The Spine Journal 13 (2013) 1708–1709
Successful conservative management of an intrathecal catheter-associated inflammatory mass A 44-year-old woman with multiple prior spinal surgeries and intrathecal (IT) pain pump managed at an outside hospital, presented with gradually progressive motor and sensory loss over several weeks. On examination, she had an incomplete T8 partial sensory level and Medical Research Council
1-2/5 motor strength in her lower extremities. Computed tomography and magnetic resonance imaging demonstrated a catheter tip inflammatory mass (CIM) at the T9–T10 level. Her IT medications were as follows: Morphine 60 mg/mL concentration at 137.8 mg/day; Clonidine 400 mcg/mL at 918.92 mcg/day; Sufentanil 250 mcg/mL concentration at 574.32 mcg/day; and Baclofen 200 mcg/mL concentration at 459.46 mcg/day. In addition, she was on Fentanyl transdermal 75 mcg/72 hours and oral Percocet (dose unknown). The patient was admitted, started on intravenous morphine patient controlled analgesia, and planned for emergent surgery, but this was postponed due to symptomatic bradycardia. While undergoing cardiac evaluation, she
Figure. (A) Initial sagittal contrast-enhanced magnetic resonance image (MRI) showing the catheter tip inflammatory mass (CIM) with surrounding peripheral enhancement, measuring 5 mm anteroposterior 7 mm transverse 4 cm craniocaudal. (B) Initial axial T2 MRI showing CIM slightly offset to the right of midline, and centered around the catheter (arrow) with displacement of the spinal cord with associated edema (arrowhead). (C) Delayed sagittal contrastenhanced MRI, 22 days later, following cessation of the intrathecal pain medications and transition to normal saline, with decrease in size of CIM. (D) Delayed axial T2 MRI, 22 days later, showing decreased size of CIM (arrow) with less mass effect on the spinal cord and return of cerebral spinal fluid around the cord (arrowhead). 1529-9430/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.spinee.2013.07.471
B.D. Dalm et al. / The Spine Journal 13 (2013) 1708–1709
was noted to regain some strength in her lower extremities, with improvement of one Medical Research Council grade in each lower limb. Given this improvement, and the concern for severe opiate withdrawal, given her high doses of IT narcotics, the decision was made to postpone surgery. The pain service was consulted, with gradual downtitration of her IT rate and dilution with normal saline, with eventual transition to normal saline over the course of 17 days. Her physical examination slowly improved throughout the hospital stay of 5 weeks, and by the time of discharge, the patient was ambulatory with 4 to 5 strength in her lower extremities, with recovery of normal sensation. Repeat magnetic resonance imaging showed decreased size of the thoracic mass with decreased spinal cord compression (Figure, C and D). She was planned for elective removal of the IT pump but was lost to follow-up. Traditionally, current management of catheter tip inflammatory mass is surgical decompression in cases of neurologic deficit [1,2] and infusion of saline in cases without neurologic deficit [3]. This case demonstrates that observing a patient with gradual cessation of the IT pump medication and saline infusion may be an acceptable management option even in the presence of neurologic deficit [4,5]. References [1] Hassenbusch S, Burchiel K, Coffey RJ, et al. Management of intrathecal catheter-tip inflammatory masses: a consensus statement. Pain Med 2002;3:313–23.
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[2] Tomycz ND, Ortiz V, McFadden KA, et al. Management of symptomatic intrathecal catheter-associated inflammatory masses. Clin Neurol Neurosurg 2012;114:190–5. [3] Toombs JD, Follett KA, Rosenquist RW, Benton LM. Intrathecal catheter tip inflammatory mass: a failure of clonidine to protect. Anesthesiology 2005;102:687–90. [4] Narouze SN, 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 Pract 2013 Jan 30. Epub ahead of print. [5] Yaksh TL, Hassenbusch S, Burchiel K, et al. Inflammatory masses associated with intrathecal drug infusion: a review of preclinical evidence and human data. Pain Med 2002;3:300–12.
Brian D. Dalm, MDa Timothy J. Brennan, MD, PhDb Foad Elahi, MDb Matthew A. Howard III, MDa Chandan G. Reddy, MDa a Department of Neurosurgery University of Iowa 200 West Hawkins Dr. Iowa City, IA 52242, USA b Department of Anesthesia University of Iowa 200 West Hawkins Dr. Iowa City, IA 52242, USA FDA device/drug status: Not applicable. Author disclosures: BDD: Nothing to disclose. TJB: Nothing to disclose. FE: Nothing to disclose. MAH: Nothing to disclose. CGR: Nothing to disclose.
