Spinal Analgesia with Intrathecal Morphine versus Conventional Analgesia after Laparoscopic Colectomy: A Retrospective Cohort Study

Objective: Postoperative pain (POP) following abdominal surgery can vary from a few hours to several days. This acute, unrelieved pain can become chronic, requiring patients to take analgesics on an almost daily basis for comfort. Analgesia using general opioids has many side effects and intrathecal morphine is a good alternative. This study was conducted to evaluate the efficacy of intrathecal morphine (ITM) versus conventional analgesia in the management of postoperative pain in colectomy performed by laparoscopic surgery. Methods: Cohort study conducted at the Hôpital Nord in Marseille, from 01 January to 31 July 2021 in patients aged at least 18 years undergoing anaesthesia for scheduled colectomy by laparoscopic surgery. The primary endpoint was postoperative pain intensity and the secondary endpoints were morphine consumption, treatment side effects and length of hospital stay. Statistical analysis was performed using XLSTAT software. Results: We included 193 patients: 131 in the control group (conventional analgesia) and 62 in the ITM group. We observed: a significant decrease in pain (assessed by numerical scale) in favour of the ITM group in the post-anaesthetic care room, i.e. 3 (±4) vs 1 (±2), p 0 and H2: 2 (±2) vs. 1 (±2);p Conclusion: These results suggest that intrathecal morphine (ITM) in laparoscopic colectomy provides effective postoperative analgesia with low morphine consumption, and a reduction in morphine side-effects compared with conventional analgesia.

Intrathecal liproxstatin-1 delivery inhibits ferroptosis and attenuates mechanical and thermal hypersensitivities in rats with complete Freund's adjuvant-induced inflammatory pain

Previous studies have confirmed the relationship between iron-dependent ferroptosis and a peripheral nerve injury-induced neuropathic pain model.However,the role of fe rroptosis in inflammatory pain remains inconclusive.Therefore,we aimed to explore whether ferroptosis in the spinal cord and do rsal root ganglion contributes to complete Freund's adjuvant(CFA)-induced painful behaviors in rats.Our results revealed that various biochemical and morphological changes were associated with ferroptosis in the spinal cord and dorsal root ganglion tissues of CFA rats.These changes included iron overload,enhanced lipid peroxidation,disorders of anti-acyl-coenzyme A synthetase long-chain family member 4 and glutathione peroxidase 4 levels,and abnormal morphological changes in mitochondria.Intrathecal treatment of liproxstatin-1(a ferroptosis inhibitor)reve rsed these ferroptosis-related changes and alleviated mechanical and thermal hype rsensitivities in CFA rats.Our study demonstrated the occurrence of fe rroptosis in the spinal cord and do rsal root ganglion tissues in a rodent model of inflammatory pain and indicated that intrathecal administration of fe rroptosis inhibitors,such as liproxstatin-1,is a potential therapeutic strategy for treating inflammatory pain.

Interpeduncular cistern intrathecal targeted drug delivery for intractable postherpetic neuralgia: A case report

BACKGROUND Intractable postherpetic neuralgia(PHN)can be difficult to manage even with aggressive multimodal therapies.Patients who experience uncontrolled refractory cranial PHN despite conservative treatment may benefit from an intrathecal drug delivery system(IDDS).For craniofacial neuropathic pain,the traditional approach has been to place the intrathecal catheter tip below the level of the cranial nerve root entry zones,which may lead to insufficient analgesia.CASE SUMMARY We describe a 69-year-old man with a 1-year history of PHN after developing a vesicular rash in the ophthalmic division of cranial nerve V(trigeminal nerve)distribution.The pain was rated 7-8 at rest and 9-10 at breakthrough pain(BTP)on a numeric rating scale.Despite receiving aggressive multimodal therapies including large doses of oral analgesics(gabapentin 150 mg q12 h,oxycodone 5 mg/acetaminophen 325 mg q6 h,and lidocaine 5%patch 700 mg q12 h)and sphenopalatine ganglion block,there was no relief of pain.Subsequently,the patient elected to have an implantable IDDS with the catheter tip placed at the interpeduncular cistern.The frequency of BTP episodes decreased.The patient’s continuous daily dose was adjusted to 0.032 mg/d after 3 mo of follow-up and stopped 5 mo later.He did not report pain or other discomfort at outpatient follow-up 6 mo and 1 year after stopping intracisternal hydromorphone.CONCLUSION The use of interpeduncular cistern intrathecal infusion with low-dose hydromorphone by IDDS may be effective for severe craniofacial PHN.

