{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,9]],"date-time":"2026-09-09T03:10:49Z","timestamp":1788923449324,"version":"build-2803163510"},"reference-count":27,"publisher":"Oxford University Press (OUP)","issue":"9","license":[{"start":{"date-parts":[[2020,5,11]],"date-time":"2020-05-11T00:00:00Z","timestamp":1589155200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/journals\/pages\/open_access\/funder_policies\/chorus\/standard_publication_model"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,9,1]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Objective<\/jats:title><jats:p>Targeted intrathecal drug delivery (TIDD) is an effective interventional pain management modality often used in postlaminectomy patients with refractory chronic low back pain. A combination of intrathecal bupivacaine with an opioid is often used. However, intrathecal catheter tip granulomas have occurred with use of morphine or hydromorphone but generally not with fentanyl. The objective of this study was to compare the efficacy of TIDD using bupivacaine\/fentanyl vs bupivacaine\/hydromorphone in patients with chronic intractable low back pain postlaminectomy.<\/jats:p><\/jats:sec><jats:sec><jats:title>Materials and Methods<\/jats:title><jats:p>A retrospective comparative analysis of consecutive patients with lumbar postlaminectomy syndrome who were trialed and later received TIDD with a combination of bupivacaine\/hydromorphone or bupivacaine\/fentanyl between June 2009 and May 2016 at a single tertiary medical center.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>We identified a cohort of 58 lumbar postlaminectomy patients receiving a TIDD admixture of either hydromorphone\/bupivacaine (30 patients) or low-dose fentanyl\/bupivacaine (28 patients) with at least two years of follow-up. The fentanyl group had significantly lower baseline opioid consumption and a lower rate of intrathecal opioid dose escalation. Both groups had similar and significant reductions in pain scores over the two-year follow-up period. No granulomas were observed.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>TIDD using a low-dose fentanyl admixture with bupivacaine in patients with postlaminectomy syndrome and refractory chronic low back pain results in similar pain relief to TIDD with hydromorphone and bupivacaine. Low-dose intrathecal fentanyl leads to a lower rate of opioid escalation and may be safer than hydromorphone.<\/jats:p><\/jats:sec>","DOI":"10.1093\/pm\/pnaa104","type":"journal-article","created":{"date-parts":[[2020,3,20]],"date-time":"2020-03-20T12:29:51Z","timestamp":1584707391000},"page":"1921-1928","source":"Crossref","is-referenced-by-count":18,"title":["Comparative Effectiveness of Targeted Intrathecal Drug Delivery Using a Combination of Bupivacaine with Either Low-Dose Fentanyl or Hydromorphone in Chronic Back Pain Patients with Lumbar Postlaminectomy Syndrome"],"prefix":"10.1093","volume":"21","author":[{"given":"Timothy","family":"Ade","sequence":"first","affiliation":[{"name":"Division of Pain Medicine, Department of Anesthesiology\/Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio"},{"name":"Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justin","family":"Roh","sequence":"additional","affiliation":[{"name":"Division of Pain Medicine, Department of Anesthesiology\/Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio"},{"name":"Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gautam","family":"Sharma","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology\/Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mahesh","family":"Mohan","sequence":"additional","affiliation":[{"name":"Division of Pain Medicine, Department of Anesthesiology\/Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio"},{"name":"Mercy One Medical Center, Waterloo, Iowa, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah J","family":"DeLozier","sequence":"additional","affiliation":[{"name":"Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica L","family":"Janes","sequence":"additional","affiliation":[{"name":"Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7936-017X","authenticated-orcid":false,"given":"Salim M","family":"Hayek","sequence":"additional","affiliation":[{"name":"Division of Pain Medicine, Department of Anesthesiology\/Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2020,5,11]]},"reference":[{"key":"2020101310150584000_pnaa104-B1","doi-asserted-by":"crossref","first-page":"219","DOI":"10.36076\/ppj.2011\/14\/219","article-title":"Intrathecal therapy for cancer and non-cancer pain","volume":"14","author":"Hayek","year":"2011","journal-title":"Pain Physician"},{"issue":"2","key":"2020101310150584000_pnaa104-B2","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1111\/ner.12538","article-title":"The