The diagnosis of intrathecal infusion pump system failure.

Abstract

Ongoing informed clinical management and rational application of various tests assist in the diagnosis of intrathecal infusion pump system failure. The goal is to rapidly identify the cause of the failure with the least risk to the patient at a reasonable cost-to-benefit ratio. We offer a review of our approach to the patient with suspected intrathecal pump failure and a brief description of the most often used diagnostic tests.

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Jones and Rawlins • Diagnosis of Pump Failure 291
Pain Physician Vol. 8, No. 3, 2005
Pain Physician. 2005;8:291-296, ISSN 1533-3159
A Focused Review
The Diagnosis of Intrathecal Infusion Pump System Failure
The use of implanted pumps for the
continuous infusion of intrathecal medi-
cations is a proven therapy for the man-
agement of spasticity and/or pain (1-2).
Most often, the systems are reliable and
only occasionally fail. Despite incidence of
system failure, patients are generally satis-
fied with their therapy (2-5). Sudden total
failure can lead to life-threatening with-
drawal, with profound immediate clinical
deterioration (6-8). Gradual or intermit-
tent failures often produce a puzzling clin-
ical picture requiring experienced clinical
decisions along with diagnostic interven-
tions (9-10).
Correctly diagnosing changes in a
patient’s clinical status may require time.
Patient symptoms and history most of-
ten dictate the initial approach. Ongoing
pump refills and maintenance visits are
important and help reduce the time re-
quired to raise a suspicion of system fail-
ure. Refill visits require significant ongo-
ing informed clinical judgment and rep-
resent a critical opportunity to make pa-
tient care changes. New pathology, dis-
ease progression, medication changes,
From: Department of Anesthesiology, University
of Kansas School of Medicine; Pain Management
Associates, L.C., and Via Christi Regional Medical
Center, Neuroscience Implant Program, Wichita, KS
Address Correspondence:
Rodney L. Jones MD, Pain Management Associates,
L.C., 650 N. Carriage Parkway, Suite 115, Wichita,
KS 67208
E-mail: rodjones@cox.net
Disclaimer: There was no external funding in prepa-
ration of this manuscript.
Confl ict of Interest: None
Manuscript received on 6/11/2005
Revision submitted on 6/23/2005
Accepted for publication on 6/23/2005
infectious processes, or metabolic diseas-
es can result in altered drug response. As
time and clinical conditions permit, these
causes are addressed before the patient is
placed at risk from diagnostic testing of
the pump system. After addressing these
concerns, attention is turned to the pump
system, including the drug mix, reservoir
volume, pump programming, the cathe-
ter and connector integrity, and catheter
tip location.
Accurate, safe, timely and cost-effec-
tive (11) diagnosis is desirable. The sever-
ity of symptoms often dictates how quick-
ly a diagnosis is needed. To avoid over-
dose, drug presence in the catheter must
be considered when diagnostic studies are
performed. Although drug withdrawal is
often the presenting symptom, drug with-
drawal and drug overdose may result from
the diagnostic workup. Liberal titration of
oral medications is often sufficient to
comfort and stabilize the patient in with-
drawal. Rarely, intermittent bolus or con-
tinuous infusion of medications by intra-
thecal puncture and/or temporary intra-
thecal catheter is required to mitigate an
acute withdrawal syndrome until surgical
correction of the failure can take place.
REVIEW OF LITERATURE
Complications with intrathecal in-
fusion therapies arise from human error,
medication, or mechanical system fail-
ure. Complication rates vary across stud-
ies and time and are dependent upon the
medication, indication for use, and clini-
cian experience. Regardless of cause, se-
vere complications have decreased over
the past 10 years largely due to improve-
ments in equipment (catheter, pump, and
programming software) as well as surgi-
cal implant and pump maintenance tech-
niques (12-13).
Human error during programming
or refilling the pump, medicine prepa-
ration, implanting, or manipulating the
device during a procedure can all lead
to complications with the therapy (14)
which could result in health complication
or life-threatening situations. System in-
terruptions such as an inflammatory mass
at the catheter tip also contribute to drug
delivery failure and complicate the clini-
cal picture (15-19). These causes of loss of
benefit or implanted system malfunction
must be considered.
