High Cervical and Prepontine Intrathecal Drug Delivery for Craniofacial Pain: A Systematic Review.

OBJECTIVES

This study aimed to systematically synthesize the evidence on high cervical intrathecal drug delivery (IDD) for the management of craniofacial pain, focusing on indications, catheter location, drug regimens, pain outcomes, and safety.

MATERIALS AND

METHODS

A systematic review was conducted according to Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed was searched from inception to July 25, 2025. Eligible studies included adults with craniofacial pain treated with IDD using high cervical catheters. Outcomes of interest included pain scores, catheter location, medications and dosing, and complications. Two reviewers independently screened studies and extracted data. Methodological quality was assessed using Joanna Briggs Institute tools.

RESULTS

A total of 14 studies comprising 143 patients were included. Craniofacial pain etiologies were predominantly cancer related, with smaller cohorts of neuropathic and mixed pain syndromes. Catheter tips were most commonly positioned at C1-C2, the prepontine cistern, or cisterna magna, with imaging confirmation in all cases. Intrathecal regimens were carried out, most frequently using an opioid alone or in combination with a local anesthetic. Baseline pain was uniformly severe and improved substantially following intervention. Follow-up ranged from one to 27 months. Marked reductions or complete discontinuation of systemic opioids were commonly reported. Device-related complications were infrequent and primarily included catheter migration and infection.

CONCLUSIONS

High cervical IDD is associated with reductions in pain and systemic opioid use in carefully selected patients with refractory craniofacial pain. Although current evidence is limited to small observational studies, outcomes were consistently favorable across all selected studies. Common complications were similar to those observed following IDD at lower neuraxial levels, including catheter migration and infections. Prospective studies using standardized outcome measures are needed to define optimal patient selection, catheter positioning, and drug regimens.