Pump granuloma

[painfre]

Need advice regarding managing a patient with Pump granuloma.
I do not offer pumps to new patients. I inherited few Pump patients from predecessor.
One of them is 43 yr old male with h/o FBSS, drug and alcohol abuse has a
morphine 20 mg/ml via intrathecal pump at rate of 3.002 mg/day . Pt has been asking for increase in the dose because of increased LBP. Denies any weakness/Incontinence no UMN signs. MRI thoracic spine showed

pt has a 7 mm enhancing, intrathecal distal tip catheter mass present
within the right anterior lateral aspect of the thecal sac at the
mid-T11 vertebral body level with associated abutment and mild
mass effect upon the subadjacent thoracic cord.


Planning to decrease the dose about 15-20% everyweek.
Refer to neurosurgeon
Not going to offer Narcotics because of his past history. can offer NSAIDS, anticonvulsants/Antidepressants which he is going to refuse them because of no benefit in the past. Anything else for his pain?

Do not like Mixing with Clonidine/Marcaine/fentanyl.

what do you guys think about option of pulling the catheter down?

?Option of Ziconitide

Thanks

---

Members don't see this ad.

 

[lobelsteve]

Would not want this patient. Would have seen by surgeon same day as have seen paralysis due to delay of care. From walking to paralyzed over 72 hrs. Would explant and offer Butrans or send for Suboxone.

 

[101N]

News flash pumps for CNP are just addiction maintenance by another name.

 

[emd123]

Stop! This thread is activating my PTSD from fellowship:

Pump Traumatic Stress Disorder

 

[NOSfan]

Planning to decrease the dose about 15-20% everyweek.
Refer to neurosurgeon
Not going to offer Narcotics because of his past history. can offer NSAIDS, anticonvulsants/Antidepressants which he is going to refuse them because of no benefit in the past. Anything else for his pain?

Given the clinical scenario you described, your plan seems very reasonable. I would also document presence or absence of vibratory sensation as the granulomas tend to be posterior and the DCML is very sensitive to perturbation. Additionally, you probably should document absence or presence of Babinski's Sign.

Finally, I've attached the Consensus Statement for management of IT catheter-tip inflammatory masses.

 

[Ducttape]

Would not want this patient. Would have seen by surgeon same day as have seen paralysis due to delay of care. From walking to paralyzed over 72 hrs. Would explant and offer Butrans or send for Suboxone.

i dont think explantation should be the very first step, if minimal to no neurologic symptoms. anyways, referring to surgeon itself may cause a delay for them to be seen, evaluated, scheduled for OR, cleared by PCP, etc.

dont taper. stop infusion or better yet remove the opioid and stop or replace with saline. send to neurosurgery.

i also dont think you can offer Butrans. the guy may be on 270+ MED, if my math is correct, and please remember there seems to be much debate about the actual "conversion" from IT morphine to oral (i see numbers of 30:1 all the way up to 300:1 (from Anesthesiology Clinics in 2007)).

 

[Aether2000]

Definitely need to stop the infusion of anything through the catheter. If there are no neuro symptoms and the infusion is stopped, the inflammatory mass (is not histological consistent with a granuloma) usually causes no more problems whereas the surgery to remove it can. The mass is not due to the catheter but is due to the concentrated opioids on the spine. So leaving the catheter intact is one option. Placing another catheter below the end of the cord can avoid the inflammatory mass formation.

 

[painfre]

made a referral to neurosurgeon. it might take atleast a week to see NS. Decreased dose by 15% . pt want me to admit and treat his pain.
. His only complaint is pain inthe lower back region and no shooting pain down legs, no incontinence or weakness.
just gave clonidine and clonazepam. he does not have umn signs or babinski. his granuloma is anterloateral and hence did not effect the dorsal column tract
if surgeon say wait and watch, then pain management will be difficult with him. He will demand high doses of narcotics. if second catheter is placed and morphine used, is there increased possibility of granuloma. I prefer not to put another catheter

 

[Aether2000]

There would be an increased risk only if the tip of the catheter lie above the conus. If it is in the area of the cauda equina, there is no significant risk of a spinal cord inflammatory mass since the morphine will be diluted with CSF and not dripping onto the cord itself. In any case, this will be a very difficult management case.

 

[painfre]

Pt saw a neurosurgeon who offered laminectomy and taking out the whole pump along with catheter. he did not like the idea of pulling the catheter down.
Neurosurgeon wants some one take care of patients pain after surgery. Pt came back to me, c/o worsening back pain. I told pt that he needs to be weaned of his morphine before surgery. He was on high dose Narcotics before pump placement. I do not want to put him on such high doses again . Thinking him of starting him on Low dose methadone, Any other options? Anticonvulsants/Antidepressants did not help in the past. Buperonorphine approved only for detox and not for chronic pain at the VA .