Complications arise with the me-
chanical implanted system that includes
the pump and a one- or two-piece cath-
eter. From 1984-1992 Gianino (20) re-
ported system complication rate of 19.9%
during baclofen clinical trials, and 18.8%
in a retrospective survey of patients re-
ceiving intrathecal drugs for pain. Stemp-
ien (12) reported a 10% re-operation rate
using data compiled from 40 centers.
Pump malfunction is rare and has
declined with successive pump model
generations. Causes of pump failure are
listed in Table 1. Unexpected battery de-
pletion, component or motor failure, and
catheter access port failure are considered
pump malfunctions. These failures can re-
sult in cessation of therapy or a change in
flow performance; they require surgical
replacement of the pump. One group of
pumps implanted between July 1996 and
October 1999 exhibited a rare increased
risk of sudden stall from gear 5 shaft
wear. Registered implanting and follow-
up physicians were notified (21). On aver-
Ongoing informed clinical management
and rational application of various tests as-
sist in the diagnosis of intrathecal infusion
pump system failure. The goal is to rapid-
ly identify the cause of the failure with the
least risk to the patient at a reasonable cost-
to-benefi t ratio. We offer a review of our ap-
proach to the patient with suspected intra-
thecal pump failure and a brief description of
the most often used diagnostic tests.
Keywords:
pump, intrathecal catheter failure, pump
malfunction, complications, drug withdrawal,
Indium 111, Baclofen
Intrathecal infusion
Rodney L. Jones, MD, and Patrice Korth Rawlins, ARNP

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Pain Physician Vol. 8, No. 3, 2005
Jones and Rawlins • Diagnosis of Pump Failure
age these failures occurred 25 months af-
ter implant and have thus been explanted,
or have safely reached the expected end of
battery life.
A change in performance or failure
of the catheter is the most common long-
term mechanical system dysfunction and
had been reported to occur in 40% of im-
plants (22-23). Penn (24) later report-
ed survival analysis with a steady rate of
catheter malfunction out to 80 months,
with the mean time to first failure record-
ed at 20 months. A more recent prospec-
tive work by Follett (25) reviewed 209 pa-
tients from 22 centers with 1,764 cumu-
lative patient months of catheter experi-
ence. He reported 49 catheter complica-
tions in 37 patients − seven related to the
catheter, and 42 to the implant procedure.
Even more recently, Follett (26) summa-
rized the relationship between implant
techniques and complication rates.
There are many possible causes for
a change in a catheter’s performance in-
cluding micro fracture, kinking, discon-
nection, breakage, dislodgement, migra-
tion to the epidural space or out of spine
completely, complete or partial occlusion
from tip fibrosis, hygroma, or inflamma-
tory mass. According to Le Breton (27),
catheter kinking and perforation repre-
sent 50% of the causes of catheter mal-
function. These events may result in un-
der infusion of the drug, causing a clinical
deterioration that ranges from a return of
mild underlying disease symptoms to life-
threatening withdrawal. Delivery of the
drug into the pocket or subcutaneous tis-
sue might also result; mostly this results in
substantially less drug effect, as the most
potent delivery site of these drugs is intra-
thecal. Additionally, if the catheter fails,
resulting cerebral spinal fluid (CSF) leak-
age may lead to spinal headache, CSF sub-
cutaneous collection or, rarely, central
nervous system (CNS) pressure-related
problems. A catheter break at the spinal
entry site may lead to a free-floating cath-
eter fragment in the thecal sac. Most often,
implanting a new catheter and connecting
to the existing pump catheter segment is
required. Seldom is retrieval of a thecal
sac catheter fragment indicated.
Although the frequency of compli-
cations with implanted intrathecal pump
systems may be decreasing, such compli-
cations continue to develop, are not al-
ways obvious, and may manifest with
subtle symptoms. A number of diagnos-
tic procedures are useful in determining
the cause of failure. Clinicians need to be
proficient when performing these proce-
dures, especially since system manipula-
tion during testing can cause severe drug
overdose or withdrawal.
SYSTEM MECHANICS
Intrathecal infusion pumps are ex-
tremely low volume by comparison to
most other drug infusion systems. Vol-
umes as low as 0.05 ml per day can be
programmed using the Medtronic Syn-
chroMed pump. Generally, volumes of
0.1-0.2 ml per day are used. The pump
is low pressure so an occlusion by cathe-
ter kinking or by fibrin clot at the catheter
tip will interfere with fluid flow, resulting
in loss of benefit (LOB). Lower than ex-
pected infusion rates will result in a great-
er than expected reservoir volume at time
of refill. This fact is the reason that careful
tracking of pump residual volume at refill
visits can be an early indication or confir-
mation of failure.
