Where to insert the catheter? Intrathecal Pump for L2 Vertebral Body Pain

[Rocuronium18]

Hi all,

Curious to hear your thoughts. We have a patient at our center with L2 vertebral body compression secondary to malignancy. Literally the entire vertebral body is eroded, nothing there to augment with kypho/vertebroplasty and she's very intolerant to oral medications. Her cancer has about a ~1 year survival.

We are thinking intrathecal pump, but the concern is where to put the catheter. We are hoping to have the catheter tip sit around T9/10, but worry that entry around T12-L1 will not leave enough catheter, and it'll migrate easily.

We were thinking retrograde catheter insertion at a higher level, like T4. Risky, I know, but we've done it before and do think this would offer some quality of life.

What are your thoughts?

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[Laryngospasm]

Why would you put it at T9?

 

[soxman]

Hi all,

Curious to hear your thoughts. We have a patient at our center with L2 vertebral body compression secondary to malignancy. Literally the entire vertebral body is eroded, nothing there to augment with kypho/vertebroplasty and she's very intolerant to oral medications. Her cancer has about a ~1 year survival.

We are thinking intrathecal pump, but the concern is where to put the catheter. We are hoping to have the catheter tip sit around T9/10, but worry that entry around T12-L1 will not leave enough catheter, and it'll migrate easily.

We were thinking retrograde catheter insertion at a higher level, like T4. Risky, I know, but we've done it before and do think this would offer some quality of life.

What are your thoughts?

You can certainly have the catheter at a higher level. T4 should be fine as long as it is in the posterior aspect of the intrathecal space . I have gone up to C2 in some cases for certain spasticity cases and for some severe pain originating high up and they do fine.

 

[callmeanesthesia]

Hi all,

Curious to hear your thoughts. We have a patient at our center with L2 vertebral body compression secondary to malignancy. Literally the entire vertebral body is eroded, nothing there to augment with kypho/vertebroplasty and she's very intolerant to oral medications. Her cancer has about a ~1 year survival.

We are thinking intrathecal pump, but the concern is where to put the catheter. We are hoping to have the catheter tip sit around T9/10, but worry that entry around T12-L1 will not leave enough catheter, and it'll migrate easily.

We were thinking retrograde catheter insertion at a higher level, like T4. Risky, I know, but we've done it before and do think this would offer some quality of life.

What are your thoughts?

Perhaps I’m missing something but why are you entering at T12-L1 for an IT catheter? Wouldn’t you want to enter below the cord, around L4-5 or so? That would also give you plenty of room to thread your catheter up to L2. Also, is radiation or vertebral body RF (e.g. STAR procedure) an option?

 

[TIVAndy]

Always access intrathecal space below the cord. Catheter tip level may be important but if u are planning morphine then it may not be too relevant.

 

[BobBarker]

Access the intrathecal space with a 14g needle at t4?? Play stupid games, win stupid prizes.

 

[Orin]

There's a few good case reports of intraparenchymal catheters, but a cordotomy is sometimes useful.

PACC guidelines counsel appropriate tip localization so I agree with the thought process.

As it's a cancer case, check the MRI to evaluate your conus location.

Accessing at or below the conus is preferable.

Accessing above the conus requires more courage but can be done, preferably with CT myelogram based guidance if in the T-spine and a lateral cervical cistern approach in the C-spine.

Be careful not to introduce tumor into the CSF.

Consider talking to neurosurgery about a minimal lami to place it under direct visualization

 

[Ferrismonk]

I don't do pumps, so forgive my ignorance, but does the catheter tip really matter when intrathecal? CSF washes around and opiates don't care as long as they can get to the cord and brain. How did the single-shot trial go? Also, I agree that there is no point in going where the cord is for an IT catheter.

Also, fwiw, I assume you've already got her in a brace.

 

[Orin]

I don't do pumps, so forgive my ignorance, but does the catheter tip really matter when intrathecal? CSF washes around and opiates don't care as long as they can get to the cord and brain. How did the single-shot trial go? Also, I agree that there is no point in going where the cord is for an IT catheter.

Also, fwiw, I assume you've already got her in a brace.

Yes. It matters.

The old school thought process caused high dose monsters. The medications typically used for analgesia don't spread far from the catheter tip unless high flow rates or boluses are used.

The goal is minimal to the brain and maximal to the cord.