Abstract

A male patient, middle-aged and BMI of 25.7 kg/ m2 (weight 69 kg, height 1.64 m) was referred to the chronic pain unit 10 years ago for shoulder and residual thalamic pain following a cerebrovascular accident. This pain was treated with conventional analgesic therapy.

Five years ago, the patient reported severe low back pain (LBP) with bilateral radiculopathy in the lower limbs without ‘red flags’. The medical history included diabetes, controlled hypertension and coronary artery bypass graft surgery. At that moment, the patient was not taking any anticoagulation therapy. CT revealed moderate spinal stenosis in L3-L4 and root compression due to herniated disc protrusion in L4-L5.

Despite six months of several systemic multimodal analgesic therapies (increasing doses and rotation of strong opioids/adjuvants by the WHO ladder), the LBP prevented the patient from physiotherapy, having a strong impact on daily living activities (DLA), mood and willingness to live.

The pain intensity (9-10 on the visual analogue scale) with bilateral radiculopathy (L4-L5 dermatomes distribution, Lasègue sign positive and without neurological deficits) had the characteristics of intractable pain through conventional treatment. An invasive analgesic technique was then considered with the patient’s consent. The patient was informed of the protocol safety when the criteria are followed strictly and of the general and rare specific risks, namely dura-mater accidental puncture, subdural haematoma, urinary retention and local/systemic infection.

A protocol of continuous epidural technique with a tunnelled catheter was then initiated. A diagnostic and therapeutic technique was used with a single-shot lumbar epidural for immediate and prolonged relief of severe bilateral pain and functional disability (6.25 mg of levobupivacaine, 14 mg of betamethasone dipropionate and 1.5 mg of morphine). After 2 weeks without pain, there was an LBP recurrence requiring the protocol’s second stage to be followed.

With the patient seated in his comfort position, a median interlaminar epidural approach was performed at L4-L5 intervertebral level, followed by 20G tunnelled catheter placement without complications. Simultaneously, with the gradual discontinuation of systemic opioids, the epidural perfusion analgesia was administered by sequential EIPs (capacity 65 mL for 5 days; 0.5 mL/ hour; with 13 mg/day of levobupivacaine 0.1% + 5 mg/day of morphine), providing pain relief without adverse effects, while ensuring the restoration of DLA.

An MRI revealed a migrated hernia fragment lodged in the L4 root without neurological compression. After ten weeks, the epidural catheter was removed without complications or inflammatory/infection signs (negative bacteriological analysis of catheter tip and blood culture).

After reassessment by the neurosurgical team, this favourable evolution of symptoms excluded criteria for surgical intervention.

During the last four years, the patient did not experience lumbosciatic pain recurrence and restored DLA. The original thalamic pain has been controlled with mild analgesic therapy. This clinical case demonstrates that a technique widely used in other contexts can be adjusted for outpatient treatment of non-cancer pain as long as the safety criteria are strictly respected. Studies confirm that continuous epidurals with opioids, anaesthetics and corticosteroids for LBP result in the control of disabling pain crises, reducing doses of systemic opioids with significant improvement of quality of life.