Intrathecal pain management: a team-based approach

Figures & data

Figure 1 IT device with mechanical infusion pump and IT catheter.

Note: Illustration © 2016 Jackie Meyer.
Abbreviation: IT, intrathecal.

Table 1 Procedure for refilling IT pumps

Items needed for refilling IT pumps:

• Kit from IT device manufacturer containing access needle and template

Step 1:

• Clean skin at site of IT pump using aseptic technique

Step 2:

• Place template provided in kit over the IT pump to detect site of pump reservoir fill port, or, alternatively, use ultrasound or fluoroscopy   – Fill port located centrally within IT pump

Step 3:

• Insert the access needle provided in the kit through the skin and self-sealing silicone septum located in the middle of the fill port

Step 4:

• Aspirate any remaining drug from the reservoir   – Assess proper pump function by comparing the volume of remaining drug with the calculated volume that should remain based on the programmed flow rate

Step 5:

• Refill the pump by injecting the appropriate volume and concentration of drug through the pump reservoir fill port   – Utilize fluoroscopy or ultrasound, if needed

Step 6:

• Reprogram the IT pump with the new volume and/or concentration of drug

Note: Data from Bottros MM and Christo PJ.³³

Abbreviation: IT, intrathecal.

Figure 2 Pain rating scales.

Notes: (A) Wong-Baker FACES^® pain rating scale; Wong-Baker FACES Foundation (2016). Wong-Baker FACES^® Pain Rating Scale. Retrieved April 18, 2017 with permission from http://www.WongBakerFACES.org.⁵⁸ (B) 0–10 numeric pain rating scale; created with data from Breivik H, et al.⁵⁹ and Herr K, et al.⁶⁰ (C) Visual analog scale; created with data from Breivik H, et al.⁵⁹; Paice JA and Cohen FL.⁶¹; and Jensen MP, et al.⁶² (D) Verbal pain intensity scale; created with data from Breivik H, et al.⁵⁹; and Breivik EK, et al.⁶³

Table 2 Potential mechanical IT pump and catheter malfunctions and complications

Pump malfunction	Description	Potential complications
Catheter pump misconnection	Usually occurs immediately after implantation but may be delayed	Leakage of IT therapy Opioid withdrawal symptoms Loss of analgesia
Loss of pump propellant	Altered rate of drug delivery	Drug overdose or underdose (eg, opioid withdrawal symptoms and loss of analgesia)
Gear shaft wear and motor stall	Reduced infusion of IT therapy	Withdrawal symptoms Decrease in or loss of analgesia
Leakage of administered agent	Occurs at pump–catheter connection and may result from catheter kinking, or catheter damage caused by punctures by needle sticks or retractors used during implantation	Opioid withdrawal symptoms Loss of analgesia
Catheter displacement	Leakage of CSF	Local hygroma
Catheter kinking	Occurs at any point from the pump along the length of the catheter	Difficulty aspirating CSF and injecting drug(s) into the pump Leakage of IT therapy Opioid withdrawal symptoms Loss of analgesia
Catheter tip granuloma	Decrease in or loss of analgesia with onset of new neurologic symptoms Evaluation includes MRI or computed tomography with myelography (when MRI contraindicated)	Spinal cord compression, possibly resulting in paraplegia, and, in some patients, death

Notes: Data from Deer TR, et al.¹⁸; Upadhyay SP and Mallick PN.²⁹; and Bottros MM and Christo PJ.³³

Abbreviations: CSF, cerebrospinal fluid; IT, intrathecal; MRI, magnetic resonance imaging.

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