An intrathecally located broken catheter used for an intrathecal drug delivery system

Myth and Truth in Opioid Consumption with Intrathecal Morphine Pump Implantation in Chronic Pain: A Retrospective Cohort Study with Claims Database in South Korea

OBJECTIVE

To investigate the opioid consumption and the healthcare resource utilization in patients with the intrathecal drug delivery system (IDDS) therapy and the comprehensive medical management (CMM) alone.

DESIGN

A retrospective cohort study with a customized claims database.

SETTING

In a university-based hospital.

SUBJECTS

Patients with complex regional pain syndrome, post-laminectomy syndrome, and fibromyalgia.

METHODS

Using propensity score matching (1:3), we selected patients with morphine infusion through IDDS (IDDS group) and CMM alone (CMM group). The primary endpoints were comparisons of average morphine equivalents daily dosages (MEDD, mg/day) for 6 and 12 months from an index date. The number of emergency room (ER) visits and hospitalizations and the total medical expenditures were compared as secondary outcomes.

RESULTS

In total, 82 patients (N = 23 in the IDDS group and N = 59 in the CMM group) were analyzed. Although a 6-month average MEDD did not reach statistical significance, a 12-month average MEDD was significantly decreased in the IDDS group compared to the CMM group (53.2 ± 46.3 vs 123.9 ± 176.4, respectively; P = 0.008). ER visits were more frequent in the IDDS group than the CMM group at baseline (5.4 vs 0.5, respectively; P = .002), which was maintained for 12 months (P < 0.001). Otherwise, the number of hospitalization and the medical expenditures for pain management were not different between the groups for 12 months.

CONCLUSIONS

The combined IDDS therapy had some benefits in reducing opioid consumption for 1-year follow-up compared to the CMM alone in chronic noncancer pain patients.

Perioperative Management of Spinal Cord Stimulators and Intrathecal Pain Pumps

Spinal cord stimulators (SCSs) and intrathecal pain pumps (IPPs) are implantable devices used in the management of chronic pain or spasticity. Complications, such as infection, lead migration/failure, cerebrospinal fluid leak, neurologic injury, and other medical complications, can occur after placement and may require surgical intervention. Orthopaedic surgeons may encounter patients with these devices and should have a basic understanding of their function. In addition, they should be aware that patients may have residual stenosis or deformity contributing to their symptoms; thus, spine surgery referral may be indicated. If a patient with a SCS or IPP is undergoing revision spinal surgery, a preoperative discussion regarding retention versus removal of the device is imperative because indications for device retention, revision, and removal are complex. This review summarizes potential complications and intraoperative considerations concerning the proper perioperative management of SCSs/IPPs and will provide evidence-based data regarding management strategies for these devices.

CE: Intrathecal Pumps for Managing Cancer Pain

: It is estimated that more than 1.6 million new cases of cancer were diagnosed in the United States in 2014. Among patients with cancer, moderate to severe pain is prevalent and can be refractory, even with the use of systemic opioids, which may cause adverse effects that are difficult to manage at the doses required to control pain. When delivered intrathecally, however, opioids and adjuvant analgesics may provide greater pain relief at dramatically lower doses and with fewer adverse effects. Although the use of intrathecal drug delivery systems for cancer pain management has increased dramatically over the past several years and is expected to continue growing, patients with intrathecal pumps often report interactions with nurses unfamiliar with the technology. This article provides an overview of intrathecal pump therapy and explains how it prolongs duration of action and improves the efficacy of certain analgesics while reducing their adverse effects. The author discusses the costs involved, the patients most likely to derive benefit, the types of pumps currently used in the United States, the medications that can be delivered intrathecally, the potential risks and complications associated with intrathecal therapy, and the nursing care required by patients who use an intrathecal pump.

Advances in intrathecal drug delivery

PURPOSE OF REVIEW

Targeted intrathecal drug delivery systems (IDDS) are an option in algorithms for the treatment of patients with moderate-to-severe chronic refractory pain. This article is intended to review the literature regarding IDDS published over the last year, with special attention to the Polyanalgesic Consensus Conference 2012.

RECENT FINDINGS

The recommendations made by the Polyanalgesic Consensus Conference 2012 are reviewed. Separate considerations of intrathecal drug therapy for neuropathic and nociceptive pain syndromes and the new concept of 'microdosing' are discussed in this article.

SUMMARY

This review includes the recommendations for the use of IDDS, trialing, and recent reports of complications (especially, the occurrence of granulomas). In addition, the latest documents on cerebrospinal fluid and potential lines of future development are discussed.

Lumbar nerve rootlet entrapment by an iatrogenically spliced percutaneous intra-thecal lumbar cerebrospinal fluid catheter

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Iatrogenic splicing of intra thecal catheter can occur and induce nerve root entrapment.

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Care should be taken not to pull back on catheter or to advance insertion needle during insertion.

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Upon attempted removal if resistance and/or neurologic involvement occurs, removal of catheter should be ceased.

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CT scan findings of a spliced catheter may include a double dot finding.

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Successful catheter removal can be performed with open decompression and durotomy.

Background

Complications associated with the use of percutaneous intra-thecal lumbar indwelling spinal catheters include infection, hematoma, neurologic dysfunction, and persistent undesired retention among others. A case of iatrogenic splicing associated with neurologic dysfunction with the use of a percutaneous intra-thecal indwelling spinal catheter is presented in this study.

Method

Single case study review.

Results

Review of case materials indicate Y pattern splicing/fragmentation of an indwelling intra-thecal catheter causing neurologic dysfunction and resistance to removal during attempted removal. Pain and weakness were evident soon after insertion of the catheter and were amplified with attempted catheter removal. Computed tomography revealed a double dot sign on axial view and a Y appearance on sagittal view. Surgical findings revealed entrapment of nerve rootlets in the axilla of the spliced catheter.

Conclusions

Splicing/fragmentation causing neurologic dysfunction as well as catheter retention is described as a potential complication of intra-thecal indwelling cerebrospinal fluid catheters. A symptom of fragmentation of a catheter may include neurologic dysfunction including pain and weakness of a lumbar nerve root. If resistance is experienced upon attempted catheter removal, with or without associated neurologic dysfunction, further attempts at removal should not be attempted. In those cases in which pain and/or lumbar weakness are evident post catheter placement and/or following attempted removal, computed tomography should be performed. If fragmentation of a catheter is evident on CT scan, spinal surgical consultation should be obtained. Recommended spinal surgical intervention includes an open durotomy and visualization of catheter fragments and nerve rootlets and removal of catheter fragments.