It’s Just Another Patient with Back Pain!

Intrathecal Delivery Device Complications Linda L. Herman, MD, FACEP

Program Director

KDHCD Emergency Medicine Residency Program

Objectives

List the indications for intrathecal pain management delivery systems

Recognize the signs and symptoms of intrathecal delivery system (ITDS) dysfunction and treat the patient appropriately

Choose the correct diagnostic test to determine what complication is present

Name the treatment for the complications

Indications

▶ Chronic

intractable pain

▶ Treatment of

spasticity

related to

neuromuscular

diseases

What is a pain pump?

Refilling the pump

What Medications?

FDA approved

▶ Morphine (infumorph)

▶ Ziconotide (Prialt)

▶ Baclofen (Lioresal,

Gablofen)

Unapproved but used

▶ Levobuivacaine

▶ Bupivicaine

▶ Hydromorphone

▶ Clonidine

▶ Midazolam

▶ Methadone

▶ 46 yo female comes to the ED with husband with AMS

which began this the PM PTA

▶ Had intrathecal pump system revised the day prior to

admission. Receives Baclofen for spasticity of cerebral

palsy

▶ 100.8 rectally – 112 – 22 – 150/92

▶ Neuro – confused, agitated, CN grossly intact, MOE X 4,

rigid extremities

Pump malfunction

Underdosing Overdosing

Overdosing

▶ Symptoms

▶ Somnolent

▶ Lethargic

▶ Respiratory

depression

▶ Treatment

▶ Naloxone

▶ Airway & ventilatory

support

▶ Removal of CSF

Baclofen Overdose

Symptoms▶ Flaccidity

▶ Hyporeflexia

▶ Respiratory depression/Apnea

▶ Seizures

▶ Coma

▶ Autonomic Instability

▶ Hallucinations

▶ Hypothermia

▶ Cardiac Conduction Abnormalities

Treatment▶ Intubate

▶ Empty the pump

▶ Turn off the pump

▶ CSF withdrawal

▶ Vasopressors

Shirley KW et al. Intrathecal baclofen

overdose and withdrawal. Pediatr Emerg

Care. 2006;22(4):258-261.

Underdosing for pain medication

▶ Symptoms

▶ Increased pain

▶ Treatment

▶ Supplemental

treatment

Baclofen withdrawal

▶ Symptoms

▶ High fever

▶ Increased spasticity

▶ Muscle rigidity

▶ AMS

▶ Treatment

▶ Fluids

▶ Benzodiazepine

▶ External cooling

Call the doctor who inserted

the pump!

I’ll help you!

Palpate the location of the pump

Order an x-ray

Migration

Disconnected

Catheter

Migration

Interrogate

the pump

Check the reservoir

Ultrasound

Maneyapanda MB, Chang Chien GC, Mattie R, Amorapanth P, Reger C, McCormick ZL:

Ultrasound guidance for technically challenging intrathecal baclofen pump refill: three

cases and procedure description. Am J Phys Med Rehabil 2016

CT scan

Morgalla, M, Fortunato M ,

Azam A, et. al. “High-

Resolution Three-Dimensional

Computed Tomography for

Assessing Complications

Related to Intrathecal Drug

Delivery.” Pain Physician

2016; 19:E775-E780•

Contrast Enhanced

Intracranial Hypotension

Syndrome

▶ Symptoms

▶ HA

▶ Neck pain/stiffness

▶ N/V

▶ Change in hearing

▶ Vertigo

▶ Sense of imbalance

▶ Treatment

▶ Bedrest

▶ Caffeine

▶ Fluids

▶ Blood patch

Subdural

▶ Rare

▶ Headaches & nausea after

implantation

▶ Altered LOC several weeks

later

https://en.wikipedia.org/wiki/Subdural_hematoma

Magro E, et. al. “Bilateral Subdural

Hematoma Following Implanatation of

Intrathecal Drug Delivery Device.”

Neuromodulation 2011;14:179-182.

