Near-resolution of persistent idiopathic facial pain with low-dose lumbar intrathecal ziconotide: a case report

• Main Authors: Staub BP, Casini GP, Monaco III EA, Sekula Jr RF, Emerick TD
• Format: Article
• Language: English
• Published: Dove Medical Press 2019-03-01
• Series: Journal of Pain Research
• Subjects: Allodynia; Chronic pain; Neuropathic Pain; Pain Disorder; Pain Management; Persistent Pain
• Online Access: https://www.dovepress.com/near-resolution-of-persistent-idiopathic-facial-pain-with-low-dose-lum-peer-reviewed-article-JPR

Brandon P Staub,1 Gianna P Casini,2 Edward A Monaco III,3,4 Raymond F Sekula Jr,3,4 Trent D Emerick4,5 1Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA; 2Pain Management, Parkview Health, Fort Wayne, IN, USA; 3Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; 4University of Pittsburgh Physicians, Pittsburgh, PA, USA; 5Division of Chronic Pain, Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA Purpose: Persistent idiopathic facial pain (PIFP) is a poorly defined and debilitating chronic pain state with a challenging and often inadequate treatment course. This is the first case report identifying the novel use of low-dose lumbar intrathecal ziconotide to successfully treat PIFP with nearly complete resolution of pain and minimal to no side effects. Methods: The patient was a 37 year-old female whose PIFP was refractory to multimodal medication management and multiple neurovascular surgical interventions. A single-shot lumbar intrathecal trial of ziconotide (2.5 mL, equivalent 2.5 μg) was injected when she was at her baseline pain level — VAS 7/10. She received complete resolution of her pain for about 9 hours, concordant with ziconotide’s half-life. She was subsequently implanted with a lumbar intrathecal delivery system. Results: The patient experienced complete resolution of her facial pain with a single-shot intrathecal trial of ziconotide. The intrathecal pump system has provided nearly complete (VAS 1/10) pain relief. Two flares of pain occurred 10 and 18 months after pump placement, which subsequently resolved after increasing the ziconotide dose by 0.5 μg/day on each occasion. The patient is currently maintained on a dose of 2.0 μg/day and is pain-free. Conclusion: This is the first case report describing the use of a single-shot lumbar intrathecal trial of ziconotide and subsequent placement of lumbar (as opposed to thoracic) intrathecal ziconotide pump for PIFP. A single-injection intrathecal trial is a low-risk, viable option for patients with this debilitating and frustrating pain condition. Successful trials and subsequent intrathecal pump placement with ziconotide may supplant multimodal medication management and/or invasive orofacial surgical intervention for PIFP. Keywords: allodynia, chronic pain, neuropathic pain, pain disorder, pain management, persistent pain