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

Authors Staub BP, Casini GP, Monaco III EA, Sekula Jr RF, Emerick TD

Received 7 November 2018

Accepted for publication 29 December 2018

Published 8 March 2019 Volume 2019:12 Pages 945—949


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Dr E Alfonso Romero-Sandoval

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

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