanish guides to assists physicians in treating patients with spasticity and identifying patients who can benefit from ITB therapy. Objectives: As a consensus statement, this guideline has established several goals: 1. To gather all the knowledge available about ITB for espasticity; 2. Teaching tool; 3. To help care providers in their decision making process; 4. To standardized clinical practice in order to obtain better results and comparable data for analysis Method: By discussing literature available and based on the group members personal experiences, and using the EBM criteria. Results: The SGNM has created this guide containing 16 chapters and 2 appendix that listed from pathophisiology of spasticity, objectives, desirable characteristics for clinicians and facilities, inclusion-exclusion criteria for patients, psychological testing, informed consent and general information, preparation for the implant, implant technique, complications and programming to cost-effectiveness analysis. Conclusion: There is no other document in our country that summarizes the theoretical and practical knowledge about intrathecal infusion of baclofen to treat severe refractory spasticity and associated chronic pain. We believe this project will be an approach for clinicians to this field. 914 COMPARISON OF ANALGESIC EFFECT OF INTRATHECAL MIDAZOLAM FOR FAILED BACK SURGERY AND LOW BACK PAIN IN MALE AND FEMALE PATIENTS J. Prochazka *. Masaryk Hospital, Usti nad Labem, Czech Republic Aims: Our department deploys intrathecal administration of midazolam for pain relief in many patients with chronic pain since 1995. This method, based on affecting spinal GABA receptors, can achieve a long-term analgesia after single-shot administration. The study compares the analgesic properties of this method according to genders. Methods: A retrospective analysis of analgesia duration in male and female patients with chronic low back pain and failed back surgery syndrome after single-shot administration performed using the Student’s t-test. Results: Between 1995 and 2007 we performed 168 administrations in 52 male patients and 183 administrations in 64 female patients. Average age of men was 51.1 years (range 28 to 67) and 49.3 years (range 30 to 86) in women respectively. The dose administered ranged from 2 to 5 mg of midazolam. The results we assess were acquired after 158 administrations in men and 178 administrations in women on the following examination at our pain relief service. The mean duration of analgesia in male patients was 12.4 weeks and in female 9.5 weeks (p = 0.11). The most frequent analgesic effect our patients reported ranged from 1 to 3 months of duration in both groups. Incidence of side effects (drowsiness, nausea, headache) was similar in both groups too. Conclusion: The Student’s t-test discovered no significant differences in analgesic effects after a single-shot intrathecal administration of 2 to 5 mg of midazolam for chronic non-malignant pain relief in both genders.
S259
915 IMPLANTABLE INTRATHECAL PUMPS FOR THE TREATMENT OF NONCANCER CHRONIC PAIN IN ELDERLY POPULATION: DRUG DOSE AND CLINICAL EFFICACY W. Raffaeli1 *, D. Righetti1 , A. Caminiti1 , P. Pantazopoulos2 , F. Facondini2 . 1 Pain Therapy and Palliative Care Unit, Infermi Hospital, Rimini, Italy; 2 Department of Anesthesiology and Intensive Care, Rimini, Italy Background and Aims: There are several clinical advantages to intrathecal (IT) therapy for pain control. Nowadays, the number of elderly people and the average age of the population are increasing. Elderly often suffer from age-related diseases resulting in serious disabilities. For this reason, it is of primary importance to find an efficient analgesic therapy for them, avoiding pharmacologic interactions and unwanted adverse events. This retrospective study aims to assess long-term follow-up of efficacy and quality of life for 34 geriatric patients with IT drug delivery systems (IDDS), implanted between 1994 and 2002, for the treatment of severe noncancer chronic pain. Methods: Patients older than 64 years were selected for the study. Clinical assessment forms and questionnaires assessing pain intensity, adverse events, complications, concommittent use of analgesics, and doses of IT drugs administered were filled out by our patients prior to and after IT drug delivery implantation. Results: Pain intensity was