Case 2 History

Presented by: Dr. Kris Kumar, MB, MS, FRCSC, FACS, SOM

• September 2000 -- September L4/5, L5S1 disc surgery

Post-op X-rays
November 2000 - Unenhanced post-op MRI showing recurrent disc protrusion
November 2000 - Enhanced post-op MRI showing recurrent disc protrusion

• December 2000 -- Recurrent disc surgery. Post op developed a cauda equina syndrome with bilateral sciatic pain and burning in both feet
  Drugs: Gabapentin 100mg tid
  Oxycontin 20mg tid
  Nabumetone 500mg bid
  
• May 2002 -- trial of spinal cord stimulation - failed
• October 21, 2002 -- 2 week trial of intrathecal dilaudid/bupivicaine - moderate reduction of pain especially the burning in feet - had some side effects (nausea, diarrhea) managed with medications
• March 20, 2003 -- Syncromed pump implanted. Dilaudid 1mg/Ropivicaine 3mg per day - pain control fair. Experiencing nausea.
• May 5, 2003 -- Pump stopped due to persistent GI complaints. (Unable to keep food down, constant diarrhea). Patient now discloses that these symptoms have been present ever since the pump implantation.
• June 13, 2003 -- Due to the intolerance to dilaudid, clondine introduced at a constant rate of 25ug/day and increased to 75ug/day. After initial improvement the pain returned to initial severity.
• July 21, 2003 -- Clondine has been slowly weaned down and stopped
• July 25, 2003 -- Patient requested retrial of dilaudid/bupivicaine combination but once again developed gairly severe GI side effects
• August 2003 -- Permit to possess marijuana obtained - smoking 2gms/day is only minimal help
• October 6, 2003 -- dilauded stopped. Pump filled with plain ropivicaine at 3mg/day
• October 15, 2003 -- Side effects: Spots in eyes, metal taste in mouth, restlessness - all have been transitory. Pain relief is minimal at this dose.

Questions

1. What is the experience ropivicaine alone?
2. What is a standard dose?
3. What other drugs could we mix in the patient's pump?