In the field of interventional pain medicine a radiocontrast agent is commonly used in conjunction with fluoroscopy. Limited work has been published regarding the use of gadolium based contrast agents (GBCA) in the intrathecal space. We report a case of an intrathecal gadobutrol injection resulting in neurotoxic manifestations.A 60-year-old female with a history significant for lumbar post-laminectomy syndrome and intrathecal drug delivery implantation was admitted for lumbar fusion and kyphoplasty. Postoperatively, the patient had escalating pain medication requirements. A pump and intrathecal catheter contrast study was completed to assess the integrity and proper placement of the intrathecal catheter. Due to patient.s allergy to iodinated contrast, the physician requested gadolinium contrast dye. Unknown to the staff was that Magnevist had recently been replaced with an alternative GBCA, Gadavist (gadobutrol). 2 cc of Gadavist was injected. The catheter was determined to be intact and in proper position. Less than five minutes after the injection of gadobutrol, the patient reported spastic pain of the lower extremities. There is a lack of evidence as it relates to the use of GBCA specifically gadobutrol in the intrathecal space. The use of gadobutrol in the intrathecal space should be used with caution.
To date, no case studies specifically describing a curved kyphoplasty needle becoming lodged in the vertebral body with the inability to be withdrawn have been reported. We describe a case involving a single level balloon kyphoplasty with a curved coaxial needle during which the cement delivery device could not be removed after cavity filling. In this case, a board-certified interventional pain management specialist was performing balloon kyphoplasty for an L2 osteoporotic vertebral compression fracture. The tools utilized in this procedure included flexible curved instruments designed to traverse the vertebral body and achieve uniform cement distribution through a unipedicular approach. Cannulation and cavity formation were completed without issue. Upon conclusion of cement filling, the curved cement delivery device was unable to be removed. After several attempts to remove the needle and consultation with both the device company and local spine surgeons, it was agreed that the device should be cut at the level of entry into the pedicle and left as a retained foreign object. The involved area was surgically exposed, the retained instrument was cut flush to the pedicle, and the free portion was removed without further complication. The patient followed up in clinic several months later without evidence of neurologic complications. Considerations when using a curved kyphoplasty device and a method of resolution when faced with the inability to remove such an instrument are discussed.
To date, no case studies specifically reporting an electrode dislodging from its lead wire have been reported. Here we describe a case involving an electrode shearing from the spinal cord stimulator lead, and lodging into the ligamentum flavum during implantation. In this case, an experienced board certified interventional pain management specialist was performing the implantation procedure of a magnetic resonance imaging (MRI) compatible spinal cord stimulator with MR conditional leads. After successful placement of the first lead, the epidural space was accessed via a T11/12 interlaminar approach using loss of resistance technique. When the lead would not advance past the tip of the needle, it was removed in order to reposition the needle slightly. Upon removal of the lead, it was discovered that the first electrode was no longer attached to the wire. Subsequent fluoroscopic imaging revealed that the electrode had lodged within the ligamentum flavum. Upon discussion with the medical director of the device company, it was agreed upon that the electrode should be left in place. The decision was made to proceed with only one lead in place and the remainder of the procedure was completed uneventfully. The patient followed up two weeks later in clinic, and no adverse effect related to the dislodged electrode was reported. The indications and common complications associated with spinal cord stimulation are discussed, followed by factors to consider to help guide decision making in the event of a retained foreign body during a procedure.
ObjectiveUnilateral analgesia often occurs with epidural analgesia. Traditional methods of troubleshooting this problem can be insufficient in obtaining adequate pain relief in a timely manner for terminal cancer patients. This case report demonstrates a safe and effective solution which can be utilized in these circumstances.Case reportA 55-year-old female with stage IV pancreatic cancer and life expectancy of a few weeks presented to the interventional pain clinic with intractable sacral pain. The decision to place an epidural catheter and external pump for analgesia was made. An epidural catheter placed at the L5-S1 level showed contrast spread only along the right nerve roots and a test dose produced only right-sided analgesia. Suspecting compartmentalization of the epidural space, a second left-sided epidural catheter was placed and bilateral analgesia was achieved by using both catheters. This dual catheter technique gave the patient effective bilateral analgesia until she passed away several weeks later.ConclusionThe bilateral epidural catheter technique is safe and effective in patients who present with persistent unilateral epidural analgesia despite exhausting traditional solutions.
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