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Gerges T, Mavropoulos A, Levin D, Dao T, Acquadro M. A Rare Intrathecal Pump Complication Caused by Prolonged Seroma Leading to a Potential Pump Pocket Fill: A Near Miss. Cureus 2023; 15:e48651. [PMID: 37954627 PMCID: PMC10638945 DOI: 10.7759/cureus.48651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2023] [Indexed: 11/14/2023] Open
Abstract
Intrathecal drug delivery systems have been used with increasing frequency in patients with chronic intractable pain. Common complications of intrathecal drug delivery systems include surgical bleeding, spinal cord injury, fractured or migrated catheter, meningitis, pump failure, granuloma formation, cerebral spinal fluid leak, and hygroma formation. We present a rare near-miss case that could have led to the inadvertent filling of an intrathecal pump pocket with a high concentration of narcotic and local anesthetic. This situation arose due to the discovery of a prolonged intrathecal pump pocket seroma during a routine maintenance and refill procedure.
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Affiliation(s)
- Teddy Gerges
- Anesthesiology, St. Elizabeth's Medical Center, Boston, USA
| | | | | | - Thuan Dao
- Anesthesiology, St. Elizabeth's Medical Center, Boston, USA
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Nagel SJ, Reddy CG, Frizon LA, Holland MT, Machado AG, Gillies GT, Howard MA. Intrathecal Therapeutics: Device Design, Access Methods, and Complication Mitigation. Neuromodulation 2017; 21:625-640. [DOI: 10.1111/ner.12693] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 07/26/2017] [Accepted: 07/29/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Sean J. Nagel
- Center for Neurological Restoration; Cleveland Clinic; Cleveland OH USA
| | - Chandan G. Reddy
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | | | - Marshall T. Holland
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
| | - Andre G. Machado
- Center for Neurological Restoration; Cleveland Clinic; Cleveland OH USA
| | - George T. Gillies
- Department of Mechanical and Aerospace Engineering; University of Virginia; Charlottesville VA USA
| | - Matthew A. Howard
- Department of Neurosurgery; University of Iowa Hospitals and Clinics; Iowa City IA USA
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Abousamra O, Rogers KJ, McManus M, Miller F, Sees JP. Evaluation of intrathecal baclofen delivery system malfunction by computed tomography scan. Dev Med Child Neurol 2016; 58:409-15. [PMID: 26358299 DOI: 10.1111/dmcn.12893] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2015] [Indexed: 11/29/2022]
Abstract
AIM To describe the computed tomography (CT) findings encountered when catheter patency is questionable. The role of CT in directing treatment is evaluated. METHOD Records of children with intrathecal baclofen pump management were reviewed. Only patients with CT evaluation who had revision pump/catheter surgery were included. RESULTS From 295 patients, 27 had CT contrast study; in three of them, baclofen could not be aspirated and the procedure was stopped, eight had normal scan and did not need surgery and 16 patients were reported. Four patients had normal CT (free contrast formed a perfect crescent shape), and had surgery because the pump battery was close to expiration. Five patients had inadequate fluid pooling (fluid was seen without a crescent shape). Five patients had fluid leak (fluid was seen around the pump or in the lumbar canal below catheter entrance level or outside the canal in the lumbar region). Two patients had catheter occlusion (fluid loculation around the catheter tip with no free flow). INTERPRETATION CT contrast study is safe and effective for locating defects in intrathecal baclofen delivery system. When catheter patency is questionable, CT plays an important role in directing the next step of management.
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Affiliation(s)
- Oussama Abousamra
- Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Kenneth J Rogers
- Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Maura McManus
- Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Freeman Miller
- Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Julieanne P Sees
- Department of Orthopedics, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
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Hnenny L, Sabry HA, Raskin JS, Liu JJ, Roundy NE, Dogan A. Migrating lumbar intrathecal catheter fragment associated with intracranial subarachnoid hemorrhage. J Neurosurg Spine 2015; 22:47-51. [DOI: 10.3171/2014.9.spine147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intrathecal catheter placement into the lumbar cistern has varied indications, including drug delivery and CSF diversion. These Silastic catheters are elastic and durable; however, catheter-associated malfunctions are well reported in the literature. Fractured catheters are managed with some variability, but entirely intradural retained fragments are often managed conservatively with observation.
