Intrathecal Analgesia Indications: Clinical Guidelines

This educational resource is based on the SFETD (Société Française d’Étude et de Traitement de la Douleur) Intrathecal Toolbox 2024 and international PACC guidelines.

Overview

Intrathecal analgesia should be made available across all healthcare systems to ensure equal access to care for patients with refractory pain. According to research cited in the SFETD Toolbox, approximately 15% of cancer patients experience refractory or intractable pain, particularly in advanced disease stages.

Primary Indications

Pain Characteristics

Intrathecal analgesia is indicated for patients presenting with:

• Intractable localized pain that is regional in distribution
• Pain insufficiently controlled despite well-administered background treatment
• Morphine doses around 300 mg/day oral morphine equivalent without adequate relief
• Adverse side effects that rule out conventional analgesic approaches

Cancer-Related Pain

Early access to intrathecal therapy is particularly recommended for:

1. Pelvic cancers or cancers with painful pelvic secondary sites
2. Pancreatic cancer and liver cancer
3. Pancoast-Tobias syndrome or localizations with strong neuropathic component
4. Hyperalgesic localized bone metastasis
5. Sarcomas
6. ENT (ear, nose, throat) cancers

Pain Type Classification

Intrathecal therapy addresses multiple pain mechanisms:

• Nociceptive pain (somatic or visceral)
• Neuropathic pain
• Mixed pain (most common in oncology practice)

Absolute Contraindications

According to SFETD guidelines, intrathecal therapy is absolutely contraindicated in:

Intracranial Pathology

• Intracranial hypertension (ICHT)
• Brain metastases with risk of herniation
• Recent brain imaging (less than one month prior) showing concerning findings

Spinal Pathway Obstruction

• Obstacle to CSF circulation in catheter path
• Spinal cord invasion
• Compressive vertebral fracture requiring recent spinal imaging confirmation

Relative Contraindications

The following conditions require case-by-case discussion with multidisciplinary consultation involving anesthetist, neurosurgeon, oncologist, and other specialists:

Hematological Concerns

• Aplasia
• Neutropenia (PNN must be > 500/mm³)
• Thrombocytopenia (platelets must be > 80,000/mm³)
• Hemostasis disorders
• Anticoagulant treatment not appropriately discontinued

Infectious Risk

• Active infection at implant site
• Epiduritis (MRI evaluation useful)

Anatomical Challenges

• Abdominal pocket not feasible (peritoneal nodules, stomas, ascites)
• Severe undernutrition affecting wound healing

Cancer Treatment Interactions

• Certain specific cancer treatments, notably bevacizumab and other anti-angiogenic agents
• Requires coordination with oncology team regarding timing

Collegial Decision-Making Process

The SFETD Toolbox emphasizes the importance of multidisciplinary consultation meetings before intrathecal therapy initiation.

Pre-Decision Process

The referring physician (oncologist, pain specialist, palliative care physician, supportive care physician) should:

1. Examine the benefit/risk ratio considering the patient’s overall situation
2. Present the situation collegially to the multidisciplinary team
3. Inform the patient and those close to the patient about the analgesic technique

Multidisciplinary Team Composition

Early multidisciplinary consultation should include:

• Oncologists
• Radiotherapists
• Pain management specialists (algologists)
• Anesthesiologists
• Interventional radiologists
• Palliative care specialists
• Attending physician
• Psychologist
• Specialized nurses
• Pharmacists

Validation Criteria

The team validates indication when:

• Theoretical indication criteria are met
• Feasibility is established (socio-familial, psychological, professional context, life prognosis)
• No formal contraindication exists at outset
• Imaging assessment is current and reviewed
• Other treatment options (drug and interventional) have been ruled out
• Coordination with outside caregivers and family is arranged
• Patient autonomy and context support the intervention

Special Anatomical Considerations

Catheter Positioning Strategy

The SFETD Toolbox provides guidance on catheter placement based on pain location:

• Subdiaphragmatic pain: D10-D11 (thoracic vertebrae 10-11)
• Chest pain: D2-D3
• Epigastric/pancreatic pain: D4-D6
• Upper limb pain: C3-C5 (cervical vertebrae 3-5)
• ENT and facial pain: C1-Cisternal level

Advanced Techniques

For ENT and cephalic (head) pain locations:

• Requires contact with specialized teams trained in cervical, cisternal, and intracerebroventricular catheter placement
• Confirmation of indication through expert consultation

Evidence Base

The SFETD Toolbox cites the Polyanalgesic Consensus Conference (PACC) recommendations, which synthesize international evidence for intrathecal drug delivery:

Deer TR, Pope JE, Hayek SM, et al. The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks. Neuromodulation. 2017 Feb;20(2):155-176.

In France, intrathecal analgesia has received official healthcare recognition through:

1. Formalized Expert Recommendations of SFETD and SFAR (2013)
2. DGOS Instruction (2017)
3. HAS Recommendations (2020)

Clinical Implementation Goals

The primary objectives of intrathecal analgesia implementation are:

• Improve quality of life for patients with intractable pain
• Reduce adverse effects compared to systemic analgesic approaches
• Preserve patient autonomy through programmable implanted systems
• Provide powerful analgesia for pain unresponsive to conventional therapies

Organizational Prerequisites

Before offering intrathecal therapy, institutions should establish:

1. Trained multidisciplinary team dedicated to intrathecal analgesia
2. Partnership with in-house pharmacy for drug mixture preparation
3. Appropriate technical platform and hospitalization facilities
4. Patient circuit and follow-up protocols
5. 24/7 telephone hotline for emergencies
6. Collaboration agreements with implanting physicians and follow-up teams

References

This educational content is derived from:

• SFETD Intrathecal Analgesia Toolbox (2024)
• Deer TR, et al. The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery. Neuromodulation. 2017
• HAS (Haute Autorité de Santé) Recommendations (2020)
• SFETD/SFAR Formalized Expert Recommendations (2013)

For institutions developing intrathecal analgesia programs aligned with SFETD guidelines, Thalivia provides structured prescription software supporting evidence-based protocols.