- Email: [email protected]
Six years of continuous intrathecal infusion of opioid and bupivacaine in the treatment of refractory pain due to intrapelvic extrusion of bone cement after total hip arthroplasty
Regional Anesthesia and Pain Medicine 23(3): 315-319, 1998
Six Years of C o n t i n u o u s Intrathecal Infusion of Opioid and B u p i v a c a i n e in the T r e a t m e n t of Refractory Pain D u e to Intrapelvic Extrusion of B o n e C e m e n t After Total Hip A r t h r o p l a s t y Peter O. Dahm, M.D., Ph.D., Petre V. Nitescu, M.D., Ph.D., Lennart K. Appelgren, M.D., Ph.D., and Ioan D. Curelaru, M.D., Ph.D.
Background and Objectives. There is at present no reliable method for long-term treatment of severe pain following complications of total hip arthroplasty. We explored the longterm use of continuous intrathecal opioid/bupivacaine analgesia in a case not amendable to corrective surgery. Methods. A 77-year-old woman, having a total hip arthroplasty, developed refractory nodceptive-neuropathic pain located at the ventral and dorsal aspects of the left hip. Radiographs showed a mandarine-sized intrapeMc mass of bone cement adhering to the roof of the acetabular cup. Further surgery had been declined by the surgeon and by the patient. An 18-gauge Portex intrathecal catheter was inserted, and an intrathecal infusion of 4.75 mg/mL bupivacaine and 0.015 mg/mL buprenorphine was started from a portable Pharmacia-Deltec (St. Paul, Minnesota) pump. Results. The mean daily doses during the treatment period (more than 6 years up to now) were 37 mg for bupivacaine and 0.114 mg for buprenorphine. The intrathecal treatment gave the patient 85-100% pain relief. The patient could transport herself in a wheelchair, was able to perform her own hygiene, receive visits, read, watch television, and also shop and visit restaurants. There has been no need to replace the intrathecal catheter. Conclusion. Intrathecal infusion of opioid/bupivacaine can provide satisfactory long-term analgesia in patients with refractory pain from the hip joint. Reg Anesth Pain Med 1998: 23: 315-319. K e y words:total hip arthroplasty, complications, pain, intrathecal opioid/ bupivacaine.
Total hip arthroplasty (THA) is n o w routinely used to i m p r o v e function of the joint and to reduce
pain in patients w i t h p r i m a r y or secondary hip arthrosis. Severe, persisting, disabling pain after THA occurs in 3 % of patients (1) and persistent slight pain in 17% of patients (2). Further, 0.4% of the THA patients u n d e r w e n t revision because of pain (3). In addition, the patients w h o u n d e r w e n t revision for failed TIq[A h a d less pain relief t h a n those w i t h p r i m a r y hip r e p l a c e m e n t (4), and 1 4 - 1 8 % of t h e m (5,6) w e r e still affected by severe pain, w h i c h was not satisfactorily relieved b y the currently available n o n i n v a s i v e a n d invasive analgesic therapy. Such pain is h e r e called refractory, or intractable, pain. This case report describes a patient w h o h a d refractory nociceptive and n e u r o p a t h i c p a i n after failed THA. The pain has n o w b e e n successfully treated for m o r e t h a n 2,000 consecutive days with
From the Department of Anaesthesia, Sahlgrenska University Hospital, G6teborg University, Gothenburg, Sweden. This work was supported by grants from families and friends of the patients with "refractory" pain treated with intrathecal morphine-bupivacaine in the City of Gothenburg and the Gothenburg region (No. 5753-24 955 02), by grant No. 8190 30 from the Research Council of the Faculty of Medidne of G6teburg University, and by a grant from Inga-Britt and Arne Lundberg's Research Foundation (No. 162194). None of the grant givers had any economic interest in the elaboration and publication of this artide. Accepted for publication January 26, 1998. Reprint requests: Ioan D. Curelaru, M.D., Ph.D., c/o Petre Nitescu, M.D., Ph.D., Department of Anaesthesiology, Pain Section, Sahlgrenska University Hospital, S-413 45 Gothenburg, Sweden. Copyright © 1998 by the American Society of Regional Anesthesia. 0146-52 lX/98/2303-001555.00/0
315
316
RegionalAnesthesia and Pain Medicine Vol. 23 No. 3 May-June 1998
a continuous intrathecal infusion of opioid (buprenorphine) and bupivacaine.
