Recurrence of Pain in Patients With Pump Implants After Initial Good Pain Control

CONSULT 1 | CONSULT 2 | CONSULT 3| CONSULT 4

CONSULT 1

Age:  49    Sex:  Male

History:

• 1984 - Compression fracture of L1 resulting in cauda equina injury

• Developed chronic crushing burning pain in both lower limbs requiring use of narcotics.

• 1999 - Had to stop working due to pain and drowsiness due to drugs

• January, 2000 - Investigations show syringomyleic cyst at site of injury

• July, 2000 - After evaluation morphine pump implanted -- Good pain control with 0.732 mg/day.

• March, 2001 - Sudden restart of pain -- fracture of the catheter detected at the point where it exits from the spinal canal. The distal part of the catheter could only be removed (intrathecal portion left behind). New catheter inserted and connected to pump. Resumption of pain control.

Pre-Op MRI 1, 2, and 3:	Post-Op X-Rays:

Question:

1. How to avoid fracturing?

2. Does the portion left intrathecally ever need to be removed?

CONSULT 2

Age:  47    Sex:  Female

History:

• Presented in 1993 with chronic back and bilateral leg pain, worse on the right following disc surgeries in 1980, 1983, laminectomy in 1986 and 1989.

• Investigations of CT and MRI showed scarring in the area of surgery.

• Spinal cord implant - April 1993: partial relief.

• 1994 - Quadripolar electrode removed and replaced with RESUME electrode as pain became more bilateral.

• 1997 - The pain relief deteriorates requiring resumption of narcotics.

• 1998 - Resume electrode system left in and Synchromed morphine pump implanted. Resumption of pain control on 2.5 mg of morphine/day.

• July 2000 - Pain relief stopped. Pump explored in Winnipeg - dislodgement of the catheter at nozzle site repaired. Developed meningitis post operatively. Meningitis treated but no pain relief.

• November 2000 - System checked. On injecting dye through the side port no dye will go in the catheter.

• March 2001 - Pump explored. Intrathecal catheter totally blocked needing replacement following which pain control resumed.

1998 Pre-Op X-Ray: Showing old Resume electrode and Intrathecal Pump.	X-Rays: Showing blocked catheter and dye leaking.

Question:

1. Role of meningitis in blockage of the catheter?

2. Could the catheter have been plugged all along even when seen in Winnipeg?

3. Did the force of injection cause catheter to disconnect?

CONSULT 3

Presented by: Dr. Kris, Kumar Neurosurgeon, Regina

Age:  37

Sex:  Female

History: 

• Chronic back and left leg pain since 1990 following L5-S1 disc surgery and development of pseudomeningocele.

• July, 2000 - Had morphine pump implanted.  Pump was fixed by sutures only. 

• Loss of weight (25 lbs).  Pump flipping makes it difficult to refill.

CONSULT 4

Presented by: Dr. Rob Brownstone, Neurosurgeon, Halifax

Age:  36

Sex:  Male

History: 

• headaches since youth, "migraines"

• initially 2 episodes per year, in late teens/early 20's went 2 years without headaches

• then returned, and became progressive

•   - increase in frequency

•   - increase in intensity

• became constant in mid 1990's increasing in intensity

• expanding pressure on the eye

• no aggravating or alleviating factors

• after a year, had nervus intermedius section (complicated by damage to VIII)

• Post op - no headaches for 5 months then would come indiscriminately with an intensity as severe as pre-op. 

Medications Prescibed:

• morphine sulphate 4500mg/day

• dilantin 100-100-300

• mogadon and halcyon at hs

• diazepam 10 mg tid

• effexor 75 bid

Methadone, acupuncture, home remedies and pain management strategies have all been tried in the past with no benefit. 

Has seen multiple MDs, including a cluster headache expert at The Mayo Clinic.  All agree that these are intractable cluster headaches.