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Acute response to intracisternal bupivacaine in patients with refractory pain of the head and neck

Journal article
Authors G. Lambert
Mikael Elam
Peter Friberg
Christopher Lundborg
Sinsia Gao
J. Bergquist
Petre Nitescu
Published in J Physiol
Volume 570
Issue Pt 2
Pages 421-8
ISSN 0022-3751 (Print)
Publication year 2006
Published at Institute of Neuroscience and Physiology, Department of Clinical Neuroscience and Rehabilitation
Institute of Medicine, Department of Molecular and Clinical Medicine
Institute of Clinical Sciences
Pages 421-8
Language en
Keywords Adult, Aged, Aged, 80 and over, Anesthetics, Local/administration & dosage/*therapeutic use, Biogenic Monoamines/cerebrospinal fluid, Blood Pressure/drug effects/physiology, Brain Stem/physiology, Bupivacaine/administration & dosage/*therapeutic use, Catecholamines/cerebrospinal fluid, Catheterization/adverse effects/methods, Cisterna Magna, Electroencephalography, Female, Heart Rate/drug effects/physiology, Humans, Male, Middle Aged, Pain, Intractable/cerebrospinal fluid/*drug therapy/*physiopathology, Serotonin/cerebrospinal fluid, Sympathetic Nervous System/drug effects/physiology, gamma-Aminobutyric Acid/cerebrospinal fluid
Subject categories Anesthesiology and Intensive Care


Continuous intracisternal infusion of bupivacaine for the management of intractable pain of the head and neck is effective in controlling pain in this patient group. With the catheter tip being located at the height of the C1 vertebral body, autonomic regulatory information may also be influenced by the infusion of bupivacaine. By combining direct sampling of cerebrospinal fluid (CSF), via a percutaneously placed catheter in the cisterna magna, with a noradrenaline and adrenaline isotope dilution method for examining sympathetic and adrenal medullary activity, we were able to quantify the release of brain neurotransmitters and examine efferent sympathetic nervous outflow in patients following intracisternal administration of bupivacaine. Despite severe pain, sympathetic and adrenal medullary activities were well within normal range (4.2 +/- 0.6 and 0.7 +/- 0.2 nmol min(-1), respectively, mean +/-S.E.M.). Intracisternal bupivacaine administration caused an almost instantaneous elevation in mean arterial blood pressure, increasing by 17 +/- 7 mmHg after 10 min (P < 0.01). Heart rate increased in parallel (17 +/- 5 beats min(-1)), and these changes coincided with an increase in sympathetic nervous activity, peaking with an approximately 50% increase over resting level 10 min after injection (P < 0.01). CSF levels of GABA were reduced following bupivacaine (P < 0.05). CSF catecholamines and serotonin, and EEG, remained unaffected. These results show that acutely administered bupivacaine in the cisterna magna of chronic pain sufferers leads to an activation of the sympathetic nervous system. The results suggest that the haemodynamic consequences occur as a result of interference with the neuronal circuitry in the brainstem. Although these effects are transient, they warrant caution at the induction of intracisternal local anaesthesia.

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