Polyanalgesic Consensus Conference (PACC): Recommendations on intrathecal drug infusion systems best practices and guidelines","volume":"20","author":"Deer","year":"2017","journal-title":"Neuromodulation"},{"issue":"2","key":"2020101310150584000_pnaa104-B3","doi-asserted-by":"crossref","first-page":"155","DOI":"10.1111\/ner.12579","article-title":"The Polyanalgesic Consensus Conference (PACC): Recommendations for intrathecal drug delivery: Guidance for improving safety and mitigating risks","volume":"20","author":"Deer","year":"2017","journal-title":"Neuromodulation"},{"key":"2020101310150584000_pnaa104-B4","article-title":"Medtronic 2013 product performance report","author":"Weaver","year":"2013"},{"issue":"2","key":"2020101310150584000_pnaa104-B5","doi-asserted-by":"crossref","first-page":"S4","DOI":"10.1016\/S0885-3924(00)00203-7","article-title":"Current practices in intraspinal therapy\u2014a survey of clinical trends and decision making","volume":"20","author":"Hassenbusch","year":"2000","journal-title":"J Pain Symptom Manage"},{"key":"2020101310150584000_pnaa104-B6","doi-asserted-by":"crossref","first-page":"590","DOI":"10.1097\/00000542-200609000-00025","article-title":"Opiate pharmacology of intrathecal granulomas","volume":"105","author":"Allen","year":"2006","journal-title":"Anesthesiology"},{"key":"2020101310150584000_pnaa104-B7","first-page":"561","article-title":"Intrathecal hydromorphone and bupivacaine combination therapy for post-laminectomy syndrome optimized with patient-activated bolus device","volume":"17","author":"Hayek","year":"2016","journal-title":"Pain Med"},{"issue":"10","key":"2020101310150584000_pnaa104-B8","doi-asserted-by":"crossref","first-page":"1481","DOI":"10.1111\/j.1526-4637.2011.01232.x","article-title":"Combination of intrathecal opioids with bupivacaine attenuates opioid dose escalation in chronic noncancer pain patients","volume":"12","author":"Veizi","year":"2011","journal-title":"Pain Med"},{"issue":"7","key":"2020101310150584000_pnaa104-B9","doi-asserted-by":"crossref","first-page":"760","DOI":"10.1111\/ner.12481","article-title":"Primary hydromorphone-related intrathecal catheter tip granulomas: Is there a role for dose and concentration?","volume":"19","author":"Veizi","year":"2016","journal-title":"Neuromodulation"},{"issue":"6","key":"2020101310150584000_pnaa104-B10","doi-asserted-by":"crossref","first-page":"577","DOI":"10.1016\/j.clineuro.2011.12.007","article-title":"Intrathecal granuloma formation as result of opioid delivery: Systematic literature review of case reports and analysis against a control group","volume":"114","author":"Duarte","year":"2012","journal-title":"Clin Neurol Neurosurg"},{"issue":"7","key":"2020101310150584000_pnaa104-B11","doi-asserted-by":"crossref","first-page":"648","DOI":"10.1111\/ner.12737","article-title":"Intrathecal trialing of continuous infusion combination therapy with hydromorphone and bupivacaine in failed back surgery patients","volume":"21","author":"Galica","year":"2018","journal-title":"Neuromodulation"},{"issue":"3","key":"2020101310150584000_pnaa104-B12","doi-asserted-by":"crossref","first-page":"581","DOI":"10.1097\/00000542-200609000-00024","article-title":"Time course and role of morphine dose and concentration in intrathecal granuloma formation in dogs: A combined magnetic resonance imaging and histopathology investigation","volume":"105","author":"Allen","year":"2006","journal-title":"Anesthesiology"},{"issue":"1","key":"2020101310150584000_pnaa104-B13","doi-asserted-by":"crossref","first-page":"159","DOI":"10.4103\/sni.sni_80_17","article-title":"Intrathecal catheter-associated inflammatory mass in a neurofibromatosis type-1 patient receiving fentanyl and bupivacaine","volume":"8","author":"Southwell","year":"2017","journal-title":"Surg Neurol Int"},{"issue":"6","key":"2020101310150584000_pnaa104-B14","doi-asserted-by":"crossref","first-page":"1161","DOI":"10.1227\/01.NEU.0000359223.11215.D9","article-title":"Surgical management of spinal catheter granulomas: Operative nuances and review of the surgical literature","volume":"65","author":"Zacest","year":"2009","journal-title":"Neurosurgery"},{"key":"2020101310150584000_pnaa104-B15","doi-asserted-by":"crossref","first-page":"343","DOI":"10.36076\/ppj.2011\/14\/343","article-title":"Patient selection and outcomes using a low-dose intrathecal opioid trialing method for chronic nonmalignant pain","volume":"14","author":"Grider","year":"2011","journal-title":"Pain Physician"},{"issue":"10","key":"2020101310150584000_pnaa104-B16","doi-asserted-by":"crossref","first-page":"1304","DOI":"10.1111\/j.1526-4637.2012.01451.x","article-title":"Prospective study of 3-year follow-up of low-dose intrathecal opioids in the management of