Case Report A 77-year-old woman was referred to the Pain Section of Sahlgrenska University Hospital (Gothenburg, Sweden) in April 1991 for refractory pain after THA of the left hip.
Chief Complaints At the time of referral, the patient suffered from resting and movement-related ("incident") pain, located at both the ventral and dorsal aspect of the left hip, the back of the left leg and the left inguinofemoral area. She described her pains as dull, aching, stabbing, burning, and "electric shocklike." The pain intensity [visual analog scale (VAS) scores = from 0 to 10] ranged from the minimum VASmin = 0 (at rest, after intake of opioid) to the maximum VASmax = 10 (with body movements and during walking). Handicapped by pain and hip instability, she had difficulties sitting, and she could only walk about 10 m without assistance. She could sleep only in a dorsal decubitus position, having her nocturnal sleep duration reduced to 4-5 hours.
Pertinent Past Medical History The patient had been operated on emergently in 1983 for a neck fracture ot the left femur. The involved femoral head eventually developed necrosis, and the patient underwent reoperation with Charnley's prosthesis in November 1986. The patient's pain had previously been treated with paracetamol, aspirin, nonsteroidal anti-inflammatory drugs, morphine mixture, and slow-release morphine tablets, without satisfactory pain relief. At the time of referral, her pain was treated with intramuscular morphine 5 mg four times a day (this low dose was given with due consideration given to the patient's age and asthma, but it was obviously insufficient to relieve her pain), paracetamol, aspirin, and benzodiazepines (to improve her nocturnal sleep).
Physical Examination The affected leg was laterally rotated, and she complained of pain on palpation over the great trochanter. A radiograph showed a mandarinesized intrapelvic mass of bone cement projected over the lower part of the greater sciatic foramen. Because of the patient's severe cardiac decompen-
sation after sustaining myocardial infarction, the orthopedic surgeon declined to reoperate.
Intrathecal Pain Treatment In April 1991, an 18-gauge intrathecal catheter (Portex, Hyte, Kent, England) was inserted via the L3-L4 interspace as previously reported (7) and advanced cranially 15 cm from the skin with its tip placed at the height of the L1-L2 interspace. An intrathecal infusion of 4.75 mg/mL bupivacaine and 0.015 mg/mL buprenorphine was started. The patient was supervised for 12 hours in the postoperative care unit and thereafter permanently treated in a nursing home. Antibiotics were given for 3 days. The pump delivery was adjusted (rate, intermittent dose, and lockout interval) to provide acceptable (80-100%) pain relief. The patient was given ad libitum access to nonopioid analgesics and sedatives and to opioids administered by various routes until she obtained satisfactory pain and anxiolytic relief. The first redressing of the insertion site was performed after 48 hours and thereafter once a week. The skin sutures (except those fixing the catheter) were removed after 7 days. The cassettes with bupivacaine and buprenorphine solution were refilled when empty by the nurses of the nursing home, and the antibacterial filter was changed once a month by the specially instructed nurses of the pain section. Daily phone contact was kept by the doctors or nurses of the pain section of the university hospital and the nurses in charge of the nursing home. The efficacy of the treatment was estimated daily from: (a) dosages of opioid administered by intrathecal and other routes and of intrathecal bupivacaine; (b) pain intensity (VAS) and pain relief (%) calculated from the VAS; (c) scores (0-5) of nocturnal sleep duration, gait and ambulation, and consumption of nonopioid analgesics and sedatives (see legend to Fig. 3). All scores were expressed as the mean of their respective periods (8).
Clinical Course of the Pain Under Intrathecal Treatment The mean daily doses of opioid administered by other routes than spinal (oral, parenteral) ranged from 4 mg during the first year to 12 mg parenteral morphine-eq during the sixth year of treatment (Fig. 1A). The mean daily doses during the 6 years of intrathecal treatment were 37 mg for bupivacaine and 0.114 mg for buprenorphine, while the highest doses were 52 mg for bupivacaine and 0.165 mg for buprenorphine (Fig. 1B, C). The cumulative doses at the time of submission of this
Intrathecal Bupivacaine for "Refractory" Hip Pain •
60 (A)
OTHER ROUTE OPIOID
.g" o¢
¢
Before i l d
lw
lm
6m
ly
2y
3y
4y
INTRATHECAL
.3 .25
i
(B)
.