Infection

Infection Intrathecal space

▶ Symptoms

▶ Encephalitis

▶ Meningitis

▶ Treatment

▶ IV Antibiotics

▶ Removal

Epidural

Abscess

▶ Symptoms

▶ fever

▶ Increase in pain

▶ Urinary incontinence

▶ Paresis or paralysis

▶ Perineal anesthesia

▶ Decreased rectal tone

▶ Treatment

▶ IV antibiotics

▶ Surgery

Hemorrhage

Catheter Tip Granuloma

Narouze S, Casanova J, Souzdalnitski D. “Patients with a History of Spine Surgery or

Spinal Injury may have a higher Chance of Intrathecal Catheter Granuloma

Formation.” Pain Practice 2014;14(1): 57 -63.

Rhabdomyolysis

▶ Ziconotide

▶ Elderly

▶ Treatment

▶ Fluids

▶ Stop the med

Horazeck C, et.al. “Acute Rhabdomylolysis in a

Patient with Long-Term Exposure to Intrathecal

Ziconotide: A Case Report.” Pain Practice 2015;

15(1):E34.

Twiddler’s syndrome

▶ Described in 1968 w/

pacemakers

▶ 3 cases reported

Shao, Jianning,et.al. (2018). Occlusion of the Ascenda Catheter in a Patient

with Pump Twiddler’s Sydrome: A Case Report. Anesthesiology and Pain

Medicine. I

Harlequin Syndrome

▶ Symptoms

▶ Hemifacial flushing

▶ Relative hyperhidrosis

▶ Related to combo of meds

▶ Clonidine

▶ Bupivicaine

▶ Hydromorphone

Zinboonyahgoon N, et. al. “Harlequin Syndrome Following

Implantation of Intrathecal Pumps: A Case Series.”

Neuromodulation: Technology at the Neural Interface 2015;

18: 772–775.

Williams BS, et.al. “Case Scenario:

Self-extraction of Intrathecal Pump

Medication with a Concomitant

Intrathecal Granulomatous Mass”

Anesthesiology 2 2011, Vol.114, 424-

430.

Can you send this Patient to

the MRI?

Can other items cause the

pump to stall?

Huh B, Roddan CJ. “Magnetic

fields and intrathecal pump

malfunction.” American

Journal of Emergency Medicine

2016;34:115e5-115e6.

Figure 1

Annals of Emergency Medicine 2018 71, 467-469DOI: (10.1016/j.annemergmed.2017.07.009)

Copyright © 2017 American College of Emergency Physicians Terms and Conditions

Arrhythmia?

Resuscitation of a Patient With an Implanted Electronic Device . Leopold Simma, MD, Matteo Fontana, MD,

Thomas Schmitt-Mechelke, MD . Annals of Emergency Medicine Volume 71, Issue 4, Pages 467-469 (April

2018)

Bibliography▶ “Baclofen – FDA prescribing information, side effects, and uses.”

https://www.drugs.com/pro/baclofen.html. Accessed on July 16, 2018. Update June 4, 2018.

▶ Bayliss CE, Beanlands DS, Baird RJ. The pacemaker-twiddler's syndrome: a new complication of implantable transvenous pacemakers. Can Med Assoc J 1968;99:371-373.

▶ Borrini L, Bensmail D, Theibaut J, et. al. “Occurrence of Adverse Events in Long-term Intrathecal Baclofen Infusion: A 1-Year Follow-UP Study of 158 Adults.” Archives of Physical Medicine and Rehabilitation 2014;85:1032-1038.

▶ Dovanda TJ, Pestereva E, Lee A. “Intrathecal Baclofen Pump Migration Into the peritoneal Cavity Case Report.” Anesthesia Pain Medicine 2016 June;6(3):e33031.

▶ Han JL, Loriaux DB, Tybout C, et. al. “Thoracic Nerve Root Entrapment by Intrathecal Catheter Coiling: Case Report and Review of the Literature.” Pain Physician 2016;19: E499 – E504

▶ Heo BH, et al. “Epidural Infusion of Morphine and Levobupivacaine through a Subcutaneous Port for Cancer Pain Management” Korean Journal of Pain 2014;27 (2):139.

▶ Horazeck C, Huh AS, Huh BK. “Acute Rhabdomylolysis in a Patient with Long-Term Exposure to Intrathecal Ziconotide: A Case Report.” Pain Practice 2015; 15(1): E34.

Bibliography▶ Magro E, et. al. “Bilateral Subdural Hematoma Following Implanatation of

Intrathecal Drug Delivery Device.” Neuromodulation 2011;14:179-182.