chronic nonmalignant pain","volume":"13","author":"Hamza","year":"2012","journal-title":"Pain Med"},{"issue":"4","key":"2020101310150584000_pnaa104-B17","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1046\/j.1533-2500.2002.02040.x","article-title":"Predictive value of intrathecal narcotic trials for long-term therapy with implantable drug administration systems in chronic non-cancer pain patients","volume":"2","author":"Dominguez","year":"2002","journal-title":"Pain Pract"},{"issue":"4","key":"2020101310150584000_pnaa104-B18","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1016\/S1529-9430(02)00199-7","article-title":"Clinical experience with intrathecal bupivacaine in combination with opioid for the treatment of chronic pain related to failed back surgery syndrome and metastatic cancer pain of the spine","volume":"2","author":"Deer","year":"2002","journal-title":"Spine J"},{"key":"2020101310150584000_pnaa104-B19","doi-asserted-by":"crossref","DOI":"10.1093\/med\/9780199931484.001.0001","article-title":"Intrathecal hydromorphone and bupivacaine combination therapy for post-laminectomy syndrome optimized with patient-activated bolus device","author":"Hayek","year":"2015","journal-title":"Pain Med"},{"key":"2020101310150584000_pnaa104-B20","doi-asserted-by":"crossref","first-page":"664","DOI":"10.1097\/ALN.0b013e31828351aa","article-title":"Role of meningeal mast cells in intrathecal morphine-evoked granuloma formation","volume":"118","author":"Yaksh","year":"2013","journal-title":"Anesthesiology"},{"issue":"6","key":"2020101310150584000_pnaa104-B21","doi-asserted-by":"crossref","first-page":"E94","DOI":"10.1111\/papr.12443","article-title":"Resolution of intrathecal hydromorphone or morphine-induced peripheral edema by opioid rotation to fentanyl: A case series","volume":"16","author":"Veizi","year":"2016","journal-title":"Pain Pract"},{"key":"2020101310150584000_pnaa104-B22","doi-asserted-by":"crossref","first-page":"739","DOI":"10.1097\/00000542-200003000-00018","article-title":"Comparative spinal distribution and clearance kinetics of intrathecally administered morphine, fentanyl, alfentanil, and sufentanil","volume":"92","author":"Ummenhofer","year":"2000","journal-title":"Anesthesiology"},{"key":"2020101310150584000_pnaa104-B23","first-page":"1107","article-title":"An isobolographic analysis of the antinociceptive effect of systemically and intrathecally administered combinations of clonidine and opiates","volume":"255","author":"Ossipov","year":"1990","journal-title":"J Pharmacol Exp Ther"},{"key":"2020101310150584000_pnaa104-B24","doi-asserted-by":"crossref","first-page":"127","DOI":"10.1097\/00000542-199707000-00017","article-title":"Assessment of the potency and intrinsic activity of systemic versus intrathecal opioids in rats","volume":"87","author":"Abram","year":"1997","journal-title":"Anesthesiology"},{"key":"2020101310150584000_pnaa104-B25","doi-asserted-by":"crossref","first-page":"355","DOI":"10.1097\/00000542-199802000-00014","article-title":"The dose-response relation of intrathecal fentanyl for labor analgesia","volume":"88","author":"Palmer","year":"1998","journal-title":"Anesthesiology"},{"issue":"2","key":"2020101310150584000_pnaa104-B26","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1097\/AAP.0000000000000368","article-title":"Sudden intrathecal drug delivery device motor stalls: A case series","volume":"41","author":"Galica","year":"2016","journal-title":"Reg Anesth Pain Med"},{"issue":"6","key":"2020101310150584000_pnaa104-B27","doi-asserted-by":"crossref","first-page":"654","DOI":"10.1097\/AAP.0000000000000849","article-title":"Sudden intrathecal drug delivery device motor stalls: A case series update","volume":"43","author":"McEwan","year":"2018","journal-title":"Reg Anesth Pain Med"}],"container-title":["Pain Medicine"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/academic.oup.com\/painmedicine\/article-pdf\/21\/9\/1921\/33875745\/pnaa104.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"http:\/\/academic.oup.com\/painmedicine\/article-pdf\/21\/9\/1921\/33875745\/pnaa104.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,10,19]],"date-time":"2022-10-19T09:24:06Z","timestamp":1666171446000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/painmedicine\/article\/21\/9\/1921\/5836000"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,5,11]]},"references-count":27,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2020,5,11]]},"published-print":{"date-parts":[[2020,9,1]]}},"URL":"https:\/\/doi.org\/10.1093\/pm\/pnaa104","relation":{},"ISSN":["1526-2375","1526-4637"],"issn-type":[{"value":"1526-2375","type":"print"},{"value":"1526-4637","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2020,9]]},"published":{"date-parts":[[2020,5,11]]}}}