Dose optimization of intrathecal administration of human umbilical cord mesenchymal stem cells for the treatment of subacute incomplete spinal cord injury

Human umbilical cord mesenchymal stem cells(hUC-MSCs)are a promising candidate for spinal cord injury(SCI)repair owing to their advantages of low immunogenicity and easy accessibility over other MSC sources.However,modest clinical efficacy hampered the progression of these cells to clinical translation.This discrepancy may be due to many variables,such as cell source,timing of implantation,route of administration,and relevant efficacious cell dose,which are critical factors that affect the efficacy of treatment of patients with SCI.Previously,we have evaluated the safety and efficacy of 4×10^(6) hUC-MSCs/kg in the treatment of subacute SCI by intrathecal implantation in rat models.To search for a more accurate dose range for clinical translation,we compared the effects of three different doses of hUC-MSCs-low(0.25×10^(6) cells/kg),medium(1×10^(6) cells/kg)and high(4×10^(6) cells/kg)-on subacute SCI repair through an elaborate combination of behavioral analyses,anatomical analyses,magnetic resonance imaging-diffusion tensor imaging(MRI-DTI),biotinylated dextran amine(BDA)tracing,electrophysiology,and quantification of mRNA levels of ion channels and neurotransmitter receptors.Our study demonstrated that the medium dose,but not the low dose,is as efficient as the high dose in producing the desired therapeutic outcomes.Furthermore,partial restoration of theγ-aminobutyric acid type A(GABAA)receptor expression by the effective doses indicates that GABAA receptors are possible candidates for therapeutic targeting of dormant relay pathways in injured spinal cord.Overall,this study revealed that intrathecal implantation of 1×10^(6) hUC-MSCs/kg is an alternative approach for treating subacute SCI.

c-Fos expression within the L_5 spinal cord dorsal horn after spinal nerve ligation in rats Is intraplantar administration of glutamate different from intrathecal administration?

