intrathecal pumps

[sweetalkr]

Just out of curiosity, does anyone as an anesthesia/pmr trained pain doc put in their own pain pumps? is this a good treatment modality? Do you have problems with the pumps or the patients? Is this vital to your practice?

It seems like a lot of pain fellowships don't give the greatest experience with them, but two of my buddies that just started say they don't mess with pumps and would never want to, and SCS does just as good, etc.
I don't know if that is true or if they never were trained well and haven't experienced it.
Any input would be appreciated. Thanks a bunch.

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[PMR 4 MSK]

I never implanted, but I used to maintain a lot of them. I found it no better than oral opioids for most pts, and useful mainly for those for whom the oral doses were difficult - due to # of pills, cost or similar. I think it best used when the pt would benefit from additives such as bupivicaine or clonidine.

I no longer am involved with them, due to lack of interest on my part, and lack of coverage for them while I'm gone.

 

[sweetalkr]

thank you very much for the response. I was worried b/c it seems a lot of training programs lack in numbers for pumps

 

[Jcm800]

I never implanted, but I used to maintain a lot of them. I found it no better than oral opioids for most pts, and useful mainly for those for whom the oral doses were difficult - due to # of pills, cost or similar. I think it best used when the pt would benefit from additives such as bupivicaine or clonidine.

I no longer am involved with them, due to lack of interest on my part, and lack of coverage for them while I'm gone.

I implanted two pumps during fellowship.

I have implanted probably 30 in the last few years(all either baclofen or for cancer), i have done many removals, revisions, etc. not that this is impressive. The surigcal part is very easy provided you know the basics. we did a fair amount of SCS, plus i started in general surgery before anesthesia. The actual act of implanting the pump is very very simple, there are tricks and nuances but thats just experience.

but what I could not have done with the minimal amount of training with pumps without my partners experience and guidance, is manage them. This is the difficult part. Trouble shooting, refilling, programming, that stuff takes experience that you cannot extrapolate from implanting SCS or doing hernias...

there are course and medtronic can help you learn this, so dont sweat it too much. But the best advise... stay away from pumps unless 1) you have an NP to run the show 2) you can just implant the baclofen pumps and send them to the neurologist that wants to manage them 3) you have a busy cancer population...

even with the three above caveats, my advice is too stay away. Every time i do it, i wonder why...

 

[sweetalkr]

I keep hearing that, shark. so I will stay away!
It makes me feel better about the programs I am interested in. i really appreciate your experiences and input. I guess i thought it was a big $ maker for a practice, and a lot of people want you to be able to do it. At least there is an argument on the contrary!

 

[Jcm800]

I keep hearing that, shark. so I will stay away!
It makes me feel better about the programs I am interested in. i really appreciate your experiences and input. I guess i thought it was a big $ maker for a practice, and a lot of people want you to be able to do it. At least there is an argument on the contrary!

go to the medtronic fellows course, so you can say you have been "trained" find someone in the community that does it and scrub if you can find someone...

then respectively decline doing it, but you can say you know how. Because if you can impant an SCS, and you can do an LP, you can put in a pump. Tunnel around to the front, make a bigger pocket, only real difference.

if you think you might wanna do this, (which you dont) a few pearls, none of this is ground breaking...

1) purse string your cather. Then make sure it still flows after the stylet is out. seems simple...

2) Go paramedian oblique.

3) leave the catheter at or below the conus, less chance for funny business. if every concerned, do a myelogram.

4) do them under intra-operative spinal. I put the needle in, get CSF. thread the catheter, give a little isobaric spinal. usually all you need. they will tell you if the catheter is hitting something, because they are awake...

5) close the fascia tight. seems simple... close in 3 layes

6) keep them overnight

7) access the side access port as many times as makes u comfortable...
espcailly right before you close...

8) lastly, use the suture loops, not a pouch (this is preferences, others will disagee) and use somehting strong for the suture loops, i use 0 prolene...

ok good luck and dont wast your time, it really doesnt make much money, but boy it can cause you headaches...

 

[Calilove]

Do the trial, send it out to NeuroSurg! and don't even blink...

 

[Disciple]

2) Go paramedian oblique.

What do you think about inserting the needle using a lateral view?, to keep the x-ray tube under the table and drapes.

I've found paramedian using AP to be much easier, but with a higher chance of contaminating the field.

 

[Jcm800]

What do you think about inserting the needle using a lateral view?, to keep the x-ray tube under the table and drapes.

I've found paramedian using AP to be much easier, but with a higher chance of contaminating the field.

huh? maybe im not following...

when i do an implant, as im sure you do too, i do it in an operating room. so i have the patient lateral, with a sterile half sheet on the side so i can swing lateral to the table all day wihtout contaminating the field, and because the half sheet is sterile, and there are full body drapes down to the floor, the bonet on the C-arm head is steril...


but i start paramedian oblique entering CSF at L3-4, if i can, i start with a AP to the patient (lateral to the table since the patient is on their side) then when the trajectory is good, or at least i think it is good, i go to lateral (AP to the patient) to guid into the CSF...


maybe this is what you are saying?

 

[Disciple]

Yes,

lateral to the patient, AP to the table.

I find it much easier to get the needle in using AP view (to the patient), but the undraped x-ray tube gets in the way a little bit of where I'm typically standing.

 

[Jcm800]

Yes,

lateral to the patient, AP to the table.

I find it much easier to get the needle in using AP view (to the patient), but the undraped x-ray tube gets in the way a little bit of where I'm typically standing.

just put a sterile half sheet accross the table on the left (if you behind the table facing the table, the left) the side you stand on, i assume you stand on the left, and the c-arm comes in on the other side.

just take two steril clamps and put a sterile half sheet accross so then the c-arm comes lateral to the table it will be covered by sterile field.

have you tried this?