,.TR.T.EC
5y
6y
Highest
PERIOD
.
.
.
i
,
6"/
Highest
..UPRE.ORP.I.E
.2 ~.15
.05 td
lw
lm
6m
fy
2y
3y
INTRATHECAL
4y
5¥
317
(Fig. 3B). Her daily consumption of nonopioid analgesics and sedatives decreased by 80-100% (Fig. 3C). The patient was able to perform daily living activities, such as; attending to her personal hygiene, receiving 'visits, reading, watching televisions, handicrafts and, during the first 3 years of treatment, transport in a wheelchair, shopping, and visiting restaurants. Before the start of the intrathecal treatment, the patient required insertion of an indwelling urinary catheter for previously existing urine incontinence. She experienced transient paresthesiae and pareses in her lower extremities. There was intermittent feces incontinence apparently related to aging, duration of the treatment, and intrathecal bupivacaine daily doses. No other complications attributable to the intrathecal treatment have occurred, and there has been no need to replace the intrathecal catheter. The tunnel outlet and the skin suture entry sites were clean and free of inflammatory reaction after 6 years of catheter indwelling.
PERIOD
,
(A)
,
I
,
.
,
I
,
,
4y
5y
6y
VAS DAILY S C O R E S
1C - -
6O
8
50 A
Dahm et al.
6
40
E
3o
g 20
2
10
0 Max. Mean[ Score Score[
0 ld
lw
tm
6m
ty
INTRATHECAL
2y
3¥
4y
5y
6y
Highest
ld
BEFORE [ [
PERIOD
Fig. 1. Bar chart representing the m e a n daily doses of opioids administered by other routes than spinal (A),
intrathecal buprenorphine (B), and intrathecal bupivacaine (C) from the first day throughout the 6 years of treatment, d, day; w, week; m, month(s); y, year(s).
lw
lm
6m
ly
3y
DURING INTRATHECAL TREATMENT
PERCENTAGE PAIN RELIEF
100
t(i3) ...........
80] 60
article (September 1997), after 2,335 days of intrathecal treatment, were 617,353 mg bupivacaine and 273 mg buprenorphine. The intrathecal treatment substantially reduced the pain intensity, giving the patient acceptable (85-100%) pain relief (Fig. 2A, B). The duration of nocturnal sleep increased from 4-5 to 6-7 hours (Fig. 3A). Ambulation was reduced from walking with support to transport in a wheelchair during the first 3 years of the intrathecal treatment. Thereafter, because of gradual deterioration of her general condition, the patient became totally bedridden
2¥
Mean Pain Scores
40
o. 20 ; Min. M e a n [ l d Pain Pain [ Relief Relief.~
BEFORE [
' lw
lm
6m
'iii! ly
2y
3y
4y
5y
6y
Mean Pain Relief
DURING INTRATNECAL TREATMENT
Fig. 2. Bar chart representing (A) VAS scores and (B)
pain relief (percentages) before and during the intrathecal pain treatment. Max., maximal; Min., minimal; d, day; w, week; m, month(s); y, year(s); VAS, visual analog scale.
318
Regional Anesthesia and Pain Medicine Vol. 23 No. 3 May-June 1998
pain. Reversible sodium channel block is the major pharmacologic property of local anesthetics (9). Thus, the intrathecal bupivacaine acts by the following mechanisms:
v
i
Before!
ld
lw
!
lm
6m
ly 2y MEAN SCORES
•
4y
5y
6y
DURING INTRATHECAL PERIOD GAIT/AM~IJLATION
0
3¥
.
Before ~ ld ;
.