BACKGROUND： Injection of glutamate （Glu） in normal animals can cause neuronal c-Fos expression; however, whether Glu can induce spinal neuronal c-Fos expression in pain models is unclear. OBJECTIVE： To examine the effects of intraplantar and intrathecal injection of Glu on c-Fos expression in the L5 spinal cord dorsal horn Ⅰ/Ⅱ and Ⅲ/Ⅳ layers after spinal nerve ligation, and to study the effects of the N-methyI-D-aspartic acid （NMDA） receptor antagonist, D-2-amino-5-phosphonopentanoate （D-AP5）, and a selective group I mGluR antagonist, 7-hydroyiminocyclo propan[a]chromen-lacarboxylic acid ethyl ester （cpccoEt）. DESIGN, TIME AND SETTING： A randomized, controlled animal study was performed at the Department of Pharmacology, Oral Anatomy, and Neurobiology, Osaka University Graduate School of Dentistry, from December 2005 to December 2006. MATERIALS： Glu （5 μmol）, D-AP5 （50 nmot） and cpccoEt （250 nmol） were provided by Wako Pure Chemical Industries, Osaka, Japan, and diluted in saline （50 μL）. The pH of all solutions was adjusted to 7.4. METHODS： Twelve rats were randomly divided into sham operation （n = 6） and spinal nerve ligation （SNL; n = 6） groups for behavioral assessments of neuropathic pain after ligation surgery of the left L5-6 nerve segment. Another 60 rats were randomly divided into sham operation, SNL, saline-intraplantar, saline-intrathecal, Glu-intraplantar, Glu-intrathecal, D-AP5-intrathecal, Glu-D-AP5-intrathecal, cpccoEt-intrathecal, and Glu-cpccoEt-intrathecal groups, with 6 rats in each group. All groups except sham operation group received a similar SNL. On day 14, rats received a 50-μL injection of saline, Glu, D-AP5, and/or cpccoEt into the left intraplantar or intrathecal L5-4 segments. MAIN OUTCOME MEASURES： The number of c-Fos positive neurons in both Ⅰ/Ⅱ and Ⅲ/Ⅳ spinal layers at L6 was observed using immunohistochemistry 2 hours after administration. RESULTS： （1） SNL increased the level of c-Fos expression in two sides of the spinal cord, particularly on Ⅲ/Ⅳ spinal layers of the ligated side. （2） Intraplantar or intrathecal administration of saline significantly increased the c-Fos labeled neurons in Ⅰ/Ⅱ spinal layers of the ligated side, compared with SNL alone （P 〈 0.01）. （3） Intraplantar Glu （5 μmol） increased the number of c-Fos positive neurons in Ⅰ/Ⅱ spinal layers compared with intraplantar saline （P〈 0.01）. （4） The number of c-Fos neurons in Ⅰ/Ⅱ spinal layers on both the ipsilateral and contralateral side after intraplantar Glu was lower than intrathecal Glu （P〈 0.01）, with a 3-fold higher induction by intrathecal Glu. （5） Co-administration of D-AP5 or cpccoEt reduced the effects of intrathecal Glu （P 〈 0.01）. CONCLUSION： Intrathecal Glu increases c-Fos expression more than intraplantar Glu. Antagonists of NMDA and group I mGluRs block this effect.

Reducing intrathecal pressure after traumatic spinal cord injury: a potential clinical target to promote tissue survival

Spinal cord injury （SCI） is an unexpected event that is both devastating and debilitating, resulting in not just motor and sensory loss, but also autonomic dysfunction of the bladder, bowel and sexual organs. Currently, there are no treatments available to improve outcome follow- ing SCI, leaving individuals with permanent and lifelong physical disability. Worldwide it is estimated that more than 500,000 people sustain a SCI each year, with average lifetime cost of paraplegia and quadriplegia estimated at $5 million and $9.5 million respectively. We therefore urgently need effective therapies to improve quality of life following SCI, and this requires a greater understanding of how cell and axonal injury develops after the traumatic event.

Safety of intrathecal injection of Wharton's jellyderived mesenchymal stem cells in amyotrophic lateral sclerosis therapy

Animal experiments have confirmed that mesenchymal stem cells can inhibit motor neuron apoptosis and inflammatory factor expression and increase neurotrophic factor expression. Therefore, mesenchymal stem cells have been shown to exhibit prospects in the treatment of amyotrophic lateral sclerosis. However, the safety of their clinical application needs to be validated. To investigate the safety of intrathecal injection of Wharton's jelly-derived mesenchymal stem cells in amyotrophic lateral sclerosis therapy, 43 patients(16 females and 27 males, mean age of 57.3 years) received an average dose of 0.42 × 106 cells/kg through intrathecal administration at the cervical, thoracic or lumbar region depending on the clinical symptoms. There was a 2 month interval between two injections. The adverse events occurring during a 6-month treatment period were evaluated. No adverse events occurred. Headache occurred in one case only after first injection of stem cells. This suggests that intrathecal injection of Wharton's Jelly-derived mesenchymal stem cells is well tolerated in patients with amyotrophic lateral sclerosis. This study was approved by the Bioethical Committee of School of Medicine, University of Warmia and Mazury in Olsztyn, Poland(approval No. 36/2014 and approval No. 8/2016). This study was registered with the ClinicalTrials.gov(identifier: NCT02881476)on August 29, 2016.