The authors describe a case of a 70-year-old man with an implanted intrathecal morphine pump for failed back surgery syndrome who presented to an outside hospital with a history of headache, neck pain, nausea, and photophobia of 3 days' duration. He also described mild weakness and intermittent numbness of both legs. Unenhanced head CT demonstrated subarachnoid hemorrhage (SAH). A right C-5 hemilaminectomy was performed.
This case is unique in that there was no indication that the lumbar intrathecal catheter had fractured prior to the patient's presentation with SAH. This case demonstrates that intrathecal catheter fragments are mobile and can precipitate intracranial morbidity. Extrication of known fragments is safe and should be attempted to prevent further neurosurgical morbidity.
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Jones RCW, Moeller-Bertram T, Wallace MS. Safety and efficacy of intrathecal drug delivery for pain. Pain Manag 2012; 2:55-61. [DOI: 10.2217/pmt.11.76] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY The practice of delivering analgesic drugs into the intrathecal space has evolved over the past several decades from a ‘last-ditch’ therapy for intractable pain in patients with terminal cancer to a more widely applied strategy for treating patients with chronic nonmalignant pain as well. This review discusses the available safety and efficacy data of intrathecal drug delivery with a focus on device- and user-related safety issues.
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Affiliation(s)
- R Carter W Jones
- Department of Anesthesiology, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037-7651, USA
- VA San Diego Healthcare System, San Diego, CA, USA
| | - Tobias Moeller-Bertram
- Department of Anesthesiology, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037-7651, USA
- VA San Diego Healthcare System, San Diego, CA, USA
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Maugans TA. Intracranial Migration of a Fractured Intrathecal Catheter From a Baclofen Pump System. Neurosurgery 2010; 66:319-22. [DOI: 10.1227/01.neu.0000363183.78323.d7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
This case report describes a new complication associated with a baclofen pump in which its fractured intrathecal catheter migrated into the patient's ventricular system. A thecal model was developed to evaluate catheter buoyancy in artificial cerebrospinal fluid (CSF). The literature was reviewed to identify possible mechanical and physiologic causes of catheter migration.
CLINICAL PRESENTATION
A 16-year-old boy with cerebral palsy presented with cervical pain, nausea, and vomiting. He was known to have a nonfunctioning baclofen pump with a 1-piece intrathecal catheter. Imaging studies showed mild ventriculomegaly and a fractured segment of the intrathecal catheter that extended from the cervical subarachnoid space into the third and fourth ventricles.
INTERVENTION
The patient had complete symptom resolution after undergoing urgent surgical removal of the catheter segment. Manufacturer analysis of the retrieved catheter revealed a crushed, jagged proximal end. In an experimental thecal sac model, catheter segments in lengths of 0.5 to 89 cm were denser than the artificial CSF and, therefore, did not float in the thecal sac. This finding negates the role of buoyancy in migration. Review of the literature advocates for caudocranial CSF flow patterns as a plausible mechanism for migration.
CONCLUSION
This complication alerts surgeons to the migration risk of loose intrathecal catheter segments into the ventricular system. CSF flow patterns and mechanical processes, but not material properties of the catheter, are likely causes.
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Affiliation(s)
- Todd A. Maugans
- Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Nakaji P, Consiglieri GD, Garrett MP, Bambakidis NC, Shetter AG. CRANIAL MIGRATION OF A BACLOFEN PUMP CATHETER ASSOCIATED WITH SUBARACHNOID HEMORRHAGE. Neurosurgery 2009; 65:E1212-3; discussion E1213. [DOI: 10.1227/01.neu.0000359222.97354.84] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Cephalad migration of an indwelling intrathecal catheter within the spinal canal has rarely been described. Cranial subarachnoid hemorrhage (SAH) related to movement of this type of catheter has not been described. We report a case of SAH coincident with the migration of a free fragment of a baclofen pump catheter into the prepontine cistern.