On occasion, catheters do not com-
pletely break, but instead develop a hole.
The catheter material is flexible and pli-
able, but it does not withstand puncture
or cutting forces. Sutures applied direct-
ly to or around the catheter may, in time,
cause a hole to develop. Splices or con-
nections with titanium pins may punc-
ture the catheter at the time of implant
or may wear a hole in the catheter. Punc-
ture of the catheter by a suture needle or
during the installation of a local anesthet-
ic solution may also occur. Mechanical
stress by continued twisting or bending
of the catheter can lead to catheter failure.
Any hole in the catheter, other than with-
in the intrathecal space, will generally re-
sult in LOB. Medication will leak out the
hole instead of being delivered into the
CSF. If a hole exists outside the intrathe-
cal space and the catheter is intact up to
that point, CSF leakage through the hole
nearly always occurs. Spinal fluid pres-
sure is transmitted down the catheter to
the hole. The low daily infusion volume
of medication is lost through the defect
along with the CSF. Determining the loca-
tion of these small holes may be difficult,
but is important for guiding surgical cor-
rection (26, 28).
DIAGNOSTIC APPROACHES
The most expeditious way to diag-
nose and correct pump malfunction is to
have a systematic approach. The history is
the appropriate place to start. This will of-
ten lead to identification of several poten-
tial causes that can be further investigat-
ed. Diagnostic approaches to pump fail-
ure are listed in Table 2.
Initial Evaluation
A thorough history will often ex-
plain LOB and provide evidence for the
need of testing. Informed consideration
of the disease process, current symp-
toms onset, physical exam findings, co-
morbidities, diagnostics or therapeu-
tics risking trauma to the system, recent
prescription or over-the-counter medi-
cations or “alternative therapy” chang-
es are used to make decisions regard-
ing therapy benefit and system function.
Refill and intrathecal therapy history
should be reviewed, including past res-
ervoir volumes as compared to expected
volumes (29). Interrogation of the pump
to verify alarm date, expected reservoir
volume, and battery life is followed by
a refill to verify expected reservoir vol-
ume. Syringe accuracy must be consid-
ered when comparing actual to expect-
♦ Change in performance, or failure of
the catheter
•
Micro-fracture,
•
Pinhole leak,
•
Disconnection
•
Breakage
•
Migration
•
Partial occlusion
•
Tip fi brosis / granuloma
•
Infl ammatory mass
♦ Unexpected battery depletion
♦ Component or motor failure
♦ Catheter access port failure
♦ Initial evaluation, including patient
history will often identify the source
of the problem
♦ Verifi cation of pump contents,
volume, and pump settings is the
critical initial step
♦ Plain X-Ray (PA and LAT to visualize
the entire catheter)
♦ Serial x-ray or fl uoroscopy to confi rm
that the pump roller is moving at the
expected rate
♦ Magnetic Resonance Imaging (MRI)
Study
♦ Catheter Access Port Aspiration
♦ Nuclear Medicine Scan
♦ Fluid Collection Assay
Table 1. Causes of pump failure
Table 2. Diagnostic approaches

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Jones and Rawlins • Diagnosis of Pump Failure 293
Pain Physician Vol. 8, No. 3, 2005
Plain X-ray Study
If the catheter is fractured, dislodged,
or disconnected at the pump site, this gen-
erally will show up on a plain x-ray or flu-
oroscopic study. Often this is all that is
needed to discover gross catheter failures.
Catheter sections at high risk of position-
al kinking or fracture may also be visu-
alized. Fractures of catheters most often
occur where the catheter pierces the in-
traspinal ligaments. This is where sheer
stresses on the catheter are the greatest.
When fractures occur at this location,
often a segment of catheter will migrate
into the intrathecal space. In this situa-
tion, the distal catheter segment will of-
ten be visible below the insertion site with
the patient x-rayed in an upright posi-
tion. These fragments are most often left
alone and attempts are not made to re-
trieve them unless they are felt to be caus-
ing some neurological problem. The sec-
ond most common place for catheters to
fracture is within the pump pocket. This
often results when a pump is not secured
and twists within the pocket, allowing the
catheter to eventually fail due to the twist-
ing. Disconnects from the pump may oc-
cur due to dense scar formations around
the connector, and then due to exter-
nal mechanical stress such as that from a
wheelchair harness.