Comparative effect of intrathecal meperidine,tramadol,magnesium sulfate,and dexmedetomidine on preventing post-spinal anesthesia shivering and adverse events in hip fracture repair patients:A randomized clinical trial

Objective:To compare effect of intrathecal meperidine,tramadol,magnesium sulfate,and dexmedetomidine on the prevention of post-spinal anesthesia shivering and adverse events in hip fracture repair patients.Methods:In a randomized,double-blind trial,132 patients with American Society of Anesthesiology(ASA)ⅠandⅡspinal anesthesia who needed hip fracture surgery were enrolled.Patients were stratified into 4 intervention groups based on a randomized block pattern:meperidine,tramadol,magnesium sulfate,and dexmedetomidine.Hemodynamic parameters including blood pressure,heart rate,and oxygen saturation,as well as the severity of shivering,core body temperature,Ramsay sedation score,adverse events,meperidine consumption were recorded and compared.Results:There was no statistically significant difference in the normal hemodynamic parameters,temperature,duration of surgery,meperidine consumption,and adverse events such as dizziness,hypotension,nausea,and bradycardia among groups(P>0.05).Compared to other groups,severity of shivering was the lower in the dexmedetomidine group 6 and 8 h after surgery.The Ramsay sedation scores were higher in the dexmedetomidine and meperidine groups 4 h after surgery(P=0.020).Conclusion:Dexmedetomidine acts better than the other three adjuvants in reducing complications such as shivering.Overall,these four adjuvants are helpful to prevent postoperative shivering and could be put forward as promising local anesthetics in spinal anesthesia,based on anesthesiologists’discretion and patients’general conditions.Clinical registration:The study was approved by the Research and Ethics Committee at the Valiasr Hospital(Arak,Iran)with the clinical trial code of IRCT20141209020258N153.

Intrathecal methotrexate in combination with systemic chemotherapy in glioblastoma patients with leptomeningeal dissemination:A retrospective analysis

BACKGROUND Glioblastoma(GBM)is one of the most common and aggressive primary malignant brain tumors with severe symptoms and a poor prognosis.Leptomeningeal dissemination(LMD)is a serious complication of GBM that often results in dire outcomes.There is currently no effective treatment.AIM To estimate the clinical outcomes of combination therapy in GBM patients with LMD METHODS A retrospective analysis was conducted using data collected from GBM patients diagnosed with LMD from January 2012 to December 2019 at our institution.All these patients had received at least one cycle of a combination therapy consisting of intrathecal methotrexate(MTX)and systemic chemotherapy.Clinical and pathological data were analyzed to explore the outcome of GBM patients with LMD and to determine the most effective treatment.RESULTS Twenty-six patients were enrolled in this study.The median time from GBM diagnosis to LMD development was 9.3 mo(range:2-59 mo).The median overall survival of LMD patients from diagnosis to after receiving systemic chemotherapy in combination with intrathecal MTX was 10.5 mo(range:2-59 mo).In the Cox univariate analysis,gross resection of tumor(P=0.022),Karnofsky performance status(KPS)>60(P=0.002),and Ommaya reservoir implant(P<0.001)were correlated with survival.Multivariate analysis showed that KPS>60(P=0.037)and Ommaya reservoir implant(P=0.014)were positive factors correlated with survival.Myelotoxicity and gastrointestinal reactions were the common toxicities of this combination therapy.According to Common Terminology Criteria of Adverse Events 4.03,most of the patients presented with toxicity less than grade 3.CONCLUSION Intrathecal MTX administration combined with systemic chemotherapy is a potentially effective treatment for patients with GBM and LMD,with mild treatment-related side effects.