CLINICAL PRESENTATION
A baclofen pump system was removed from a 47-year-old man with spasticity related to multiple sclerosis. A section retained in the spinal canal extended up to the T9 level. Ten days after the pump and lower portion of the catheter were removed, the patient presented with a severe headache and a classic aneurysmal pattern of SAH. The patient's catheter was found to have migrated adjacent to the basilar artery at the level of the superior cerebellar artery. An extensive evaluation, including computed tomography angiography, digital subtraction angiography performed twice, magnetic resonance imaging, and magnetic resonance angiography, showed no apparent cause for the hemorrhage. Initially, the catheter was left in place. However, 5 months after the SAH, the patient elected to have the catheter removed.
INTERVENTION
The catheter was pulled out from below through a C6–C7 laminoplasty without complications. The patient made an excellent recovery.
DISCUSSION
Cephalad catheter migration is a rare phenomenon. The mechanism of rostral migration remains unclear. The forces that propel a free fragment of catheter under these circumstances seem to be sufficient to cause a small vessel to rupture and bleed. Given the lack of an observed arterial injury, we postulate that venous bleeding caused this hemorrhage.
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Affiliation(s)
- Peter Nakaji
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Giac D. Consiglieri
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark P. Garrett
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nicholas C. Bambakidis
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Andrew G. Shetter
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Rosenfeld DM, Trentman T, Patel NP. Pontine hemorrhage following a recently implanted intrathecal drug delivery system. Pain Pract 2009; 9:312-6. [PMID: 19500275 DOI: 10.1111/j.1533-2500.2009.00290.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND This report describes a pontine hemorrhage in a patient following implantation of an intrathecal drug delivery system. CASE REPORT A 70-year-old old female patient with metastatic breast carcinoma underwent placement of an implantable intrathecal drug delivery system. Before implant she was neurologically intact with only mild memory deficiencies attributed to narcotics and malignancy. No recent brain magnetic resonance imaging (MRI) was on record. On post-implant day 2 after the initiation of intrathecal hydromorphone 0.45 mg/day and bupivacaine 2.7 mg/day, she developed dizziness, lethargy, and mild gait instability. Despite decreasing drug dosages, these symptoms progressed over the ensuing days, and subsequently the patient developed upper extremity numbness and tinnitus. The device was turned off on post-implant day 9 with the patient showing no signs of improvement. She underwent computerized tomography scan of the head, which identified an acute pontine hemorrhage. A follow-up MRI scan confirmed the hemorrhage and revealed a previously undiagnosed underlying metastatic lesion with surrounding vasogenic edema. She was treated with supportive measures in hospice and expired 20 days after implantation. CONCLUSIONS This case emphasizes several important points. First, changes in neurologic and mental status after initiating intrathecal drug therapy may be related to new or pre-existing pathology and not due to intrathecal medications. Second, consideration should be given to central nervous system imaging before intrathecal pump insertion in patients with widely metastatic malignancies. Finally, cerebral spinal fluid hypotension from dural puncture may have contributed to the timing of the hemorrhage in this patient.
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Affiliation(s)
- David M Rosenfeld
- Division of Pain Management, Mayo Clinic Arizona-Anesthesiology, Phoenix, Arizona 85054, USA.
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Singh PK, Jain R, Mishra S, Kumar S, Bhatnagar S, Deo S. Management of Pericatheter Cerebrospinal Fluid Leak After Intrathecal Implantation of a Drug Delivery System. Am J Hosp Palliat Care 2008; 25:237-9. [DOI: 10.1177/1049909108315520] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Persistent cerebrospinal fluid leak is a known complication of intrathecal pump system insertion for drug delivery. Various treatment modalities, such as an epidural blood patch, use of glue, removal of catheter, and surgical closure of dura and subdural blood patch, have been reported previously. This report presents a 35-year-old woman in whom an intrathecal pump system was inserted for cancer pain management with intrathecal morphine. This was complicated by a persistent cerebrospinal fluid leak that was successfully managed by purse-string sutures over the dura around the catheter, without removing the intrathecal implant. The cause of the cerebrospinal fluid leak and different treatment approaches are discussed.
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Affiliation(s)
- Prem K. Singh
- Department of Anesthesia All India Institute of Medical Sciences
| | - Roopesh Jain
- Department of Anesthesia All India Institute of Medical Sciences
| | - Seema Mishra
- Department of Anesthesia All India Institute of Medical Sciences
| | - Sunil Kumar
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Anesthesia All India Institute of Medical Sciences,
| | - Suryanand Deo
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India
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