.
lw
i
. lm
. 6m
SCORES
--:'--
. ly 2y 3y MEAN SCORES
4y
"7-
5y
m
6y
(a) Producing a ditferential block of the peripheral noxious input at the level of the dorsal nerve roots and spinal ganglion cells by concentrations of local anesthetic w h i c h are lower t h a n those n e e d e d for total block of a given nerve fiber (10). (b) Blocking the superficial layers of the spinal cord and the w i d e - d y n a m i c range interneurons involved in noxious transmission thereby impeding release of some neurotransmitters (e.g., neurokin i n - A and substance P) and inhibiting the excitability increases of second-order n e u r o n s (11). Addition of intrathecal b u p r e n o r p h i n e (because of its spinal and supraspinal analgesic effect) to intrathecal bupivacaine might potentiate the analgesic effect of intrathecal bupivacaine. Continuous intrathecal infusion of bupivacaine and b u p r e n o r p h i n e appears to be a reliable and effective m e t h o d of neural block in the long-term treatment of intractable pain after THA.
DURING INTRATHECAL PERIOD
References 4 E
3 2
Before| l d
1
lw
lm
6m
ly 2y MEAN SCORES
3y
4y
5y
DURING INTRATHECAL PERIOD
Fig. 3. Bar chart representing (A) nocturnal sleep pattern scores: 0 = coma; 1 = <2 hours of uninterrupted sleep; 2 = >2 hours; 3 = >4 hours; 4 = >6 hours; 5 = 7-8 hours. (B) Gait and mobility scores: 0 = bedridden; 1 = could be moved; 2 = could move independently, e.g., with a wheelchair; 3 = could walk with help (crutches, frame, other person, etc.); 4 = could walk without help; 5 = returned to normal activities. (C) Nonopioid analgesic and sedative drug consumption scores: 0 = high daily doses of "lytic cocktails"; t = four drugs; 2 = three drugs; 3 = two drugs; 4 = one drug; 5 = no drug. N.B.: This is an inversed score[
Discussion Abnormalities of axonal sodium channel distribution have been described in patients with chronic
1. Jinnah RH, Amstutz HC, Tooke SM, Dorey F, Dalseth T. Charnley experience: A long-term follow-up study using survival analysis. Clin Orthop 1986: 21I: 164-172. 2. Callaghan JJ, Dysart SH, Savory CG. The uncemented porous-coated anatomic total hip prosthesis. Two-year results of a prospective consecutive series. J Bone Joint Surg Am 1988: 70: 337-346. 3. Malchau H, Herberts P. Prognosis of total hip replacement. Scientific Exhibition Presented at the 3rd Annual Meeting of the American Academy of Orthopedic Surgeons, February 22-26, 1996, Atlanta, GA.
4. Arajarvi E, Santavirta S. Revision arthroplasty of the hip joint. A retrospective analysis. Arch Orthop Trauma Surg 1987: 106: 152-156. 5. Chamay A, Taillard W, Kritsikis N, Burckhardt A. Die Huftresektion nach Girdlestone. Klinische und elektromyokinesigraphische Studie. Orthopade 1987: 16: 287-294. 6. de Laat EA, van der List J J, van Horn JR, Sloof TJ. Girdlestone's pseudoarthrosis alter removal of a total hip prosthesis: A retrospective study of 40 patients. Acta Orthop Belg 1991: 57:109-113. 7. Nitescu P, Appelgren L, Hultman E, Linder LE, Sj6berg M, Curelaru I. Long-term, open catheterization of the spinal subarachnoid space for continuous infusion of narcotic and bupivacaine in patients with "refractory" cancer pain. A technique
Intrathecal Bupivacaine for "Refractory" Hip Pain of catheterization and its problems and complications. Clin J Pain 1991: 7: 143-161. 8. Jensen MP. Increasing the reliability and validity of pain intensity m e a s u r e m e n t in chronic pain patients. Pain 1993: 55: 195-203. 9. Chaplan SR, Bach FW, Sharer SL, Yaksh TL. Prolonged alleviation of tactile allodynia by intravenous lidocaine in neuropathic rats. Anesthesiology 1995: 83: 775-785.
•
Dahm et al.
319
10. Frumin MJ, Schwartz H, Burns J, Brodie BB, Papper EM. Dorsal root ganglion blockade during threshold segmental spinal anesthesia in man. J Pharmacol Exp Ther 1954: 112: 387-392. 11. Cohen ML. Arthralgia and myalgia. In: Campbell JN, ed. Pain 1 9 9 6 - - A n u p d a t e d review. Refresher course syllabus. IASP C o m m i t t e e on Refresher Courses. Seattle, WA, IASP Press, I996: 327-337.