Intrathecal morphine for postoperative analgesia: Current trends

The practice of anesthesiology has always been governed by evidence-based medicine. The quick turnover rate of patients in the operating room and patient safety and satisfaction, have also further changed the way we practice anesthesia. The use of intrathecal(IT) opiates as an effective form of postoperative pain relief has been established for many years. Morphine was the first opioid used by IT route. In clinical practice, morphine is regarded as the gold standard, or benchmark, of analgesics used to relieve intense pain. Perhaps for this reason, IT morphine has been used for over 100 years for pain relief. IT morphine is one of the easiest, costeffective and reliable techniques for postoperative analgesia and technical failures are rare. And yet there is no consensus amongst anesthesiologists regarding the dose of IT morphine. Like all other methods of pain relief, IT morphine also has some side effects and some of them are serious though not very common. This review article looks into some of the key aspects of the use of IT morphine for post-operative analgesia and various doses for different procedures are discussed. This article also describes the side effects of IT morphine and how to treat and prevent them.

Intrathecal morphine vs femoral nerve block for postoperative-analgesia after total knee arthroplasty:A two-year retrospective analysis

AIM To compare the efficacy of intrathecal morphine and single shot femoral nerve block for patients undergoing primary total knee arthroplasty.METHODS Data was extracted from electronic medical records and case-paper record files of patients who underwent unilateral primary total knee arthroplasty under spinal anesthesia using bupivacaine 12.5 mg with intrathecal morphine(ITM) 0.2 mg and under general anesthesia(GA) with single shot femoral nerve block(FNB) using 20 m L 0.5% bupivacaine at our hospital in 2013 and 2014.All patients had received peri-articular infiltration as per the hospital protocol.Data for gender,age,weight,American Society of Anesthesiologists status,total surgical time,postoperative pain score using visual analogue scale(VAS) from 1 to 10 at 6 h,12 h and 24 h postoperatively,24 h opioid consumption,use of oral multimodal analgesia,postoperative high dependency unit(HDU) admission and the time to discharge from the hospital was collected.The data was analyzed using Mann-Whitney U test for continuous variables and Fischer's exact-t-test for categorical variables.RESULTS Twenty-two patients in ITM group and 32 patients in FNB group were analyzed.Median pain scores using VAS in ITM group were significantly lower at 6 h(0.0 vs 2.0,P<0.001),12 h(0.0 vs 2.0,P<0.001) and 24 h(0.0 vs 2.0,P<0.001) postoperatively.Also,postoperative morphine consumption in ITM group was significantly lower(P<0.001).However,median of nonsteroid anti-inflammatory drug unit requirement in 24 h postoperatively was statistically significant higher in ITM compared to FNB group(2.0 vs 1.0,P=0.025).The difference in postoperative paracetamol consumption in 24 h was not statistically significant(P=0.147).There was no significant difference in the postoperative HDU admission or time to discharge from the hospital.No respiratory depression in either group was noticed.CONCLUSION The ITM group patients had much lower pain scores and morphine requirement in the first 24 hour postoperatively compared to FNB group.

Total pancreatectomy with islet cell transplantation vs intrathecal narcotic pump infusion for pain control in chronic pancreatitis

AIM: To evaluate pain control in chronic pancreatitis patients who underwent total pancreatectomy with islet cell transplantation or intrathecal narcotic pump infusion.METHODS: We recognized 13 patients who underwent intrathecal narcotic pump(ITNP) infusion and 57 patients who underwent total pancreatectomy with autologous islet cell transplantation(TP + ICT) for chronic pancreatitis(CP) pain control between 1998 and 2008 at Indiana University Hospital. All patients had already failed multiple other modalities for pain control and the decision to proceed with either intervention was made at the discretion of the patients and their treating physicians. All patients were evaluated retrospectively using a questionnaire inquiring about their pain control(using a 0-10 pain scale), daily narcotic dose usage, and hospital admission days for pain control before each intervention and during their last follow-up. RESULTS: All 13 ITNP patients and 30 available TP + ICT patients were evaluated. The mean age was approximately 40 years in both groups. The median duration of pain before intervention was 6 years and 7 years in the ITNP and TP + ICT groups, respectively. The median pain score dropped from 8 to 2.5(on a scale of 0-10) in both groups on their last follow up. The median daily dose of narcotics also decreased from 393 mg equivalent of morphine sulfate to 8 mg in the ITNP group and from 300 mg to 40 mg in the TP + ICT group. No patient had diabetes mellitus(DM) before either procedure whereas 85% of those who underwent pancreatectomy were insulin dependent on their last evaluation despite ICT. CONCLUSION: ITNP and TP + ICT are comparable for pain control in patients with CP however with high incidence of DM among those who underwent TP + ICT. Prospective comparative studies and longer follow up are needed to better define treatment outcomes.