▶ Maino P, et. al. “Fentanyl Overdose Caused by Malfunction of SynchroMed II Intrathecal Pump.” Regional Anesthesia and Pain Medicine 2014 Sept-Oct; 13(5):434 – 437.

▶ Maneyapanda MB, Chang Chien GC, Mattie R, Amorapanth P, Reger C, McCormick ZL: Ultrasound guidance for technically challenging intrathecal baclofen pump refill: three cases and procedure description. Am J Phys Med Rehabil 2016;95:692Y697.

▶ Moens M, DeSmedt A, Duerinck J, D/Haens J, Brouns R. “Twiddler's Syndrome Complicating Neuromodulation Systems For Chronic Pain.” World of Neurosurgery. 2012 January;77 (1): 213.

▶ Morgalla, M, Fortunato M , Azam A, et. al. “High-Resolution Three-Dimensional Computed Tomography for Assessing Complications Related to Intrathecal Drug Delivery.” Pain Physician 2016; 19:E775-E780• ISSN 2150-114.

▶ Narrang S, Srinisavan SK, Zinboonyahgoon N, et. al. “Upper Antero-Medial Thigh as an Alternative Site for Implantation of Intrathecal Pumps: A Case Series.” Neuromodulation 2016;19:655-663.

▶ Narouze S, Casanova J, Souzdalnitski D. “Patients with a History of Spine Surgery or Spinal Injury may have a higher Chance of Intrathecal Catheter Granuloma Formation.” Pain Practice 2014;14(1): 57 -63.

▶ Padalia D, Jassal N, Patel S. “Near Death Experience from Placement of an Intrathecal Catheter.” Pain Physician 2016;19:E621-E623.

Bibliography▶ Perruchoud C, Bovy M, Rutschmann B, et. al. “Silicone Septum Leakage at the Origin of a Drug

Overdose in a Patient with Implanted with an Intrathecal Pump.” Neuromodulation 2013;16:467 – 470.

▶ Pope JE, Deer TR. “Guide to Implanatable Devices for Intrathecal Therapy.” https://www.practicalpainmanagement.com/treatments/interventional/pumps/guide-implantable-devices-intrathecal-therapy?page=0,1. Accessed on August 28, 2017. Updated on September 25, 2013.

▶ Shao, Jianning & Frizon, Leonardo & Machado, Andre & McKee, Keith & Bethoux, Francois & Hartman, Jennifer & J. Nagel, Sean. (2018). Occlusion of the Ascenda Catheter in a Patient with Pump Twiddler’s Sydrome: A Case Report. Anesthesiology and Pain Medicine. In Press. 10.5812/aapm.65312.

▶ Shirley KW et al. Intrathecal baclofen overdose and withdrawal. Pediatr Emerg Care. 2006;22(4):258-261. PMID: 16651918

▶ Stetkarova I, Brabec K, Vasko P, et.al. “Intrathecal Baclofen in Spinal Spasticity: Frequency and Severity of Withdrawal Syndrome.” Pain Physician 2015; 18:E633-E641 • ISSN 2150-1149.

▶ Swaminathan, A. “Rebel EM: Baclofen Withdrawal” http://rebelem.com/baclofen-withdrawal/Accessed on July 16, 2018. Updated on October 27, 2016.

▶ Varhabhatla N, Zuo Z. “Rising Complication Rates After Intrathecal Catheter and Pump Placement in the Pediatric Population: Analysis of National Data Bank Between 1996 and 2006.” Pain Physician 2012; 15:65 -74.

▶ Vivek V, Kavar B, Hogg M, Eisen DP, Butzxkueven. “Asperigillus arachnoiditis post intrathecal baclofen pump insertion.” Journal of Clinical Neuroscience 2013; 20:1159 – 1160.

▶ Williams BS, Wong D, Amin S. Case Scenario: Self-extraction of Intrathecal Pump Medication with a Concomitant Intrathecal Granulomatous Mass. Anesthesiology 2 2011, Vol.114, 424-430.

▶ Zinboonyahgoon N, et. al. “Harlequin Syndrome Following Implantation of Intrathecal Pumps: A Case Series.” Neuromodulation: Technology at the Neural Interface 2015; 18: 772–775.