Six Years of C o n t i n u o u s Intrathecal Infusion of Opioid and B u p i v a c a i n e in the T r e a t m e n t of Refractory Pain D u e to Intrapelvic Extrusion of B o n e C e m e n t After Total Hip A r t h r o p l a s t y Peter O. Dahm, M.D., Ph.D., Petre V. Nitescu, M.D., Ph.D., Lennart K. Appelgren, M.D., Ph.D., and Ioan D. Curelaru, M.D., Ph.D.
Background and Objectives. There is at present no reliable method for long-term treatment of severe pain following complications of total hip arthroplasty. We explored the longterm use of continuous intrathecal opioid/bupivacaine analgesia in a case not amendable to corrective surgery. Methods. A 77-year-old woman, having a total hip arthroplasty, developed refractory nodceptive-neuropathic pain located at the ventral and dorsal aspects of the left hip. Radiographs showed a mandarine-sized intrapeMc mass of bone cement adhering to the roof of the acetabular cup. Further surgery had been declined by the surgeon and by the patient. An 18-gauge Portex intrathecal catheter was inserted, and an intrathecal infusion of 4.75 mg/mL bupivacaine and 0.015 mg/mL buprenorphine was started from a portable Pharmacia-Deltec (St. Paul, Minnesota) pump. Results. The mean daily doses during the treatment period (more than 6 years up to now) were 37 mg for bupivacaine and 0.114 mg for buprenorphine. The intrathecal treatment gave the patient 85-100% pain relief. The patient could transport herself in a wheelchair, was able to perform her own hygiene, receive visits, read, watch television, and also shop and visit restaurants. There has been no need to replace the intrathecal catheter. Conclusion. Intrathecal infusion of opioid/bupivacaine can provide satisfactory long-term analgesia in patients with refractory pain from the hip joint. Reg Anesth Pain Med 1998: 23: 315-319. K e y words:total hip arthroplasty, complications, pain, intrathecal opioid/ bupivacaine.
Total hip arthroplasty (THA) is n o w routinely used to i m p r o v e function of the joint and to reduce
pain in patients w i t h p r i m a r y or secondary hip arthrosis. Severe, persisting, disabling pain after THA occurs in 3 % of patients (1) and persistent slight pain in 17% of patients (2). Further, 0.4% of the THA patients u n d e r w e n t revision because of pain (3). In addition, the patients w h o u n d e r w e n t revision for failed TIq[A h a d less pain relief t h a n those w i t h p r i m a r y hip r e p l a c e m e n t (4), and 1 4 - 1 8 % of t h e m (5,6) w e r e still affected by severe pain, w h i c h was not satisfactorily relieved b y the currently available n o n i n v a s i v e a n d invasive analgesic therapy. Such pain is h e r e called refractory, or intractable, pain. This case report describes a patient w h o h a d refractory nociceptive and n e u r o p a t h i c p a i n after failed THA. The pain has n o w b e e n successfully treated for m o r e t h a n 2,000 consecutive days with
From the Department of Anaesthesia, Sahlgrenska University Hospital, G6teborg University, Gothenburg, Sweden. This work was supported by grants from families and friends of the patients with "refractory" pain treated with intrathecal morphine-bupivacaine in the City of Gothenburg and the Gothenburg region (No. 5753-24 955 02), by grant No. 8190 30 from the Research Council of the Faculty of Medidne of G6teburg University, and by a grant from Inga-Britt and Arne Lundberg's Research Foundation (No. 162194). None of the grant givers had any economic interest in the elaboration and publication of this artide. Accepted for publication January 26, 1998. Reprint requests: Ioan D. Curelaru, M.D., Ph.D., c/o Petre Nitescu, M.D., Ph.D., Department of Anaesthesiology, Pain Section, Sahlgrenska University Hospital, S-413 45 Gothenburg, Sweden. Copyright © 1998 by the American Society of Regional Anesthesia. 0146-52 lX/98/2303-001555.00/0
315
316
RegionalAnesthesia and Pain Medicine Vol. 23 No. 3 May-June 1998
a continuous intrathecal infusion of opioid (buprenorphine) and bupivacaine.
