Presented by:  Dr.Kris Kumar Neurosurgeon, Regina

Age:  49

Sex:  Female

History:

• 1991 - Back pain after a work related injury.

• 1992 - L4-5 right disc surgery in Medicine Hat.  No relief.

• 1996 - Re-exploration of the L4-5 right disc along with a laminectomy followed by physiotherapy.  No benefit.  Started to walk wit the help of a cane.  Consuming large amounts of analgesics and narcotics.

• 1999 - Persistent back and left leg pain.  The axial pain more predominant.  She was considered for a morphine pump implant.  A trial was held.  She responded to it.

• August 1999 - A morphine pump was installed.  Initial dose was 0.6 mg per day.  However, soon after surgery she started to complain bitterly of pain at the site of the pump implanted subsequently in the mid-lumbar region where the catheter enters the spine.  Her pain control was also poor.  Gradually we were forced to increase the dose of the intrathecal morphine to 3mg a day butthe pain control was still less than satisfactory.  

• April, 2000 - Changed morphine to Dilaudid.  Initially the Dilaudid was started at 1.55 mg per day.  As the pain control was still poor the dose was increased to 3.510 mg by December, 2000.  By June 2001, her Dilaudid dose was 6.837 mg a day.  She also required a lot of oral Dilaidid in addition to intrthecal infusion.  Extensive psychiatric and psychological help was also rendered without much help.

• November, 2001 - Presented with acute right sciatic pain and subsequent investigations confirmed that she had a recurrence of L4-5 right disc protrusion which required surgery.  She improved but returned three weeks later with recurrent pain.  She was re-explored when no disc was found but intrathecal catheter as found to be fractured and replaced.  Post-operatively she still continues to complain bitterly about her pain.  

• January, 2002 - We tried to intrograte the pump.  On injecting dye through the access port, she would complain of severe pain in the back.  The pump however, continues to empty as per program.

Investigations:

• CT/myelogram in August of 1992 shows epidural fibrosis.

• MRI of November, 1995 again shows fibrosis in the lateral recess.

• MRI of July 1996 and August 199 post op after the second operation again shows further increase in the degree of fibrosis in the area of surgery.  

Question:

1. What to do next with poor control in spite of resumption of intrathecal Dilaudid?
2. What is the cause of the pain on trying to inject hrough the side port and the act that the pump is emptying properly?
3. Should the pump be re-explored?
4. What other drugs could be combined with Dilaudid to achieve better pain control?