substantially reduced (60%) from three to 48 months of treatment. The mean visual analog scale (VAS) decreased from 8.09 before implantation to 1.68 at the 48-months follow-up, with mean doses of IT morphine and bupivacaine, 1.03±0.61 mg and 1.15±0.58 mg, respectively. Only two patients had complications related to the implantation procedure. Drug-related side-effects were reported by 50% of the patients: constipation (34.4%), drowsiness (21.9%), nausea (21.9%), and urinary retention (18.8%). No side-effects of therapy resulted in removal of the IDDS. Conclusion: The use of IDDS for the treatment of non-cancer- and cancer-related pain in geriatric patients is successful. 916 SINGLE-CENTRE CLINICAL EXPERIENCE USING ZICONOTIDE FOR THE TREATMENT OF CHRONIC NEUROPATHIC PAIN SYNDROMES D. Rasche *, D. Klase, V. Tronnier. Department of Neurosurgery University of L¨ ubeck, L¨ ubeck, Germany Background and Aims: In a selected group of chronic pain patients invasive treatment options like intrathecal applied pharmacological analgesics are required if conservative therapies fail. Since a few years a new analgesic drug is legalized in Europe for intrathecal pain therapy – ziconotide. Methods: 13 patients were treated with ziconotide intrathecally. All patients suffered from chronic neuropathic or mixed neuropathic/nociceptive symptoms. In all patients a de-novo testing with an externalized lumbar drain was initiated. In case of pain reduction of more than 50%, measured with a visual analogue scale, a pump delivery system was internalized. Results: Starting dose of ziconotide varied from 0.5 up to 1.5 mg/d. In all patients dose escalation was performed until pain reduction or side effects were documented. In nine patients a positive effect was noted and pump implantation performed. Side effects of ziconotide, like dizziness, gait disturbances, headache, diplopia or psychiatric disorders were observed, more or less, in all patients during the titration phase. After a follow-up of three and six months after pump implantation a positive effect was evaluated in four, respectively three patients. Daily dosage of ziconotide varied from 5 up to 20 mg/d. Conclusions: Ziconotide is an alternative pharmacological agent for intrathecal pain therapy. Due to its biochemical profile complex and sensitive testing and dose titration is necessary. The rate of side effects is high. Currently, based on the clinical experience of
Poster Sessions / European Journal of Pain 13 (2009) S55–S285
pre-interventional clinical evaluation. In patients developing a headache after dural puncture, Careful clinical evaluation is also needed to differentiate between causative anatomic and functional pathologies, and to stratify for specific interventions, if necessary supplemented by diagnostic procedures. We report a case of acute subdural haematoma triggered by intraspinal analgesia for prostate radioactive seeds implantation for the treatment of prostate carcinoma, in a 65 year old patient with an undiagnosed chronic subdural haematoma after a symptom-free interval of three weeks following a sports accident. Risk factors, clinical features, differential diagnoses, and specific therapeutic strategies are presented and discussed. Though being a rare complication, anaesthetists and pain therapists should include intracerebral haemorrhage in the differential diagnosis of post-dural puncture headache and other central nervous complications. 910 IS A SCREENING FOR EPIDURAL CORTICOSTEROID INJECTIONS USEFUL? K. Lathouwers1 *, M. Puylaert2 , J. Van Zundert, P. Vanelderen, P. Devooght, R. Heylen. 1 Department of Anesthesiology, Intensive care and Pain therapy, Ziekenhuis Oost Limburg, Genk, Belgium; 2 Department of Anesthesiology, Intensive care and Pain therapy, Ziekenhuis Oost Limburg, Genk, Belgium Background: Administration of corticosteroids in the epidural space for pain management remains controversial. Therefore, we introduced 7 years ago a pre-operative screening to evaluate patients referred to our centre for an epidural infiltration. At this assesment the indication was evaluated, the planned intervention explained and informed consent obtained. Methods: Over a 4 month period we reviewed retrospectively 207 files of patients referred to our centre with the request for an epidural infiltration. Results: 64% of the patients were referred by a neurosurgeon, 23% by a GP, 5% by a rheumatologist, 5% by an orthopaedic surgeon and 1% by other specialists. In 72% or 149 patients an epidural infiltration was performed. 