Case Report A 77-year-old woman was referred to the Pain Section of Sahlgrenska University Hospital (Gothenburg, Sweden) in April 1991 for refractory pain after THA of the left hip.
Chief Complaints At the time of referral, the patient suffered from resting and movement-related ("incident") pain, located at both the ventral and dorsal aspect of the left hip, the back of the left leg and the left inguinofemoral area. She described her pains as dull, aching, stabbing, burning, and "electric shocklike." The pain intensity [visual analog scale (VAS) scores = from 0 to 10] ranged from the minimum VASmin = 0 (at rest, after intake of opioid) to the maximum VASmax = 10 (with body movements and during walking). Handicapped by pain and hip instability, she had difficulties sitting, and she could only walk about 10 m without assistance. She could sleep only in a dorsal decubitus position, having her nocturnal sleep duration reduced to 4-5 hours.
Pertinent Past Medical History The patient had been operated on emergently in 1983 for a neck fracture ot the left femur. The involved femoral head eventually developed necrosis, and the patient underwent reoperation with Charnley's prosthesis in November 1986. The patient's pain had previously been treated with paracetamol, aspirin, nonsteroidal anti-inflammatory drugs, morphine mixture, and slow-release morphine tablets, without satisfactory pain relief. At the time of referral, her pain was treated with intramuscular morphine 5 mg four times a day (this low dose was given with due consideration given to the patient's age and asthma, but it was obviously insufficient to relieve her pain), paracetamol, aspirin, and benzodiazepines (to improve her nocturnal sleep).
Physical Examination The affected leg was laterally rotated, and she complained of pain on palpation over the great trochanter. A radiograph showed a mandarinesized intrapelvic mass of bone cement projected over the lower part of the greater sciatic foramen. Because of the patient's severe cardiac decompen-
sation after sustaining myocardial infarction, the orthopedic surgeon declined to reoperate.
Intrathecal Pain Treatment In April 1991, an 18-gauge intrathecal catheter (Portex, Hyte, Kent, England) was inserted via the L3-L4 interspace as previously reported (7) and advanced cranially 15 cm from the skin with its tip placed at the height of the L1-L2 interspace. An intrathecal infusion of 4.75 mg/mL bupivacaine and 0.015 mg/mL buprenorphine was started. The patient was supervised for 12 hours in the postoperative care unit and thereafter permanently treated in a nursing home. Antibiotics were given for 3 days. The pump delivery was adjusted (rate, intermittent dose, and lockout interval) to provide acceptable (80-100%) pain relief. The patient was given ad libitum access to nonopioid analgesics and sedatives and to opioids administered by various routes until she obtained satisfactory pain and anxiolytic relief. The first redressing of the insertion site was performed after 48 hours and thereafter once a week. The skin sutures (except those fixing the catheter) were removed after 7 days. The cassettes with bupivacaine and buprenorphine solution were refilled when empty by the nurses of the nursing home, and the antibacterial filter was changed once a month by the specially instructed nurses of the pain section. Daily phone contact was kept by the doctors or nurses of the pain section of the university hospital and the nurses in charge of the nursing home. The efficacy of the treatment was estimated daily from: (a) dosages of opioid administered by intrathecal and other routes and of intrathecal bupivacaine; (b) pain intensity (VAS) and pain relief (%) calculated from the VAS; (c) scores (0-5) of nocturnal sleep duration, gait and ambulation, and consumption of nonopioid analgesics and sedatives (see legend to Fig. 3). All scores were expressed as the mean of their respective periods (8).
Clinical Course of the Pain Under Intrathecal Treatment The mean daily doses of opioid administered by other routes than spinal (oral, parenteral) ranged from 4 mg during the first year to 12 mg parenteral morphine-eq during the sixth year of treatment (Fig. 1A). The mean daily doses during the 6 years of intrathecal treatment were 37 mg for bupivacaine and 0.114 mg for buprenorphine, while the highest doses were 52 mg for bupivacaine and 0.165 mg for buprenorphine (Fig. 1B, C). The cumulative doses at the time of submission of this
Intrathecal Bupivacaine for "Refractory" Hip Pain •
60 (A)
OTHER ROUTE OPIOID
.g" o¢
¢
Before i l d
lw
lm
6m
ly
2y
3y
4y
INTRATHECAL
.3 .25
i
(B)
.
