Myers, J., Chan, V., Jarvis, V., & Walker-Dilks, C. (2010). Intraspinal techniques for pain management in cancer patients: a systematic review. Supportive Care in Cancer, 18(2), 137–149.

To examine the evidence related to intraspinal analgesia and outline resources required to support patients with cancer-related pain

Databases searched were MEDLINE (1950-2008), EMBASE (1980-2008), CINAHL (1982-2008), and the Cochrane Database. A Google internet search was also performed.

Search keywords were intraspinal, epidural, intrathecal injections, pain, cancer, and study design terms for randomized controlled trials and systematic reviews.

Studies were included in the review if they

• Used a randomized controlled trial (RCT) study design, were systematic reviews of RCTs, or were clinical practice guidelines.
• Involved patients of any age and gender experiencing cancer-related pain.
• Compared intraspinal techniques alone or in combination with different intraspinal techniques or other pain management interventions, compared external versus internal pumps, or evaluated timing of intraspinal techniques.
• Measured pain outcomes with a validated scale.

Studies and reviews were excluded if they

• Used intraspinal techniques for procedure-related pain.
• Were not in the English language.
• Were case reports, letters, comments, or news only.

Three systematic reviews, three consensus conferences, and 12 RCTs met the inclusion criteria for evidence of effectiveness. The Appraisal of Guidelines for Research and Evaluation instrument was used to evaluate guidelines. Indicators to evaluate the quality of the other references were publication status (full versus abstract), statement of statistical power or sample size calculation, intention-to-treat analysis, and statement of sponsorship or funding. The final collection of references were eight practice guidelines (which included four local, internal-use, clinical care algorithms or policy and procedure documents and one practice standard), two systematic reviews, and 12 RCTs. Specific information was provided for two systematic reviews, one consensus statement, and 12 RCTs.

• The studies involved a total of 617 patients with samples ranging from 10–102.
• Ages ranged from 22–82 years.
• Follow-up in RCTs ranged from 18 hours to 169 days.
• Most patients included in RCTs had refractory pain.

• Three studies compared intraspinal pain management to other interventions. Of these, two had small sample sizes and showed no differences. The other study, which involved 202 patients, showed reduced pain on a visual analog scale (p = 0.055) and significant reduction in fatigue and depressed consciousness with intrathecal pain management (p < 0.05). Crossover analysis showed greater clinical success with combined therapy.
• Seven RCTs compared different types of drugs or compared drugs with placebos. Most of these studies had small samples and demonstrated mixed results.
• Two small RCTs compared different intraspinal techniques, including epidural infusion by internal pump, intermittent bolus via porta catheter, and epidural administration of morphine in the thoracic versus cervical regions. No differences in pain outcomes were found. The thoracic route was associated with a greater rate of adverse effects.
• Five documents addressed contraindications for intraspinal analgesia, such as anticoagulation, active systemic or local infection, and neurologic conditions such as unstable central nervous system (CNS) disorders and spinal canal pathology. Unmotivated and noncompliant patients also were identified as contraindicated to this approach.
• Documents addressing care needs discussed equipment types, aftercare, monitoring, hospital discharge, follow-up, interprofessional roles, professional education and competencies, patient and family education, and patient safety. The need to prevent infection and to monitor catheter malposition, vital signs, and complications were emphasized. Recommendations included certification of staff who administer intraspinal analgesia, patient protection from infection, appropriate patient monitoring, and comprehensive discharge planning to support this therapy.
• Indications that were supported across all consensus documents for this therapy were intractable pain that could not be controlled by other methods and side effects from conventional routes that prevented dose escalation.
• The most clinically relevant findings were with the use of nonopioids.

Intraspinal analgesia for cancer pain has been shown to provide adequate pain control and fewer side effects than conventional therapy. Because this is an infrequent intervention, high-quality evidence evaluating effectiveness is limited; however, effectiveness has been demonstrated in carefully selected patient groups with intractable pain. Nonopioid effectiveness suggests that use may be most beneficial in situations of opioid refractory pain.

The intraspinal route should be considered as part of a comprehensive pain management strategy. To ensure patient safety, this approach requires appropriate resources and staff guidance via policy and procedures.