Neuropathic pain represents a substantial burden on society. The treatment of neuropathic pain is challenging and typically involves multiple medication classes such as anticonvulsants, antidepressants, and opioids. The advent of intrathecal medication delivery in the late 1970s provided an additional option for the treatment of refractory neuropathic pain. This article presents a review of the evidence regarding intrathecal medications for neuropathic pain. There is strong evidence to support the use of intrathecal opioids in malignant pain of mixed characteristics, and moderate evidence for their use in non-malignant, neuropathic pain. The use of baclofen is strongly supported for spasticity, but there is only intermediate-level evidence for its use in neuropathic pain. With respect to clonidine and ziconotide, there is moderate evidence to support their use for neuropathic pain, although the effectiveness of the latter agent is limited by the high incidence of adverse effects. For steroids, there is weak evidence in favor of its use in neuropathic pain, predominantly in combination with opioids. The evidence is moderate to strong for the use of steroids in post-herpetic neuralgia, which must be weighed against the possibility of neurotoxicity if depot steroids are injected.