28% or 58 patients were referred incorrectly, independent of the basic training of the referring physician: • 48% or 27 patients presented with low back pain which were treated with a facet joint block or a sacroiliacal joint infiltration; • Another drop out of 45% or 26 patients was recognized because of spontaneous pain relief; • Two patients needed further investigation to exclude orthopaedic or oncological problems; • One patient refused therapy after reading the informed consent; • Two patients chose to discuss it with their GP and followed physiotherapy instead. Conclusions: Epidural steroids should be administered only in cases of subacute radicular pain. These results show that in 28% of referrals an infiltration of steroids and the concommitant risks could be avoided. Screening is advised to select the precise indication. 911 SACRAL NEUROPLASTY FOR POSTLAMINECTOMY CHRONIC LOW BACK PAIN G.R. Lauretti *, A.L. Mattos, W. Trevellin, C.C.F. Righeti, C.S. Resende. Faculty of Medicine of Ribeirao Preto, University of S˜ ao Paulo, Ribeirao Preto, Brazil Background and Objectives: This study evaluated the efficacy of caudal neuroplasty with clonidine, lidocaine, hyaluronidase, hypertonic saline and dexamethasone after postlaminectomy pain. Methods: 17 patients with pain VAS8–9 cm were evaluated. All patients were regularly taking 20 mg oral fluoxetine/day and an oral tablet of the cytidine-uridine-hydroxicobalamine complex twice daily during 21 days. Patients were submitted to a caudal:
1) 60 mg lidocaine followed by 2) 5 ml 10% hypertonic saline; and 3) 30 mg clonidine combined with 10 mg dexamethasone, 666 UI hyaluronidase and 30 mg lidocaine. The caudal block was done at days 1, 14 and 28. Patients were evaluated at days 49 and 84. Results: The pain VAS (cm) at day 1 was 8.6±1.2. The pain VAS (cm) at days 14, 28, 49 and 84 were: 4.7±1; 3.4±1.1; 2.7±0.8 and 3.5±1.3. There was improvement in pain since day 14 (p < 0.0005). Eleven patients referred decrease in pain intensity, less consumption of oral pain killers and better sleep pattern. The others 6 patients were in bed at the time of first evaluation. Two of them restarted to walk after the treatment, while the other could keep seated, instead of lying down all day. The other three patients described 40–60% improvement in pain intensity. The intake of oral ketoprofeno changed from 10 to 3 tablets/week after the treatment (p < 0.005). Conclusions: There was a decrease in pain intensity, and increase in the quality of life with the proposed treatment in the population evaluated. 912 THE COMBINATION OF EPIDURAL METHADONE AND DEXAMETHASONE FOR CANCER PAIN C.C. Rizzo, G.R. Lauretti *, A.L. Mattos. Faculty of Medicine of Ribeirao Preto, University of S˜ ao Paulo, Ribeirao Preto, Brazil Background and Objectives: Patients suffering from severe cancer pain may become resistant to epidural morphine. Methadone is still regarded as a second line opioid for patients suffering from severe cancer pain, probably due to its long plasma half-life that could lead to accumulation and toxicity. However, epidural methadome may be advantageous for those patients. Methods: 32 patients with intractable cancer pain were divided into 4 groups. Group M-2.5 received 2.5 mg epidural methadone diluted in 60 mg lidocaine. Group M-5 received 5 mg methadone diluted in 60 mg lidocaine, Group M-7.5 received 7.5 mg methadone diluted in 60 mg lidocaine. Finally, Group M-D received 7.5 mg methadone combined with 60 mg liodocaine and 10 mg dexamethasone. Analgesia end side effects were evaluated weekly. All patients were taking oral 25 mg amitriptyline at bed time. Results: Epidural methadone resulted in analgesia varying from 1±1 day to the Group M-2.5, 3±1 days to the Group M-5 and 5±2 days for group M-7.5. The association of epidural 10 mg dexamethasone resulted in 11±3 days of analgesia. One patient from group M-5 showed mild sedation for two hours. Conclusions: Epidural methadone was an effective analgesic in patients refractory to epidural morphine, resulting in dosedependent analgesia, which was further improved by the association of epidural dexamethasone, reflecting a good option for pain control in this population. 