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The authors describe the clinical case of a patient suffering from severe cervico-facial pain syndrome with great incident component from inoperable pharynx cancer. The patient that was poorly responding to systemic therapy with high doses of opioids, benefi ted from intrathecal administration of ziconotide in combination with morphine and bupivacaine. After a long period of effectiveness (16 months), the patient complained of pain recurrence.The increase of ziconotide dose caused a serious adverse effect (psychosis), which led to the suspension of the drug. After four weeks washout, lower doses of the drug (1/4) administered at cervical segmental level; the patient achieved again a good pain relief.

The aim of this report is to describe the emission of a erious painful symptomatology in a 57 years patient that suffered from low back pain and pain to the inferior limbs for several years. The pain was a result of surgical treatment (Failed Back Surgery Syndrome, FBSS) and the gravity of the symptoms had negatively influenced the patient’s quality of life. The pain, nociceptive and neuropathic,was resistant to several therapeutic approaches (pharmacological or not). Also a period of test with dorsal spinal cord stimulation (SCS) was ineffective. After careful analysis, the patient has been submitted to period of test with ziconotide intrathecally administered. The result that surpassed all one’s expectations, was a remarkable reduction of the pain. Such reduction allowed the patient to totally recover its autonomy and clearly improve the quality of life.

The Author reports the case of ziconotide intrathecal treatment in three terminal cancer patients, with nociceptive and neuropathic pain, unresponsive to the treatment with intrathecal opioid and adjuvant drugs. An external pump for continuous subarachnoid infusion was implanted to the three patients. The initial dose was 2,4 mcg/die, with increments of 1,2 mcg/die every three days till the maximum dose of 4,8 mcg/die in two patients (survival 61 and 45 days) and 7,2 mcg/die in a patient (survival 52 days). VAS reduction was 50% in the fi rst patient, of 57% in the second one and 70% in the third one. In one case, at the dose of 4,8 mcg/die, the treatment was associated with important collateral effects, that requested the temporary suspension of the drug.

The Author reports the case of a patient with severe lumbar pain unresponsive to NSAIDs. Initial treatment with tramadol gave poor results and a new protocol with hydromorphone – pregabalin was started. The analgesic response was observed only following high hydromorphone doses, associated with unacceptable side effects. A spinal device for continuous intrathecal infusion was then implanted, in order to administer ziconotide, a new opioid drug. Associated therapy included hydromorphone – pregabalin. At the 4 mcg/die dose ziconotide resulted highly effective (with a VAS reduction pain 6-7 to 2-3) even at 1st day after implantation; in addition at day 10, opioid dose was strongly reduced and pregabalin withdrawn. The treatment was associated with a good tolerability. The encouraging results prompted the Author to test ziconotide in further cases of severe chronic pain.

Erythromelalgia is a rare clinical syndrome, characterized by erythema, burning pain and increased skin temperature in the extremities. The therapeutic treatment of this pathology is not yet standardized and both the administration of several drugs or the use of invasive techniques can be effective in some patients and without effect in others. We report the case of a 31-yearsold women affected by primary erythromelalgia that after several ineffective therapeutic treatments, was successfully treated with intrathecal ziconotide.