Comparison of impact of adjuvant treatment of midazolam, fentanyl, and magnesium sulfate with intrathecal bupivacaine on block characteristics and postoperative analgesia in knee arthroplasty: A randomized clinical trial

Objective:To compare the efficacy of midazolam,fentanyl,and magnesium sulfate as adjuvants to intrathecal bupivacaine on both block characteristics and postoperative analgesia in knee arthroplasty.Methods:This randomized double-blind clinical trial recruited spinal anesthesia patients of the American Society of Anesthesiologists classⅠorⅡ,who needed knee arthroplasty.Patients were stratified into three intervention groups,including the midazolam group,the fentanyl group,and the magnesium sulfate group,and the patients were administered with midazolam,fentanyl,and magnesium sulfate,respectively.Hemodynamic parameters,sensory and motor block,and pain score(Visual Analogue Scale)were measured and compared among the three groups.Results:A total of 105 patients were included in this study with 35 patients in each group.There was no statistically significant difference in terms of oxygen saturation,mean blood pressure,duration of surgery,and postoperative complications,including nausea,vomiting,bradycardia,dizziness,and hypotension,as well as the time of opioid administration among the three groups(P>0.05).Statistically significant differences were found in terms of heart rate at 15,30,45,60,75,and 105 min after beginning of operation among the three groups,which was lower in the midazolam group(P<0.05).The midazolam group showed a shorter time to achieve sensory block after spinal anesthesia,sensory block to T8 or higher and sensory block to T12 and L1(P<0.05).Besides,the three groups showed significantly differences in terms of onset of motor block after spinal anesthesia and time to achieve motor block to T8 or higher or Bromage score 3(P=0.001).No significant difference was noted in pain scores among the three groups(P>0.05).Conclusion:Midazolam resulted in a shorter time to achieve sensory and motor block to T8 or higher,the onset of motor block and sensory block after spinal anesthesia,and time to achieve sensory block to T12 and L1,and the pain scores were not significantly different among the groups.Thus,midazolam can be highly underlined,if a shorter onset of sensory and motor blocks is targeted.[Funded by the research deputy of Arak University of Medical Sciences(No.99258);fa.irct.ir number,IRCT20141209020258N164].

Intrathecal hematoma and sacral radiculitis following repeat epidural blood patch

Postdural puncture headache(PDPH)is an incapacitating complication that can occur following spinal anesthesia and with inadvertent dural puncture during epidural anesthesia.We present a case of a 32-year-old G2 P1 female who was admitted for induction of labor and received epidural catheter placement for analgesia.After an inadvertent dural puncture and development of a PDPH,the patient was offered conservative measures for the first 48 hours without improvement.An epidural blood patch(EBP)was placed achieving only moderate relief.Two days later,a second EBP was performed and the patient developed severe back pain which radiated bilaterally to her buttocks.Magnetic resonance imaging(MRI)demonstrated the presence of blood in the intrathecal space.This could be the cause of sacral radiculitis,an uncommon complication of an EBP.This suggests that EBPs could potentially cause neurologic symptoms which may be more common than people previously thought.As complicated outcomes have followed both conservative and aggressive management,MRI can be an early diagnostic tool in such cases and a multidisciplinary approach should be taken.