Although the catheter is somewhat
radio-opaque, “overexposure” may be
needed to visualize the entire catheter.
Anterior-posterior and lateral views of
the abdomen and thoracic/cervical spine
are done to view the tip of catheter. Physi-
cians often request an abdominal x-ray at
the expected level of the catheter tip. The
catheter portion coiled behind the pump
is difficult to visualize with complete cer-
tainty. When the x-ray is directed along
the length of a segment, it will often ap-
pear to have a kink and in our experience,
it is very difficult to discern catheter kinks
on plain x-ray.
Roller Study
Based on the pump’s calibration con-
stant, one can calculate how long it should
take the pump’s roller to turn 90 degrees.
Serial x-ray or fluoroscopy is used to con-
firm that the pump roller is moving at the
expected rate. One can then assume that
the pump is at least trying to infuse the
medication and is not stalled. If the cathe-
ter is occluded, the roller will still turn but
no drug will be infused. Some pumps have
been shown to be susceptible to roller
ed volumes. Many syringes have 20% ac-
curacy and when a pump is filled with
one syringe and the residual volume is
checked using a different syringe, con-
siderable discrepancies may occur due to
these syringe errors.
As in many situations, patient his-
tory will most often point to the prob-
lem and tests are used to confirm the clin-
ical impression. As mentioned previously,
when the failure is sudden and complete,
time may not be available to perform the
necessary testing and quick decisions
must be made to correct the problem. Of-
ten this results in the implementation of
supportive measures and emergent surgi-
cal intervention. It may seem obvious, but
the critical initial step is verification of the
pump contents and volume as well as cor-
rect pump settings. If the situation is such
that time is available and the clinical situ-
ation allows, programming an appropri-
ate medication bolus may help determine
if the clinical change is the result of sys-
tem failure or some change in the patient’s
clinical state.
Our protocol includes programming
a bolus dose equal to approximately three
hours of regular rate infused over five
minutes. The basal infusion rate is contin-
ued in addition to the bolus. Depending
on drug or drug mixture in the pump, an
effect from the bolus will take up to three
hours before a clinical change is noticed.
Minimal, or no response, to the bolus may
indicate system malfunction and usual-
ly indicates need for further diagnostic
studies. A positive effect, however, usual-
ly supports patient-related change, such as
an infectious process or disease progres-
sion, and may indicate a need for contin-
ued dose titration. Tachyphylaxis, or drug
tolerance, is not well understood and var-
ies with different drugs and patient pop-
ulations. Consideration of drug tolerance
may be important in some management
situations (30-31).
Diagnostic Studies
There are multiple tests and diagnos-
tic studies that can be employed when de-
termining the cause of failure. The ratio-
nal application of these studies in a sys-
tematic manner by knowledgeable clini-
cians will most often lead to the proper
diagnosis. Clinical conditions, patient his-
tory, facility resources and clinician expe-
rience will play varying roles in the selec-
tion of which tests will be implemented,
and in what order (32).
stall, however, this issue has mostly been
resolved and very rarely occurs (33).
Magnetic Resonance Imaging (MRI)
Study
Standard MRI (1.5 Tesla or less with
20 minute pulse sequence) is considered
safe for patients implanted with the Syn-
chroMed pump and is the study of choice
to detect catheter tip masses, epidural he-
matoma, abscess, or to verify the loca-
tion of the intraspinal catheter segment.
However, the magnetic field temporarily
stops the roller of the pump motor from
turning and prevents drug infusion for
the length of the MRI magnet exposure.
Therefore, precautions may need to be
taken to prevent drug deprivation effects
during exposure for those patients receiv-
ing high intrathecal drug doses. These
precautions include a drug bolus before
the procedure which also enhances com-
fort and minimizes movement during the
procedure. Interrogation of the pump af-
ter the study verifies pump settings. Pro-
grammable pumps have, on rare occasion,
been reset due to exposure to the MRI
magnet. Although this magnetic force and
torque on the pump is less than gravity,
the magnetic field of 2.0 T or greater may
cause a sensation of tugging at the pump
implant site, risk of tissue heating, and
greater image distortion (34-35).
