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Intrathecal Morphine alone mananging Spasticity and Chronic Pain following Spinal Cord Injury: A case report

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INTRODUCTION

After spinal cord injury (SCI), spasticity and chronic pain are common challenges and can be refractory to oral treatment with antispasmodics and opiates; intrathecal therapy (IT) with Baclofen and Morphine has been shown to be efficacious for treatment of both these chronic disease states while simultaneously limiting side effects. (1)

 Opiates act receptor specific on the multi-synapses of the alpha and C fibers with in the dorsal horn (DH) and is the primary site for IT therapy(3)

 We report a patient with SCI who presented with spasticity and chronic pain who was treated with IT drug delivery of morphine alone with complete resolution of spasticity.

 

Discussion

CASE STUDY:

-48-year-old man with T7 ASIA A complete paraplegia was referred to our Spine center to discuss the placement of an IT drug delivery system to treat long-standing increasing spasticity and chronic neuropathic pain below his level of injury.

-His examination revealed 5/5 motor strength in the upper extremities and 0/5 in lower extremities. His modified ash worth scale was ¾across his knee flexors&extensors. Muscle stretch reflex was a hyper-reflexic3/4 at the bilateral patella and Achilles without clonus. He was on oral baclofen 10 mg TID, Tizanadine8 mg QID, Pregablin100 mg QID, & Amitriptyline 100 mg QHS.

-IT drug delivery was sought to treat both his chronic pain and refractory spasticity. After psychological screening, he underwent a drug delivery trial where he responded well to both IT Baclofen and IT Morphine with improvements in spasticity and his chronic pain.

-He proceeded with the implantation of the IT pump deep to the external oblique muscle with the catheter being placed intrathecal at T11-T12. The pump was initially filled with Morphine alone to be run at a low dose.

-At 12 day follow up, pain was reduced from average 6/10 to a 2/10.

His MAS had changed to 0/4 in his lower extremity. NO BACLOFEN ADDED

At follow up over the next few months his intrathecal morphine was titrated down from 300 to 200 mcg/day, which is now his current steady dose.

-He completely weaned off his oral Baclofen and Tizanadine; reduced his Pregablinfrom 4 times daily to 2; and had reduced his bedtime Amitriptyline from 150à50mg.

-His clinical exam exhibits the expected flaccid paralysis, with out measurable tone. The patient states in his own words that this is "Awesome! " and doing well s/p implantation with no adverse effects.


Morphine, a mu agonist that acts on opiate receptors in the spinal cord has also been shown to have crossover affect on spasticity. (3)

 

Opiates act receptor specific on the multi-synapses of the alpha and C fibers with in the dorsal horn (DH) and is the primary site for IT therapy(3)

 

With the primary site of afferent pain blockage in the neuron pool within the DH, the reflex arc traveling within the DH that contributes to spasticity may also be inhibited (3)

Soniet al. showed that a patient with an incomplete spinal cord injury with worsening spasticity from Baclofen tolerance was switched to IT morphine and months later was stable at 300 mcg/day with spasticity managed, improved function, and resumption of employment

 

 

CONCLUSIONS

 

Confirmed that this intrathecal delivery of morphine in a continuous pump can be effective for treatment of not only the pain, but also spasticity

 

 

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