Epidural and subarachnoid administration of opioids for nonmalignant pain: technical issues, current approaches and...

As intraspinal opioid infusions are being offered to an increasing number of patients with chronic noncancer pain, technical considerations and complications have become important. For these technical considerations, there are points that are unclear and controversial and others that appear to be "minor" but, if missed, can lead to disastrous pump complications. Among the controversial areas are type of testing for a spinal infusion, method for needle placement in the spine, and type of pump. For the apparently minor considerations, important areas are attention to the method of puncture of the paraspinal fascia, anchoring of catheter, pump placement, and initial filling of the pump. As experience with these infusions is accumulated, and as the financial climate in medicine changes, the approaches to these techniques appear to be changing toward a general consensus. Recent scientific advances, both in newer analgesic substances and in innovative methods for intraspinal delivery of these substances, also are affecting these approaches.