Neurosurgery

underlying conditions for which this has been used is long and covers the full range of patients seen in a chronic pain service.

The patients can be categorized into two groups: pain secondary to malignant disease and the non-malignant pain group.

With pain due to malignant disease, relatively simple intraspinal techniques may suffice, as they are unlikely to be required in the long term; epidural infusions of opiate with or without local anesthetic are popular and effective in well chosen patients. The potential problems of long-term intraspinal drug administration need not be addressed.

In the case of chronic non-malignant pain, the long-term issues of neurotoxicity, dependence and the ever present possibility of intrathecal infection are real. The numbers of reported patients are not yet large enough for us to pronounce on these with any certainty. Patients need to be aware of the experimental nature of the therapy and it must be doubtful if any treatment on these lines should be undertaken outside of a clinical trial setting. The very minimum assessment should include psychiatric and psychological evaluation. Trials of efficacy of single-dose opiate (or other chosen drug) should be undertaken, possibly even including placebo administration. If all trials are positive, then implantation of continuous drug delivery systems is a simple task; attention to detail is important, especially concerning catheter fixation, as movement or "plumbing" problems dominate the complication list.

There is a tendency for dose requirements of opiates to rise with time and, if other drugs are included in the mixture (e.g. clonidine), then it may require complete emptying of the reservoir to enable dose changes to be made, thus losing some of the elegant advantages of the implantable computerized systems (Synchromed) available from Medtronics (Minneapolis/St Paul)[13-15].

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