,.TR.T.EC
5y
6y
Highest
PERIOD
.
.
.
i
,
6"/
Highest
..UPRE.ORP.I.E
.2 ~.15
.05 td
lw
lm
6m
fy
2y
3y
INTRATHECAL
4y
5¥
317
(Fig. 3B). Her daily consumption of nonopioid analgesics and sedatives decreased by 80-100% (Fig. 3C). The patient was able to perform daily living activities, such as; attending to her personal hygiene, receiving 'visits, reading, watching televisions, handicrafts and, during the first 3 years of treatment, transport in a wheelchair, shopping, and visiting restaurants. Before the start of the intrathecal treatment, the patient required insertion of an indwelling urinary catheter for previously existing urine incontinence. She experienced transient paresthesiae and pareses in her lower extremities. There was intermittent feces incontinence apparently related to aging, duration of the treatment, and intrathecal bupivacaine daily doses. No other complications attributable to the intrathecal treatment have occurred, and there has been no need to replace the intrathecal catheter. The tunnel outlet and the skin suture entry sites were clean and free of inflammatory reaction after 6 years of catheter indwelling.
PERIOD
,
(A)
,
I
,
.
,
I
,
,
4y
5y
6y
VAS DAILY S C O R E S
1C - -
6O
8
50 A
Dahm et al.
6
40
E
3o
g 20
2
10
0 Max. Mean[ Score Score[
0 ld
lw
tm
6m
ty
INTRATHECAL
2y
3¥
4y
5y
6y
Highest
ld
BEFORE [ [
PERIOD
Fig. 1. Bar chart representing the m e a n daily doses of opioids administered by other routes than spinal (A),
intrathecal buprenorphine (B), and intrathecal bupivacaine (C) from the first day throughout the 6 years of treatment, d, day; w, week; m, month(s); y, year(s).
lw
lm
6m
ly
3y
DURING INTRATHECAL TREATMENT
PERCENTAGE PAIN RELIEF
100
t(i3) ...........
80] 60
article (September 1997), after 2,335 days of intrathecal treatment, were 617,353 mg bupivacaine and 273 mg buprenorphine. The intrathecal treatment substantially reduced the pain intensity, giving the patient acceptable (85-100%) pain relief (Fig. 2A, B). The duration of nocturnal sleep increased from 4-5 to 6-7 hours (Fig. 3A). Ambulation was reduced from walking with support to transport in a wheelchair during the first 3 years of the intrathecal treatment. Thereafter, because of gradual deterioration of her general condition, the patient became totally bedridden
2¥
Mean Pain Scores
40
o. 20 ; Min. M e a n [ l d Pain Pain [ Relief Relief.~
BEFORE [
' lw
lm
6m
'iii! ly
2y
3y
4y
5y
6y
Mean Pain Relief
DURING INTRATNECAL TREATMENT
Fig. 2. Bar chart representing (A) VAS scores and (B)
pain relief (percentages) before and during the intrathecal pain treatment. Max., maximal; Min., minimal; d, day; w, week; m, month(s); y, year(s); VAS, visual analog scale.
318
Regional Anesthesia and Pain Medicine Vol. 23 No. 3 May-June 1998
pain. Reversible sodium channel block is the major pharmacologic property of local anesthetics (9). Thus, the intrathecal bupivacaine acts by the following mechanisms:
v
i
Before!
ld
lw
!
lm
6m
ly 2y MEAN SCORES
•
4y
5y
6y
DURING INTRATHECAL PERIOD GAIT/AM~IJLATION
0
3¥
.
Before ~ ld ;
.
