Practical guide to intrathecal drug delivery: short-term and long-term management and complications

Intrathecal drug delivery (IDD) is an established therapy for patients with refractory pain across cancer and non-cancer populations. By enabling targeted spinal drug delivery, IDD can provide durable symptom control at substantially lower doses than systemic therapy, often reducing systemic medication burden and treatment-limiting adverse effects. Despite decades of clinical experience and supportive evidence, IDD remains underutilized and largely concentrated in high-volume centers, reflecting persistent uncertainty related to patient selection, trialing, device planning, long-term management, limited evidence, and complication mitigation.This practical guide synthesizes current evidence, consensus recommendations, and collective international clinical experience to provide a structured approach to short-term and long-term management of implantable IDD systems. Shared principles applicable across indications are emphasized, while cancer-specific considerations are addressed separately, including prognosis, coordination with oncologic therapies, evolving spinal anatomy, and compressed treatment horizons. Key topics include preimplant evaluation and risk mitigation, trialing strategies and their limitations, pump and catheter selection, perioperative management, early post-implant troubleshooting, long-term maintenance, and surveillance for device-related, biological, and operational complications. Intrathecal pharmacologic strategies for pain are examined, including opioids, local anesthetics, ziconotide, clonidine, and baclofen, with attention to indication-specific dosing, titration, and safety considerations.Clinical outcomes are framed beyond pain intensity alone, emphasizing functional improvement, quality of life, and reduction in systemic medication use as clinically meaningful endpoints. Differences in therapeutic goals, time horizons, and risk tolerance between cancer and non-cancer populations are integrated into a practical decision framework aligned with real-world pain practice. International and regional practice variations are also discussed to contextualize differences in drug availability, compounding practices, and reimbursement. By consolidating pragmatic guidance across the full lifecycle of intrathecal therapy, this guide aims to support consistent, safe, and effective use of IDD for complex pain management in contemporary practice.