Hassenbusch S J, Stanton-Hicks M D, Soukup J, Covington E C, Boland M B
Department of Neurosurgery, Cleveland Clinic Foundation, Ohio.
Neurosurgery. 1991 Jul;29(1):76-81; discussion 81-2. doi: 10.1097/00006123-199107000-00013.
Intraspinal narcotic (usually intrathecal morphine) infusions with implanted pumps are increasingly used in patients with intractable chronic pain not caused by cancer. In some patients, pain control is difficult with infusions of morphine. Seven patients with diagnoses of arachnoiditis, epidural scarring, and/or vertebral body compression fracture were treated with alternative solutions in an epidural route. For maximal flexibility, Medtronic implanted programmable infusion pumps with catheters to T6-T10 were used, and pain was monitored by verbal pain scales. In three patients, epidural infusions of morphine in 0.5% bupivacaine (MS-MARC) resulted in little or no pain relief without significant side effects (e.g., headache, nausea, or vomiting). In these same patients, epidural infusions of sufentanil citrate resulted in pain scale reductions of 92%, 82%, and 40%, respectively, with no side effects. Four other patients found more effective pain relief when switched from initial sufentanil citrate infusions to MS-MARC. Pain scale reductions (with no side effects) were 92%, 76%, 59%, and 47% in these patients. Pain relief and minimal side effects with sufentanil citrate is theorized to result from its higher lipophilicity promoting local transdural diffusion to spinal cord and limiting upward diffusion to the brain stem. Sufentanil citrate is also advantageous for programmable pumps because it is 100 times more potent than morphine and therefore allows longer pump refill times and higher infusion doses. Although this study was done on a limited number of patients, sufentanil citrate and MS-MARC in epidural infusions using programmable infusion pumps for non-cancer patients provide significant alternative drug combinations and routes.
对于非癌症所致的顽固性慢性疼痛患者，越来越多地使用植入式泵进行脊髓内麻醉剂（通常是鞘内注射吗啡）输注。在一些患者中，吗啡输注难以控制疼痛。7例诊断为蛛网膜炎、硬膜外瘢痕形成和/或椎体压缩骨折的患者接受了硬膜外途径的替代溶液治疗。为了实现最大灵活性，使用了美敦力植入式可编程输注泵，其导管可达T6 - T10，并通过言语疼痛量表监测疼痛。在3例患者中，硬膜外输注0.5%布比卡因中的吗啡（MS - MARC）几乎没有或根本没有缓解疼痛，且无明显副作用（如头痛、恶心或呕吐）。在这些相同的患者中，硬膜外输注枸橼酸舒芬太尼分别使疼痛量表评分降低了92%、82%和40%，且无副作用。另外4例患者从最初的枸橼酸舒芬太尼输注改为MS - MARC后，疼痛缓解更为有效。这些患者的疼痛量表评分降低（无副作用）分别为92%、76%、59%和47%。据推测，枸橼酸舒芬太尼缓解疼痛且副作用最小是由于其较高的亲脂性促进了局部经硬膜扩散至脊髓，并限制了向上扩散至脑干。枸橼酸舒芬太尼对于可编程泵也具有优势，因为它的效力比吗啡强100倍，因此允许更长的泵重新填充时间和更高的输注剂量。尽管这项研究是在有限数量的患者中进行的，但对于非癌症患者，使用可编程输注泵进行硬膜外输注时，枸橼酸舒芬太尼和MS - MARC提供了重要的替代药物组合和途径。
