Technical Nuances of Surgical Implantation of Intrathecal Pain

Pumps

Susan Garruto MSN,CRNP,RNFA

Thomas Jefferson University Hospital

Disclosure

• I have no affiliations to disclose

Objectives

• Identify patients who would benefit from intrathecal drug delivery

• Describe the technique used for catheter/pump implantation

• Explain the troubleshooting aspects of catheter/pump implantation

Applications for Intrathecal Pain Pumps

Spasticity (baclofen)• Multiple sclerosis• Traumatic brain injury• Cerebral Palsy• Cord injury• Paraparasis• Stroke

Chronic pain (morphine, prialt)

• Nociceptive pain

Upper Spasticity Patterns

Lower Spasticity Patterns

Spasticity Trial

• Single bolus injection (50 mcg)

• Check effect over 8 hours

• >8 hour- start with ½ dose

• <8 hour- start with 2X dose

• No effect- increase bolus for trial

• Baclofen (Lioresal)- concentration for direct delivery is much more effective than oral baclofen.

Pain Pump Trial

• Morphine

• Single bolus- will indicate adverse effects

• Indwelling catheter to increase morphine dose to gain starting point for dosage in permanent pump.

Patient selection

Diagnostic Work Up

• MRI

• CT

• Plain X-rays

• Labs, INR, PTT

Pre-op

• Pump size: 40 cc vs. 20 cc

• Drug of choice: Lioresal, other

• Chlorahexadine shower & wipes

• Revision- always have representative interrogate before surgery.

Pre-op

• Confirm pump size/ drug amount

• Confirm plan for admission-including rehabilitation unit

• Often involves caregiver

• Introduce representative

Intra-opOperating Room

• Pre-operative antibiotics

• Patient positioned in full lateral decubitus- may have to be creative!

• Gel pressure points

• Prep and drape back and abdomen simultaneously.

Intra-opOperating Room

• Local anesthesia• Minimal incision- don’t let the incision

sacrifice accuracy or angle of reach. Need room to secure catheter.

• Para-spinal lumbar puncture (L2-3-4) to prevent shearing of the catheter

• Brisk flow of CSF• C-arm fluoroscopy to check catheter

placement

Implantation

• Catheter is placed intrathecally (usually L3 or L4) and tunneled subcutaneously to the pump.

• Tip placement at the T10-T11 level

• Acute hospital length of stay is 3-5 days

Posterior lumbarAnchoring the catheter

• 2 pursestring sutures- with Touhy needle in place

• 2 butterfly anchors- anchor butterfly to catheter, anchor butterfly to fascia

• Need to have fascial tissue, not fat

• Protect catheter at all times (new catheter is not as delicate)

• Allow for strain relief loop

Abdomen

• Placement in RLQ or LLQ-patient preference• Below the waistline• 2.5 cm beneath the skin• Sub-fascial –extremely thin patients• Trim catheter- hand off excess to be measured• Check for CSF flow after tunneling• 2 sutures to anchor pump• Catheter lies posterior to the pump• Access pump to confirm CSF flow before closing

incision.• Copious antibiotic irrigation, anterior & posterior

Intra-opOperating Room

• Interrogate system before closure

• Meticulous closure

• Antibiotic ointment

• Tegaderm dressing

• Abdominal binder to prevent migration of generator

• Flat for 12 hours

Post-op

• Pain medications

• Antibiotics for 24 hours

• Bathing instructions

• Wound care instructions

• Watch for complications- lack of drug delivery, infection

Thomas Jefferson UniversityPhiladelphia, PA – USA

Short video