Sulfametoxazol

Case Report

Intrathecal Opioids for Control of Chronic Low Back Pain During Deep Brain Stimulation Procedures
Michelle Lotto, MD* Nicholas M. Boulis, MD†
Patients with chronic low back pain may not be able to endure the supine position required by the lengthy deep brain stimulation procedure. Many neurophysiologists severely restrict the use of opioids and sedative drugs during deep brainstimulation procedures due to the concern for depression of cellular firing frequencies used to map the brain for placement of the stimulator leads. We present two cases in which spinal opioids were used to achieve prolonged pain relief in patients with chronic back pain, without altering cellular firing critical for brain mapping.
(Anesth Analg 2007;105:1410 –2)

eep brain stimulation (DBS)has been revolutionary in restoring quality of life to patients with refractory Parkinson’s disease. Unfortunately, the procedure is lengthy and requires minimal administration of anesthetic medications to avoid interference with the microrecordings used to identify the subthalamic nucleus (STN) during placement of the DBS leads (1–3). The patient must remain capable of cooperating with theneurologic examination so that the therapeutic motor effects and somatic side effects of subcortical stimulation can be assessed. Anesthetics can alter neuronal firing frequency and impair patient assessment, and are avoided during most cases of STN stimulation (1–3). Limitations imposed on the anesthesiologist complicate the care of patients who are unable to tolerate many hours in a single position asrequired by the procedure. We report the successful use of intrathecal opioids to treat chronic neuromuscular back pain in two patients unable to tolerate the positioning for DBS.

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and considered discontinuing the surgery. Several options were discussed to control the patient’s pain and to allow him to continue with the procedure. Administration of IV opioids was discussed and dismisseddue to the potential effects of opioids on intracellular firing and neuronal monitoring for DBS lead placement. Neuraxial blockade with local anesthetics was not an option since the motor blockade would interfere with assessment of effectiveness of STN stimulation in treating the lower extremity Parkinsonian symptoms. The patient consented to placement of a subdural catheter and administration ofintrathecal opioids before repositioning. The initial dose of 25 g of fentanyl did not improve the patient’s back pain in the supine position. Two subsequent 25 g doses of fentanyl also did not suppress the pain. Sixty micrograms of preservative-free hydromorphone was administrated. The patient reported an improvement in pain from 9/10 to 2/10 within 10 min of the injection. He was able totolerate the supine position for the entire length of the procedure (7.25 h) without further dosing of the intrathecal catheter. After surgery, the patient was monitored in the Neurological Stepdown unit. He was very satisfied with his pain control during the procedure and reported excellent pain control throughout the first postoperative night.

Case 2

CASE REPORTS
Case 1
A 78-yr-old man with ahistory of postlaminectomy syndrome presented for bilateral STN DBS for Parkinson’s disease refractory to medical management. After placement of the steriotactic head frame, the patient was positioned supine and the head frame was affixed to the bed. Fifteen minutes after positioning, the patient complained of severe low back pain and requested to sit upright. Despite attempts at repositioning,the patient felt he would not be able to tolerate the supine position for the duration of the procedure
From the *Section of Neurological Anesthesia, Cleveland Clinic, and †Cleveland Clinic Lerner College of Medicine, Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio. Accepted for publication July 31, 2007. Address correspondence and reprint requests to Michelle Lotto, MD,...