De Pietri, L., Siniscalchi, A., Reggiani, A., Masetti, M., Begliomini, B., Gazzi, M., . . . Pasetto, A. (2006). The use of intrathecal morphine for postoperative pain relief after liver resection: A comparison with epidural analgesia. Anesthesia and Analgesia, 102, 1157–1163. 

To determine if the intrathecal analgesia technique is not inferior to continuous epidural (EP) infusions for postoperative pain in patients undergoing liver resections

Patients who had epidural analgesia had catheters inserted at the T9-10 or T10-11 levels. Ropivacaine and morphine were injected prior to anesthesia. In the intrathecal group, a dural puncture was done at the L3-4 or L 5-6 level, and morphine and saline were injected prior to anesthesia. In the EP group analgesia was continued with ropivacaine. In both groups, patients could receive 1 mg boluses of morphine from a patient-controlled IV pump. A value of 10 mm was used to determine noninferiority. Assessments were done at four, eight, 12, 24, 36, and 48 hours.

• N = 50
• AGE = Not provided
• MALES: Not provided        
• FEMALES: Not provided
• KEY DISEASE CHARACTERISTICS: Undergoing liver resection for cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Patients with elevated international normalized ratios or reduced platelet counts were excluded.

• SITE: Single site  
• SETTING TYPE: Inpatient  
• LOCATION: Italy

PHASE OF CARE: Active antitumor treatment

Prospective noninferiority trial

• Morphine consumption
• Visual Analog Scale (VAS) for pain (100 mm assumed but not specified)

The time to first morphine requirement was longer in the epidural group at all time points, and by 48 hours, morphine use in the intrathecal group was four times higher than in the epidural group (p < 0.001). Extubation time and recovery room time were significantly shorter in the epidural group (p < 0.05). The total amount of morphine required in the intrathecal group was higher (p < 0.01). No significant differences between the groups in postoperative pain scores were reported.

Although this study reported that a single dose of intrathecal preoperative analgesia was not inferior to epidural analgesia, other measures reflecting postoperative pain were in favor of epidural analgesia. A single preoperative dose of intrathecal morphine may be a viable alternative approach to manage acute pain.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Other limitations/explanation: No demographic information was reported.

The findings of this study suggested that a single intrathecal dose of morphine preoperatively can provide an alternative approach for the management of postoperative pain, which may be useful for patients in whom continuous epidural analgesia is not appropriate.