913 SPANISH CONSENSUS GUIDE FOR THE TREATMENT OF SEVERE REFRACTORY SPASTICITY WITH INTRATHECAL BACLOFEN J.M. Lopez-Millan Infantes1 *, G. Cerda´ Olmedo2 , M.L. Franco 6 Gay3 , J. Insausti4 , M.D. Lopez ´ Alarcon ´ 5 , S. Moliner Velazquez ´ , V. Monsalve Dolz7 , J. Perez ´ Cajaraville8 , M. Tio´ Felip9 , E. Uriarte10 . 1 Hospital Universitario Virgen Macarena, Sevilla, Spain; 2 Hospital General Universitario de Valencia, Valencia, Spain; 3 Hospital Universitario de Cruces, Bilbao, Spain; 4 Hospital de Legan´es, Madrid, Spain; 5 Hospital General Universitario de Valencia, Valencia, Spain; 6 Hospital General Universitario de Valencia, Valencia, Spain; 7 Hospital General Universitario de Valencia, Valencia, Spain; 8 Cl´ınica Universitaria de Navarra, Pamplona, Spain; 9 Hospital Cl´ınico de Barcelona, Barcelona, Spain; 10 Hospital de Legan´es, Madrid, Spain Introduction: The SGNM was created and the supported by ESRASpain to promote the knowledge and to standard the indications of the neuromodulation procedures in our country. In this issue SGNM approches to the standard management of chronic severe refractory spasticity with intrathecal baclofen (ITB). Spasticity is a
Poster Sessions / European Journal of Pain 13 (2009) S55–S285
motor disorder characterized by ‘tight’ or ‘stiff’ muscles that may interfere with voluntary muscle movements and affect a patient’s ability to function. There are no Spanish guides to assists physicians in treating patients with spasticity and identifying patients who can benefit from ITB therapy. Objectives: As a consensus statement, this guideline has established several goals: 1. To gather all the knowledge available about ITB for espasticity; 2. Teaching tool; 3. To help care providers in their decision making process; 4. To standardized clinical practice in order to obtain better results and comparable data for analysis Method: By discussing literature available and based on the group members personal experiences, and using the EBM criteria. Results: The SGNM has created this guide containing 16 chapters and 2 appendix that listed from pathophisiology of spasticity, objectives, desirable characteristics for clinicians and facilities, inclusion-exclusion criteria for patients, psychological testing, informed consent and general information, preparation for the implant, implant technique, complications and programming to cost-effectiveness analysis. Conclusion: There is no other document in our country that summarizes the theoretical and practical knowledge about intrathecal infusion of baclofen to treat severe refractory spasticity and associated chronic pain. We believe this project will be an approach for clinicians to this field. 914 COMPARISON OF ANALGESIC EFFECT OF INTRATHECAL MIDAZOLAM FOR FAILED BACK SURGERY AND LOW BACK PAIN IN MALE AND FEMALE PATIENTS J. Prochazka *. Masaryk Hospital, Usti nad Labem, Czech Republic Aims: Our department deploys intrathecal administration of midazolam for pain relief in many patients with chronic pain since 1995. This method, based on affecting spinal GABA receptors, can achieve a long-term analgesia after single-shot administration. The study compares the analgesic properties of this method according to genders. Methods: A retrospective analysis of analgesia duration in male and female patients with chronic low back pain and failed back surgery syndrome after single-shot administration performed using the Student’s t-test. Results: Between 1995 and 2007 we performed 168 administrations in 52 male patients and 183 administrations in 64 female patients. Average age of men was 51.1 years (range 28 to 67) and 49.3 years (range 30 to 86) in women respectively. The dose administered ranged from 2 to 5 mg of midazolam. The results we assess were acquired after 158 administrations in men and 178 administrations in women on the following examination at our pain relief service. The mean duration of analgesia in male patients was 12.4 weeks and in female 9.5 weeks (p = 0.11). The most frequent analgesic effect our patients reported ranged from 1 to 3 months of duration in both groups. Incidence of side effects (drowsiness, nausea, headache) was similar in both groups too. Conclusion: The Student’s t-test discovered no significant differences in analgesic effects after a single-shot intrathecal administration of 2 to 5 mg of midazolam for chronic non-malignant pain relief in both genders.
