Epidural and Intrathecal Catheter Use at the End of Life for Cancer Pain

More than 80% of patients with advanced malignancy experience pain as they approach death, and up to 30% fail to achieve adequate relief from systemic analgesics or cannot tolerate their side effects. For these patients, externalized epidural or intrathecal catheters offer a targeted alternative, delivering analgesic agents directly to the neuraxis. This narrative review examines patient selection, technical approaches, pharmacological regimens, clinical outcomes, and complications associated with externalized epidural and intrathecal catheter systems for refractory cancer pain at end of life.

The available literature comprises predominantly small, single-center retrospective cohort studies and prospective case series, with one double-blind randomized controlled trial identified. Neuraxial analgesia was consistently associated with three benefits: reductions in pain intensity from severe baseline levels (NRS 7-10) to mild-to-moderate ranges (NRS 2-5), with some patients achieving near complete relief; opioid-sparing effects, including systemic opioid discontinuation in a subset of patients; and functional improvements sufficient to support discharge to home or hospice. Infectious complications were the leading cause of early catheter removal, with epidural abscess rates as high as 12% reported in one cohort; tunneled subcutaneous port systems appeared to confer lower infectious risk than percutaneous catheters. Externalized catheters provide meaningful pain relief, opioid sparing, and functional benefits for carefully selected patients with refractory cancer pain at the end of life. Given the heterogeneity of study designs and inconsistent outcome reporting, prospective multicenter studies employing standardized pain, functional, and complication metrics are needed to better define the role of neuraxial analgesia in this population.