I do pumps.
I don't recommend starting with them for cancer unless you do other implants and feel comfortable with complex pump management. It's like jumping into the ocean during a storm to learn to swim rather than starting in a shallow pool.
Start with something simple and rewarding like a baclofen pump or the geriatric patient with focal pain that can't tolerate systemic analgesics.
ITB is a great Level 1 therapy with strong data to support it with an easily measurable phenotype.
The data above show efficacy and relatively minimal risks, but also the problem with these devices and the studies. In the 20 years at Cleveland Clinic, they did a total of ~350 baclofen pumps in adults. The complications there also better with the Ascenda catheter, as the old Indura catheter was not very durable. In the 20 years at Slovenia, they had 150 pumps implanted. They also recognized the complications reduced with the newer Ascenda hardware. Same with the Saudi paper which shows the catheter is the primary failure mode of the system. I just want to note that these papers are coming from places that did 8 - 17 implants a year on average, or in the Saudi paper a total of ~50 refills in a year. This isn't what you'd consider high-volume practices that have a lot of lived experience with the device.
There's a reason a conservative and risk averse company like Medtronic keeps making them. Despite all their problems and the lack of penetration/usage by pain physicians as compared to SCS, they know >90% of those devices come back for a replacement. Ask your local SCS rep what percent of their SCS batteries are coming back.
It's not that they don't work. It's that we ask them to do what they can't. It's not meant to be an internal reservoir for filling the body with opioid. It's meant to create a high local concentration in a region of the spinal cord. It requires understanding of the weaknesses of pharmacology as well as the ability to optimize/interrogate the mechanical function of the device.
I think the reason most people don't do it is that it doesn't pay as much as it used to, creates more stress since they don't do it much, and they've seen all the problems in training.
