IPG pocket site injection

[DrSwede]

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I could have sworn in 2024 I came across an article regarding a technique involving IPG pocket site injections but I cannot find it. My Google-Fu is failing me. All I can see are articles from 2021 to 2022.

Any help?

 

[BobBarker]

Injecting local at the IPG site for pocket or incisional pain? I wouldn’t recommend. I would recommend moving it lower, deeper, more lateral.

 

[DrSwede]

This is a patient I inherited from a colleague after performing an intercostal nerve block. Complex history including having had the IPG moved twice after initial implantation. I don't know all of the details surrounding that as she has seen more than one physician for this, but she followed up with a surgeon who wants the pocket site injected. My understanding is that the last time the IPG was moved was perhaps over a year ago, but not entirely sure on that. This is a chronic issue, not acute. I've not been asked to do this injection before but I've heard some people having done it. I was more encouraged when I came across (or thought I came across) an article outlining a technique for this.

 

[nvrsumr]

I wouldn’t do it but similar to a pump refill risk wise

 

[GlowInTheDark]

Just inject it with saline. They’ll get the same response.

when people say “complex”, I say “nuts”.

 

[DrSwede]

I definitely have reservations about injecting that area. Out of curiousity, is this even done even if it's for acute pain? Perhaps I'm mistaken in hearing that people have done it before.

 

[lobelsteve]

I would offer to explant and say goodbye. Or tell the patient to suck it up.

 

[Agast]

How would injecting it help? Surgeons suggest all sorts of goofy things because they don’t know what they are talking about. Doesn’t mean you have to jump to do it.

 

[callmeanesthesia]

Why doesn’t the surgeon just do it? It doesn’t sound terrible to me though - if you’re not sure if the pain is from the pocket site, and you fill the pocket with a little lidocaine it could help diagnostically. Lower risk than surgically moving the device again.

 

[CleanUp]

I’m curious - what’s the risk besides puncturing a lead?

 

[lobelsteve]

I’m curious - what’s the risk besides puncturing a lead?

Complex history including having had the IPG moved twice after initial implantation.

Furthering the notion that care will be helpful. Would be more likely to believe patient depending on why pump was put in, oral regimen, and current pump dosing.

 

[MitchLevi]

I would not do it because I do not see how this will help, and an IPG that's been moved twice already means it has been exposed to air and hands several times. I wouldn't touch it. Local in an IPG is laughable at best, idiotic at worst.

Agree with Steve, explant or live with it.

It's been manipulated afer implant twice now, both with poor results.

 

[CleanUp]

Thank you @MitchLevi and @lobelsteve

Generally, speaking for patients who have not had the generator moved twice and are largely credible what would be the downside? I’m not trying to argue here. Just trying to think this one out more.

 

[MitchLevi]

Thank you @MitchLevi and @lobelsteve

Generally, speaking for patients who have not had the generator moved twice and are largely credible what would be the downside? I’m not trying to argue here. Just trying to think this one out more.

I don’t think anything happens that answers any questions or provides a therapeutic benefit. It’s local, the most nonspecific substance in medicine if we’re honest. It always makes everything feel better for a few hrs. It really doesn’t help you, and there’s an infection risk as well. It’s a sterile environment in the IPG pocket.

 

[DrSwede]

How would injecting it help? Surgeons suggest all sorts of goofy things because they don’t know what they are talking about. Doesn’t mean you have to jump to do it.

Not sure personally, which is why I was looking for the article. Was hoping it would shed some light. Learned to tell surgeons "No" a long time ago 😎

Why doesn’t the surgeon just do it? It doesn’t sound terrible to me though - if you’re not sure if the pain is from the pocket site, and you fill the pocket with a little lidocaine it could help diagnostically. Lower risk than surgically moving the device again.

Great question and I'm not sure.

I would not do it because I do not see how this will help, and an IPG that's been moved twice already means it has been exposed to air and hands several times. I wouldn't touch it. Local in an IPG is laughable at best, idiotic at worst.

Agree with Steve, explant or live with it.

It's been manipulated afer implant twice now, both with poor results.

Great points.

Thanks for the feedback everyone.

 

[Ronin1]

I’ve done it a few times when I thought there might be an incisional neuroma with mixed results. Relatively harmless

 

[Orin]

I could have sworn in 2024 I came across an article regarding a technique involving IPG pocket site injections but I cannot find it. My Google-Fu is failing me. All I can see are articles from 2021 to 2022.

Any help?

Only paper I see from 2024 is a reference to this paper from 2021
Treatment Strategies for Generator Pocket Pain - PMC or https://academic.oup.com/painmedicine/article/22/6/1305/6121311

"When there is no success with two to four weeks of medical management, we recommend using pocket injections of bupivacaine and triamcinolone, commonly done in spine/joint procedures with no documented increased risk of infection [43]. If patient has an increased risk of infection (e.g., diabetes, immunocompromised status) or of coagulopathy, injections should be deferred or used with caution. In both the injection and no injection groups, if conservative therapy fails, we have generally moved our batteries cranially or caudally on the same side if a waistband or iliac crest issue existed. "

There is this paper https://www.sciencedirect.com/science/article/pii/S2341192924001203 but it's not really an injection of local

"Techniques to relief pocket pain​

The most commonly used technique for the relief of the pocket pain was the application of a topical local anesthetic (Lambdalina ointment, EMLA ointment, or Versatis patch), used in 100% of cases, with iontophoresis added in 22% of patients. The degree of relief from pocket pain had a mean score of 3.4 points (2.0–4.8 points). The average duration of pain relief was 0.5 months [0.5–2 months]."

 

[MitchLevi]

Only paper I see from 2024 is a reference to this paper from 2021
Treatment Strategies for Generator Pocket Pain - PMC or https://academic.oup.com/painmedicine/article/22/6/1305/6121311

View attachment 397331
"When there is no success with two to four weeks of medical management, we recommend using pocket injections of bupivacaine and triamcinolone, commonly done in spine/joint procedures with no documented increased risk of infection [43]. If patient has an increased risk of infection (e.g., diabetes, immunocompromised status) or of coagulopathy, injections should be deferred or used with caution. In both the injection and no injection groups, if conservative therapy fails, we have generally moved our batteries cranially or caudally on the same side if a waistband or iliac crest issue existed. "

There is this paper https://www.sciencedirect.com/science/article/pii/S2341192924001203 but it's not really an injection of local

"Techniques to relief pocket pain​

The most commonly used technique for the relief of the pocket pain was the application of a topical local anesthetic (Lambdalina ointment, EMLA ointment, or Versatis patch), used in 100% of cases, with iontophoresis added in 22% of patients. The degree of relief from pocket pain had a mean score of 3.4 points (2.0–4.8 points). The average duration of pain relief was 0.5 months [0.5–2 months]."

Problem is, this case involves someone who has revised it twice after implant.