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There is not as yet clear consensus regarding the indications. However intrathecal drug delivery (ITDD) is most appropriate in patients with uncontrolled bilateral or axial pain, despite adequate trials of systemic drugs. The technique has been shown to be of benefit in failed back syndrome and chronic mechanical back pain. It may be helpful in neuropathic pain of spinal cord origin: the importance of the trial and assessment process is re-emphasized. In this context there is interest in new agents such as ziconatide. A ‘competitor’ treatment is spinal cord stimulation (SCS): as yet there is no agreement as to

when one technique is favoured over the other, but SCS may be favoured if the pain is more focal, and if the efficacy is equivalent by virtue of the fact that the need for regular drug refills is avoided. Cognitive behavioural therapy may be delivered in parallel with ITDD therapy. The importance of long-term commitment of both patient and physician should not be underestimated.