Successful conservative management of an intrathecal catheter-associated inflammatory mass A 44-year-old woman with multiple prior spinal surgeries and intrathecal (IT) pain pump managed at an outside hospital, presented with gradually progressive motor and sensory loss over several weeks. On examination, she had an incomplete T8 partial sensory level and Medical Research Council
1-2/5 motor strength in her lower extremities. Computed tomography and magnetic resonance imaging demonstrated a catheter tip inflammatory mass (CIM) at the T9–T10 level. Her IT medications were as follows: Morphine 60 mg/mL concentration at 137.8 mg/day; Clonidine 400 mcg/mL at 918.92 mcg/day; Sufentanil 250 mcg/mL concentration at 574.32 mcg/day; and Baclofen 200 mcg/mL concentration at 459.46 mcg/day. In addition, she was on Fentanyl transdermal 75 mcg/72 hours and oral Percocet (dose unknown). The patient was admitted, started on intravenous morphine patient controlled analgesia, and planned for emergent surgery, but this was postponed due to symptomatic bradycardia. While undergoing cardiac evaluation, she
Figure. (A) Initial sagittal contrast-enhanced magnetic resonance image (MRI) showing the catheter tip inflammatory mass (CIM) with surrounding peripheral enhancement, measuring 5 mm anteroposterior 7 mm transverse 4 cm craniocaudal. (B) Initial axial T2 MRI showing CIM slightly offset to the right of midline, and centered around the catheter (arrow) with displacement of the spinal cord with associated edema (arrowhead). (C) Delayed sagittal contrastenhanced MRI, 22 days later, following cessation of the intrathecal pain medications and transition to normal saline, with decrease in size of CIM. (D) Delayed axial T2 MRI, 22 days later, showing decreased size of CIM (arrow) with less mass effect on the spinal cord and return of cerebral spinal fluid around the cord (arrowhead). 1529-9430/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.spinee.2013.07.471
B.D. Dalm et al. / The Spine Journal 13 (2013) 1708–1709
was noted to regain some strength in her lower extremities, with improvement of one Medical Research Council grade in each lower limb. Given this improvement, and the concern for severe opiate withdrawal, given her high doses of IT narcotics, the decision was made to postpone surgery. The pain service was consulted, with gradual downtitration of her IT rate and dilution with normal saline, with eventual transition to normal saline over the course of 17 days. Her physical examination slowly improved throughout the hospital stay of 5 weeks, and by the time of discharge, the patient was ambulatory with 4 to 5 strength in her lower extremities, with recovery of normal sensation. Repeat magnetic resonance imaging showed decreased size of the thoracic mass with decreased spinal cord compression (Figure, C and D). She was planned for elective removal of the IT pump but was lost to follow-up. Traditionally, current management of catheter tip inflammatory mass is surgical decompression in cases of neurologic deficit [1,2] and infusion of saline in cases without neurologic deficit [3]. This case demonstrates that observing a patient with gradual cessation of the IT pump medication and saline infusion may be an acceptable management option even in the presence of neurologic deficit [4,5]. References [1] Hassenbusch S, Burchiel K, Coffey RJ, et al. Management of intrathecal catheter-tip inflammatory masses: a consensus statement. Pain Med 2002;3:313–23.
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[2] Tomycz ND, Ortiz V, McFadden KA, et al. Management of symptomatic intrathecal catheter-associated inflammatory masses. Clin Neurol Neurosurg 2012;114:190–5. [3] Toombs JD, Follett KA, Rosenquist RW, Benton LM. Intrathecal catheter tip inflammatory mass: a failure of clonidine to protect. Anesthesiology 2005;102:687–90. [4] Narouze SN, 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 Pract 2013 Jan 30. Epub ahead of print. [5] Yaksh TL, Hassenbusch S, Burchiel K, et al. Inflammatory masses associated with intrathecal drug infusion: a review of preclinical evidence and human data. Pain Med 2002;3:300–12.
Brian D. Dalm, MDa Timothy J. Brennan, MD, PhDb Foad Elahi, MDb Matthew A. Howard III, MDa Chandan G. Reddy, MDa a Department of Neurosurgery University of Iowa 200 West Hawkins Dr. Iowa City, IA 52242, USA b Department of Anesthesia University of Iowa 200 West Hawkins Dr. Iowa City, IA 52242, USA FDA device/drug status: Not applicable. Author disclosures: BDD: Nothing to disclose. TJB: Nothing to disclose. FE: Nothing to disclose. MAH: Nothing to disclose. CGR: Nothing to disclose.