.
lw
i
. lm
. 6m
SCORES
--:'--
. ly 2y 3y MEAN SCORES
4y
"7-
5y
m
6y
(a) Producing a ditferential block of the peripheral noxious input at the level of the dorsal nerve roots and spinal ganglion cells by concentrations of local anesthetic w h i c h are lower t h a n those n e e d e d for total block of a given nerve fiber (10). (b) Blocking the superficial layers of the spinal cord and the w i d e - d y n a m i c range interneurons involved in noxious transmission thereby impeding release of some neurotransmitters (e.g., neurokin i n - A and substance P) and inhibiting the excitability increases of second-order n e u r o n s (11). Addition of intrathecal b u p r e n o r p h i n e (because of its spinal and supraspinal analgesic effect) to intrathecal bupivacaine might potentiate the analgesic effect of intrathecal bupivacaine. Continuous intrathecal infusion of bupivacaine and b u p r e n o r p h i n e appears to be a reliable and effective m e t h o d of neural block in the long-term treatment of intractable pain after THA.
DURING INTRATHECAL PERIOD
References 4 E
3 2
Before| l d
1
lw
lm
6m
ly 2y MEAN SCORES
3y
4y
5y
DURING INTRATHECAL PERIOD
Fig. 3. Bar chart representing (A) nocturnal sleep pattern scores: 0 = coma; 1 = <2 hours of uninterrupted sleep; 2 = >2 hours; 3 = >4 hours; 4 = >6 hours; 5 = 7-8 hours. (B) Gait and mobility scores: 0 = bedridden; 1 = could be moved; 2 = could move independently, e.g., with a wheelchair; 3 = could walk with help (crutches, frame, other person, etc.); 4 = could walk without help; 5 = returned to normal activities. (C) Nonopioid analgesic and sedative drug consumption scores: 0 = high daily doses of "lytic cocktails"; t = four drugs; 2 = three drugs; 3 = two drugs; 4 = one drug; 5 = no drug. N.B.: This is an inversed score[
Discussion Abnormalities of axonal sodium channel distribution have been described in patients with chronic
1. Jinnah RH, Amstutz HC, Tooke SM, Dorey F, Dalseth T. Charnley experience: A long-term follow-up study using survival analysis. Clin Orthop 1986: 21I: 164-172. 2. Callaghan JJ, Dysart SH, Savory CG. The uncemented porous-coated anatomic total hip prosthesis. Two-year results of a prospective consecutive series. J Bone Joint Surg Am 1988: 70: 337-346. 3. Malchau H, Herberts P. Prognosis of total hip replacement. Scientific Exhibition Presented at the 3rd Annual Meeting of the American Academy of Orthopedic Surgeons, February 22-26, 1996, Atlanta, GA.
4. Arajarvi E, Santavirta S. Revision arthroplasty of the hip joint. A retrospective analysis. Arch Orthop Trauma Surg 1987: 106: 152-156. 5. Chamay A, Taillard W, Kritsikis N, Burckhardt A. Die Huftresektion nach Girdlestone. Klinische und elektromyokinesigraphische Studie. Orthopade 1987: 16: 287-294. 6. de Laat EA, van der List J J, van Horn JR, Sloof TJ. Girdlestone's pseudoarthrosis alter removal of a total hip prosthesis: A retrospective study of 40 patients. Acta Orthop Belg 1991: 57:109-113. 7. Nitescu P, Appelgren L, Hultman E, Linder LE, Sj6berg M, Curelaru I. Long-term, open catheterization of the spinal subarachnoid space for continuous infusion of narcotic and bupivacaine in patients with "refractory" cancer pain. A technique
Intrathecal Bupivacaine for "Refractory" Hip Pain of catheterization and its problems and complications. Clin J Pain 1991: 7: 143-161. 8. Jensen MP. Increasing the reliability and validity of pain intensity m e a s u r e m e n t in chronic pain patients. Pain 1993: 55: 195-203. 9. Chaplan SR, Bach FW, Sharer SL, Yaksh TL. Prolonged alleviation of tactile allodynia by intravenous lidocaine in neuropathic rats. Anesthesiology 1995: 83: 775-785.
•
Dahm et al.
319
10. Frumin MJ, Schwartz H, Burns J, Brodie BB, Papper EM. Dorsal root ganglion blockade during threshold segmental spinal anesthesia in man. J Pharmacol Exp Ther 1954: 112: 387-392. 11. Cohen ML. Arthralgia and myalgia. In: Campbell JN, ed. Pain 1 9 9 6 - - A n u p d a t e d review. Refresher course syllabus. IASP C o m m i t t e e on Refresher Courses. Seattle, WA, IASP Press, I996: 327-337.