The Delayed Appearance of Neurological Signs in Intrathecal Granuloma Warrants Imaging Surveillance: A Case Series and Review of the Literature
West Forsyth Pain Management, Clemmons, North Carolina Carolinas Pain Institute, Wake Forest University Health Sciences, Winston-Salem, North Carolina, U.S.A. Pain Practice
(Impact Factor: 2.36).
04/2012; 12(7):561-9. DOI: 10.1111/j.1533-2500.2012.00540.x
Intrathecal pump therapy (ITP) has become a mainstay of treatment for the chronic, refractory nonmalignant pain patient. Increasingly, ITP therapy is being instituted for the failed back pain population. Inflammatory mass or granuloma is a complication that is considered "rare" or "uncommon." In this patient population, the symptoms of granuloma can often mimic the symptoms for which the patient is being treated. The case series reported here illustrates 4 cases of inflammatory mass. One patient presented with paralysis before she was diagnosed, and the remainder of the patients were asymptomatic at the time of diagnosis. The cases presented illustrate the need for broader education of inflammatory mass among nonpain specialists. Etiology, diagnosis and treatment guidelines of inflammatory mass are reviewed. The literature reviewed highlights the number of patients who present with paralysis as well as the need for regular screening of ITP patients.
Available from: Samer Narouze
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ABSTRACT: Background goals:
Intrathecal drug delivery is an effective method to treat intractable pain. However, intrathecal catheter tip granuloma (ICTG) is a devastating complication of intrathecal drug delivery systems. It typically occurs in the thoracic region; particularly, in patients receiving high doses or high concentrations of intrathecal drug infusions.
Materials and methods:
The PUBMED/MEDLINE and Cochrane databases were also systematically searched for all reports on ICTG published in any language. The key words included "intrathecal," "granuloma," and "spine surgery," and all related publications between the earliest available date (the first granuloma-related chronic complication of intrathecal infusion reported in PUBMED/MEDLINE in 1996) and June (week 1) of 2012 were searched. This case report is unique because it describes the formation of an intrathecal granuloma in the lumbar region of a patient who received a low-dose intrathecal infusion.
Results and conclusion:
Cerebrospinal fluid flow dynamics within the spinal canal along with the physical, chemical, and immunological properties of intrathecal medications have been suggested to be responsible for the growth of inflammatory mass lesions at the tips of intrathecal drug delivery catheters. Our literature review supports the possible role of certain factors, specifically previous spine surgery or spinal injury, in granuloma formation. The rate of development of ICTG appears to be higher in patients who have had previous spine surgery or spinal injury (68%) than in a general cohort of patients (48%), with an intrathecal pump. Therefore patients with a history of spine surgery or injury may be at increased risk of ICTG when receiving chronic intrathecal analgesia.
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