INTRATHECAL GLYCINE SIGNIFICANTLY DECREASES THE MINIMUM ALVEOLAR CONCENTRATION OF ISOFLURANE IN RATS

To evaluate the effect of intrathecal administration of glycine on the minimum alveolar concentration （MAC） of isoflurane in rats. Methods Intrathecal catheters were implanted in 40 adult male rats anesthetized with isoflurane. Baseline MAC of isoflurane was measured during the infusion of artificial cerebrospinal fluid （CSF） alone. Subsequently, 10, 40, 80, 160, and 300 mmol/L of glycine dissolved in artificial CSF were infused for two hours at the same rate as under control conditions, and MAC for isoflurane was re-determined. Results Intrathecal administration of glycine produced a significant, dose-dependent decrease in MAC for isoflurane （up to -65.2% ± 16. 2% ）. Conclusions Intrathecal administration of glycine decreases anesthetic requirement. This result supports the idea that glycine receptors may be important to the immobilizing effect of anesthetics that enhance glycine receptor function such as isoflurane.

Biochemical indicators for neuronal regeneration during intrathecal triamcinolone application in multiple sclerosis

Multiple sclerosis （MS） is a chronic inflammatory disease of the central nervous system （CNS）. Essential charac- teristics are demyelination, inflammation and neurode- generation. This process affects the white and grey matter in the CNS. MS patients experience various progression subtypes in association with the cerebral or spinal, acute inflammatory or glial sclerotic lesions （Mtiller, 2009）. Most patients end up in a progressive, smouldering, chronic inflammatory process （MUller, 2009）. Current predominantly used 1.5 respectively 3 Tesla MRI with Gadolinium~ application visualize the various old and acute lesions. They serve as a biological marker in com- bination with standardised assessment of brain atrophy, black holes, etc. However, MRI with a stronger magnetic 7 Tesla field with better sensitivity gave hints on an on- going, acute inflammatory, smouldering process even with Gadolinium~ enhancing acute lesions in the brain and the spinal cord in progressive, so-called relapse free MS patients （Mtiller, 2009; Sinnecker et al., 2012）. Ad- ditionally, progress of MS is determined with subjective standardised clinical ratings （Sinnecker et al., 2012）. Both methods are used for the evaluation of the efficacy of relapse rate reducing drugs. These compounds, i.e., in- terferons, teriflunamide, glatiramer acetate, fingolimod, fumarate or monoclonal antibodies, preponderantly weaken the malfunction of the peripheral immune system in relapse remitting MS patients. These MS drugs share one common disadvantage. They do not stop progression or improve MS within a framework of a regenerative process. They do not enable reversal of symptoms, for in- stance functional deficits or spasticity （Mtiller, 2009）.

Long-term effect of intrathecal baclofen treatment on bone health and body composition after spinal cord injury:A case matched report

BACKGROUND Severe spasticity may negatively impact functionality and quality of life after spinal cord injury(SCI).Intrathecal baclofen treatment(IBT)is effectively used to manage severe spasticity and reduce comorbidities.However,long-term IBT may have a negative effect on bone mineral content(BMC),bone mineral density(BMD)and body composition(such as percentage fat mass and lean body mass).We demonstrated the negative effects of long-term IBT use in a single case compared with two non-IBT users.CASE SUMMARY A 46-year old Caucasian male Veteran(case)with a 21 year history of complete tetraplegia(complete C6 SCI)was implanted with IBT for 20 years.The case was matched to two participants with different time since injuries[2(match 1)and 13(match 2)years]without IBT.Knee BMC and BMD at the epiphysis and metaphysis of the distal femur and proximal tibia were evaluated using dual knee and the dual femur modules of GE Lunar iDXA software.Total and leg body composition assessments were also conducted for the three participants.Potential effect of long-term IBT was demonstrated by changes in BMD,consistent with bone demineralization,at the distal femur and proximal tibia and changes in percentage fat mass and lean mass of legs.The case showed 113%lower BMD at the distal femur,and 78.1%lower at the proximal tibia compared to match 1,moreover the case showed 45%lower BMD at the distal femur,and no observed changes at the proximal tibia compared to match 2.The case had 27.1%and 16.5%greater leg%fat mass compared to match 1 and match 2,respectively.Furthermore,the case had 17.4%and 11.8%lower%leg lean mass compared to match 1 and match 2,respectively.CONCLUSION Long-term IBT may impact bone health and body composition parameters in persons with complete SCI.It may be prudent to encourage regular screening of individuals on long-term IBT considering the prevalence of osteoporosis related fractures,cardiovascular diseases,and metabolic disorders in this population.