Catheter Access Port Aspiration
Pumps with a catheter access port
(CAP) allow for aspiration and flush of
the catheter. This provides information
about intrathecal position and basic cath-
eter integrity and is useful as a first line as-
sessment. CAP aspiration provides useful
information if the catheter appears gross-
ly intact from x-ray and/or the patient has
no response to a drug bolus. The CAP port
should not be injected unless the solution
has first been aspirated. Injecting without
first aspirating can result in a significant
drug overdose. For example, a pump and
catheter containing baclofen 2000µg per
ml would have 2000 µg/ml x 0.18 ml cath-
eter volume or 360 µg baclofen from port
to catheter tip. This is enough for a signif-
icant overdose in most patients.
Following a careful surgical prepara-
tion, a Huber type none-coring needle is
used to access the port. A special “catheter
access kit” is available for the procedure
from the manufacturer. Read the manu-
facturers’ instructions to perform the test
for a specific pump. Aspirate at least 1.5ml

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Pain Physician Vol. 8, No. 3, 2005
Jones and Rawlins • Diagnosis of Pump Failure
to ensure the medication is out of the
catheter. If 2-3 ml of CSF can be easily
aspirated with a steady flow, there is gen-
eral support that the catheter tip is in the
CSF and the catheter is not obstructed.
If the catheter is partially occluded from
a kink or fibrin clot, then it is generally
more difficult to aspirate. If a small hole
is present, CSF will still be easily aspirat-
ed through the otherwise intact catheter.
A larger catheter defect will allow CSF
to be aspirated, but may not be a steady
flow. If a catheter is fractured or develops
a defect within a space such as the pump
pocket, then CSF often will leak from the
catheter and fill this space. Also, seroma
fluid may be present within the pocket or
at the catheter spinal insertion site. This
fluid may be aspirated through a cathe-
ter defect via the catheter access port and
may be thought to demonstrate an intact
catheter. This “false” aspiration may lead
to the improper assumption of a grossly
intact catheter. If x-ray is available, once
the catheter has been cleared of medica-
tion, infusion of 2-4 ml of contrast suit-
able for intrathecal administration us-
ing fluoroscopy may be useful to veri-
fy the catheter tip location in the intra-
thecal space. The contrast injection will
not help in detecting small holes in the
catheter as the contrast will preferential-
ly flow through the catheter and not out
the defect. A completely fractured cath-
eter may not allow for aspiration of any
significant fluid. In this instance, injec-
tion of contrast into the catheter access
port is not recommended.
Nuclear Medicine Scan
The most useful test of catheter in-
tegrity is a nuclear medicine evaluation
using the radioisotope Induim 111 DTPA
with a half-life of several days. This tool
should be considered if the patient is sta-
ble, that is, not expected to develop un-
manageable withdrawal over the next
24-48 hours. The length of the evalua-
tion depends on the current pump infu-
sion rate and availability of Indium which
requires preparation in a cyclotron and is
not available at all centers. Our method
is similar to methods described by oth-
ers (36-37).
Interrogate the pump to verify the
pump model, expected reservoir volume,
drug concentration and dose. Refer to the
implant record to determine the catheter
length and volume as well as manufactur-
er references for expected internal pump
site without continuation of counts fur-
ther within the catheter indicates a cathe-
ter failure at that location. The most com-
mon site for this to occur is the spinal ca-
nal entry site. With a two piece catheter
this location is generally where the splice
to the pump catheter segment resides, the
catheter is anchored, and the spinal liga-
ment shear stress is greatest.
Fluid Collection Assay
Seroma formation is common fol-
lowing surgical trauma and forms around
most implanted foreign bodies. The
amount and duration of the seroma are
variable, but may require analysis when
there is concern over system malfunc-
tion or infection. Some seroma fluid col-
lection is expected during the first two to
three months following implant and gen-
erally decreases to some small, but of-
ten perceptible, amount. This is normal,
and attempts to drain by repeated aspira-
tion are generally avoided. Needle punc-
ture into the capsule increases the infec-
tion risk and often the seroma will re-ac-
cumulate within a short time. In rare sit-
uations, the amount of seroma may be
so large that concerns of wound heal-
ing compromise are raised. Reducing the
pressure within the pocket by needle aspi-
rations may improve the outcome. Surgi-
cal suction drains are avoided in the initial
surgical implant, but may be employed
when pocket revisions are required due
to wound dehiscence or other non-infec-
tion related pocket complications. When
a catheter fractures, CSF will usually leak
into the surrounding tissue. Differentiat-
ing between seroma and CSF may be dif-
ficult with simple chemistry and micro-
scopic studies. Analyzing for beta-trans-
ferrins can be used as a marker for CSF
(38). If beta-transferrins are present in the
aspirated fluid, then one may assume that
at least a portion of the fluid is CSF in ori-
gin and therefore a catheter leak exists.
