Ade Timothy, Roh Justin, Sharma Gautam, Mohan Mahesh, DeLozier Sarah J, Janes Jessica L, Hayek Salim M
Division of Pain Medicine, Department of Anesthesiology/Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio.
Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.
Pain Med. 2020 Sep 1;21(9):1921-1928. doi: 10.1093/pm/pnaa104.
Targeted intrathecal drug delivery (TIDD) is an effective interventional pain management modality often used in postlaminectomy patients with refractory chronic low back pain. A combination of intrathecal bupivacaine with an opioid is often used. However, intrathecal catheter tip granulomas have occurred with use of morphine or hydromorphone but generally not with fentanyl. The objective of this study was to compare the efficacy of TIDD using bupivacaine/fentanyl vs bupivacaine/hydromorphone in patients with chronic intractable low back pain postlaminectomy.
A retrospective comparative analysis of consecutive patients with lumbar postlaminectomy syndrome who were trialed and later received TIDD with a combination of bupivacaine/hydromorphone or bupivacaine/fentanyl between June 2009 and May 2016 at a single tertiary medical center.
We identified a cohort of 58 lumbar postlaminectomy patients receiving a TIDD admixture of either hydromorphone/bupivacaine (30 patients) or low-dose fentanyl/bupivacaine (28 patients) with at least two years of follow-up. The fentanyl group had significantly lower baseline opioid consumption and a lower rate of intrathecal opioid dose escalation. Both groups had similar and significant reductions in pain scores over the two-year follow-up period. No granulomas were observed.
TIDD using a low-dose fentanyl admixture with bupivacaine in patients with postlaminectomy syndrome and refractory chronic low back pain results in similar pain relief to TIDD with hydromorphone and bupivacaine. Low-dose intrathecal fentanyl leads to a lower rate of opioid escalation and may be safer than hydromorphone.
靶向鞘内药物递送（TIDD）是一种有效的介入性疼痛管理方式，常用于椎板切除术后患有难治性慢性下腰痛的患者。鞘内布比卡因与阿片类药物联合使用很常见。然而，使用吗啡或氢吗啡酮时会出现鞘内导管尖端肉芽肿，但使用芬太尼时一般不会出现。本研究的目的是比较布比卡因/芬太尼与布比卡因/氢吗啡酮用于椎板切除术后慢性顽固性下腰痛患者的TIDD疗效。
对2009年6月至2016年5月在一家三级医疗中心接受试验并随后接受布比卡因/氢吗啡酮或布比卡因/芬太尼联合TIDD治疗的腰椎椎板切除术后综合征连续患者进行回顾性比较分析。
我们确定了一组58例接受氢吗啡酮/布比卡因（30例患者）或低剂量芬太尼/布比卡因（28例患者）TIDD混合剂的腰椎椎板切除术后患者，随访至少两年。芬太尼组的基线阿片类药物消耗量显著较低，鞘内阿片类药物剂量增加率也较低。在两年的随访期内，两组的疼痛评分均有相似且显著的降低。未观察到肉芽肿。
在椎板切除术后综合征和难治性慢性下腰痛患者中，使用低剂量芬太尼与布比卡因混合的TIDD与使用氢吗啡酮和布比卡因的TIDD止痛效果相似。低剂量鞘内芬太尼导致阿片类药物增加率较低，可能比氢吗啡酮更安全。