Epidural Blood Patch for Treatment of Postdural Puncture Headache in a Patient with Spinal Fusion and Recent Implantation of Intrathecal Pain Pump

We present an interesting case report of a 49-year-old female who presented with symptoms of post-dural puncture headache following implantation of an intrathecal pain pump. Her history was complicated by previous multi-level spinal fusion with hardware. The patient was evaluated and felt to be a candidate for epidural blood patch, which she elected to proceed with. Under fluoroscopic guidance epidural blood patch was successfully performed. Immediately following the procedure the patient noted significant improvement in the headache and six hours following the procedure was headache free and remained so at follow up three weeks later.

Three Different Doses of Intrathecal Morphine as Part of a Multimodal Regimen for Post-Cesarean Delivery Analgesia: A Randomized Double-Blinded Trial

Brazil is one of the countries that carry out cesarean delivery in the world. The pain after cesarean delivery (CD) is one of the main concerns of parturient. Intrathecal Morphine (ITM) is widely used for the treatment of pain after CD;however, the optimal dose with minimal side effects is to be established. Objectives: To compare the analgesia and side effects resulted by three different doses of ITM as part of a multimodal regimen for post-cesarean delivery analgesia. Methods: One hundred ninety-four patients were sampled in this randomized, double-blinded, three-arm study (group 0.075: ITM 0.75 mg;group 0.1: ITM 0.1 mg and group 0.15: ITM 0.15 mg). All patients received intravenous dexamethasone, dipyrone and ketoprofen. The primary endpoint was pain intensity measured at rest and on movement, while the secondary endpoint was overall satisfaction with pain relief, the incidence of nausea and vomiting, intensity of pruritus, and the use of additional tramadol, antipruritic and antiemetic use within 24 hours after postoperation. Results: The three groups showed similar pain intensity at rest and on movement. The pain intensity on movement was significantly higher than at rest in the groups (p 0.001). There were no significant differences among the groups regarding secondary endpoint. Conclusions: Our findings suggest that in cases of an elective CD, 0.075 mg of ITM produces postoperative analgesia of similar quality that provided by 0.1 or 0.15 mg ITM. The patients should have a multimodal analgesia approach that includes: ITM, anti-inflammatory agents and access to additional systemic analgesic if necessary.

Subdural Hematoma and Postdural Puncture Headache from Intrathecal Pump Placement Resolved with Lumbar Epidural Blood Patch

Intrathecal drug delivery systems are commonly used in the management of chronic pain, cancer pain and neuromuscular disorders with muscle spasticity. The complications associated with in-trathecal pump placement include persistent cerebrospinal fluid (CSF) leak, hygroma, meningitis, and granuloma formation. A severe persistent CSF leak may cause postdural puncture headache along with acute intracranial subdural hematoma, which can be potentially life threatening. Surgical exploration with dural repair is required to treat this severe complication when conservative treatments fail. We present a case report of severe persistent CSF leak after intrathecal pump revision that resulted in a subdural hematoma and postdural puncture headache. In this case, an epidural blood patch was performed using epidural catheter under fluoroscopic guidance to target the site of CSF leak and to avoid damaging the intrathecal catheter. This patient’s headache was resolved and intrathecal catheter remained intact after this blood patch.