S259
915 IMPLANTABLE INTRATHECAL PUMPS FOR THE TREATMENT OF NONCANCER CHRONIC PAIN IN ELDERLY POPULATION: DRUG DOSE AND CLINICAL EFFICACY W. Raffaeli1 *, D. Righetti1 , A. Caminiti1 , P. Pantazopoulos2 , F. Facondini2 . 1 Pain Therapy and Palliative Care Unit, Infermi Hospital, Rimini, Italy; 2 Department of Anesthesiology and Intensive Care, Rimini, Italy Background and Aims: There are several clinical advantages to intrathecal (IT) therapy for pain control. Nowadays, the number of elderly people and the average age of the population are increasing. Elderly often suffer from age-related diseases resulting in serious disabilities. For this reason, it is of primary importance to find an efficient analgesic therapy for them, avoiding pharmacologic interactions and unwanted adverse events. This retrospective study aims to assess long-term follow-up of efficacy and quality of life for 34 geriatric patients with IT drug delivery systems (IDDS), implanted between 1994 and 2002, for the treatment of severe noncancer chronic pain. Methods: Patients older than 64 years were selected for the study. Clinical assessment forms and questionnaires assessing pain intensity, adverse events, complications, concommittent use of analgesics, and doses of IT drugs administered were filled out by our patients prior to and after IT drug delivery implantation. Results: Pain intensity was substantially reduced (60%) from three to 48 months of treatment. The mean visual analog scale (VAS) decreased from 8.09 before implantation to 1.68 at the 48-months follow-up, with mean doses of IT morphine and bupivacaine, 1.03±0.61 mg and 1.15±0.58 mg, respectively. Only two patients had complications related to the implantation procedure. Drug-related side-effects were reported by 50% of the patients: constipation (34.4%), drowsiness (21.9%), nausea (21.9%), and urinary retention (18.8%). No side-effects of therapy resulted in removal of the IDDS. Conclusion: The use of IDDS for the treatment of non-cancer- and cancer-related pain in geriatric patients is successful. 916 SINGLE-CENTRE CLINICAL EXPERIENCE USING ZICONOTIDE FOR THE TREATMENT OF CHRONIC NEUROPATHIC PAIN SYNDROMES D. Rasche *, D. Klase, V. Tronnier. Department of Neurosurgery University of L¨ ubeck, L¨ ubeck, Germany Background and Aims: In a selected group of chronic pain patients invasive treatment options like intrathecal applied pharmacological analgesics are required if conservative therapies fail. Since a few years a new analgesic drug is legalized in Europe for intrathecal pain therapy – ziconotide. Methods: 13 patients were treated with ziconotide intrathecally. All patients suffered from chronic neuropathic or mixed neuropathic/nociceptive symptoms. In all patients a de-novo testing with an externalized lumbar drain was initiated. In case of pain reduction of more than 50%, measured with a visual analogue scale, a pump delivery system was internalized. Results: Starting dose of ziconotide varied from 0.5 up to 1.5 mg/d. In all patients dose escalation was performed until pain reduction or side effects were documented. In nine patients a positive effect was noted and pump implantation performed. Side effects of ziconotide, like dizziness, gait disturbances, headache, diplopia or psychiatric disorders were observed, more or less, in all patients during the titration phase. After a follow-up of three and six months after pump implantation a positive effect was evaluated in four, respectively three patients. Daily dosage of ziconotide varied from 5 up to 20 mg/d. Conclusions: Ziconotide is an alternative pharmacological agent for intrathecal pain therapy. Due to its biochemical profile complex and sensitive testing and dose titration is necessary. The rate of side effects is high. Currently, based on the clinical experience of