CONCLUSION
Management of the patient with an
intrathecal infusion pump requires con-
tinued assessment of the patient’s clinical
state and response to the therapy with vig-
ilance toward possible refill errors and me-
chanical system failures. When a patient’s
condition changes, skilled evaluation and
assessment of multiple factors needs to
be accomplished in a timely manner to
avoid overlooking causes of change that
may not be pump related. For instance,
catheter volume. Calculate volume flow
rate to determine time interval for the
tracer to infuse to catheter tip. Using asep-
tic technique, infuse 0.5 to 1.0 millicurie
of Indium 111 DTPA into the pump res-
ervoir. The Indium solution depends on
the volume of current infusing medicine
already in the reservoir. After injecting the
Indium, flush the needle with some previ-
ously withdrawn pump contents so that a
tract of Indium is not left in the skin. Ide-
ally, infusion of 0.5-0.75 millicurie of ra-
dioisotope in 1 ml of preservative-free
sterile normal saline into a 10 ml reser-
voir volume to infuse over 48 hours pro-
vides adequate dilution. Slower infusion
rates or greater reservoir volumes may
require higher Indium doses. The addi-
tion of this volume to the pump reservoir
will somewhat lessen the drug concentra-
tion. If this is of concern, to account for
this concentration change, calculate and
program a slight increase in the infusion
rate with a bridge bolus. It is important
to maintain the current infusion dose to
avoid overdose or withdrawal symptoms
and to allow current flow to evaluate actu-
al expected flow of the infusing drug. Se-
quential schographic analysis over the ap-
propriate time frame allows evaluation of
the Indium’s course out of the pump, into
the catheter and, if functioning properly,
into the CSF. A large field-of-view gam-
ma camera fitted with a medium energy
collimeter with a 20% window for three
minutes is used. A pump-sized lead shield
is used to cover the pump to increase the
sensitivity to the background and achieve
an accurate count of Indium outside of
the pump reservoir. Anterior, posterior,
and oblique views may be needed. Out-
lining the patient’s anatomical features
with a spot marker allows for quick iden-
tification of flow out of the catheter, into
the CSF and ventricle. Evidence of ra-
dioisotope in the kidneys or bladder pri-
or to visualization of radioisotope in the
spinal anatomy is highly suggestive of a
catheter defect. However, if some radio-
isotope contamination occurred during
pump filling, then this can lead to uptake
and early kidney and bladder counts. This
false finding will generally be verified by
continuation of the study to a point where
either there is continued bladder and kid-
ney activity without evidence of migra-
tion of the radioisotope out the catheter,
or the bladder and kidney counts subside
and the radioisotope is seen coursing out
the catheter. Collection of isotope at any

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Jones and Rawlins • Diagnosis of Pump Failure 295
Pain Physician Vol. 8, No. 3, 2005
in a person with chronic illness, infec-
tion is more common than is failure of
a baclofen pump system. With mounting
data suggesting catheter tip masses may be
more common than once thought, special
vigilance is necessary regarding their for-
mation and early diagnosis when patients
complain of new pain or new neurologic
findings. Ascribing multiple patient prob-
lems to the intrathecal pump is common.
Having the clinical experience and confi-
dence to correctly identify a change as be-
ing related to the pump, or not, is expect-
ed of those who implant intrathecal infu-
sion pumps and manage the often com-
plex care of these patients.
Rodney L. Jones, MD
Asst. Clinical Professor of Anesthesiology
University of Kansas School of Medicine
Department of Anesthesiology
Pain Management Associates, L.C.
650 N. Carriage Parkway, Suite 115
Wichita, KS 67208
E-mail: rodjones@cox.net
Patrice Korth Rawlins, ARNP
Clinical Nurse Specialist
Neuro Implant Program
Via Christi Regional Medical Center
707 N. Emporia
Wichita, KS 67214
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