Background and Aims Intrathecal analgesia is a powerful yet underused modality for refractory pain. Compared to epidural analgesia, it provides a quicker onset of effect and a denser sensory block, while reducing side effects and adjuvant requirements.

Methods A 43-year-old male with a history of chronic pain and opioid abuse was referred to the Pain Unit due to intractable pain following multiple surgeries due to lower limb trauma. Despite multimodal schemes, including epidural analgesia and a sciatic-popliteal perineural catheter, the patient reported pain greater than 7 out of 10 in the Numeric Rating Scale (NRS). In an attempt to improve analgesia and reduce opioid consumption, an intrathecal catheter was inserted and 2 mL 0.2% ropivacaine and 0.3 mg morphine were administered. Analgesia was maintained with intermittent boluses of 2 mL 0.2% ropivacaine every 2 hours. The patient significantly improved, reporting 0 out of 10 in the NRS. Systemic analgesia was optimized and a transdermal buprenorphine patch was initiated. The catheter was removed following 72 hours with optimal pain control.

Results Management of acute pain in patients with a history of chronic pain is challenging due to opioid dependence, tolerance and hyperalgesia, such that traditional postoperative analgesic schemes may fail. Intrathecal pain therapy is advocated for moderate and severe and intractable pain when other conservative therapies fail, appearing as an attractive and effective analgesic tool in patients with refractory pain, allowing optimization of long-term systemic analgesia.

Conclusions Intrathecal analgesia may be a successful short-term option for pain relief in opioid tolerant patients with acute postoperative refractory pain.