Catheter Tip Granuloma Associated with Sacral Region Intrathecal Drug Administration

Abstract

Spinal cord compression from catheter tip granulomatous masses following intrathecal drug administration may produce devastating permanent neurologic deficits. Some authors have advocated intrathecal catheter placement below the conus medullaris to avoid the possibility of spinal cord involvement. Multiple cases of catheter tip granulomas in the thoracolumbar region have been reported. We present a unique case of a sacral region catheter tip inflammatory mass producing permanent neurologic deficits. A 71-year-old white male with a diagnosis of failed back surgery syndrome was referred to the senior author for evaluation. After more extensive conservative therapy, including spinal cord stimulation, failed to yield adequate pain relief, he was offered implantation of an intrathecal pump for opioid administration. Excellent pain relief was achieved in the postoperative period; however, three years after implantation, he presented with progressive saddle anesthesia and bowel/bladder incontinence. Magnetic resonance imaging demonstrated a space occupying lesion associated with the catheter tip. The patient underwent emergent second level complete sacral laminectomy with partial resection of an intradural extra-axial mass and removal of intrathecal catheter. At discharge, the patient had no restoration of neurologic function. Histologic examination of the mass confirmed a sterile inflammatory mass. It has been suggested that intrathecal catheters be placed below the conus medullaris to avoid the possibility of spinal cord involvement. We present an unusual case documenting devastating permanent neurologic deficits from a catheter tip granuloma in the sacral region.

Management of Intrathecal Catheter-Tip Inflammatory Masses: An Updated 2007 Consensus Statement From An Expert Panel

“…Several data‐driven reports and editorial opinion, including the published guidelines of the 2002 Polyanalgesia Consensus Conference (5), have called for IT catheter placement to be below the conus medullaris to prevent the severe and sometimes permanent neurologic sequelae associated with catheter‐tip inflammatory masses (23). However, evidence from case reports suggests that implantation of IT catheters tips located at or below the conus medullaris does not necessarily remove all risk of neurologic injury that can result from inflammatory granulomas.…”

“…In another unique case study, an intradural extra‐axial mass was detected in the sacral region in a 71‐year‐old white male patient implanted with an IT pump for opioid treatment of failed back surgery syndrome (23). The patient experienced some postoperative pain relief but presented with progressive saddle anesthesia and bowel/bladder incontinence three years after undergoing implantation.…”

Programmable Intrathecal Opioid Delivery Systems for Chronic Noncancer Pain: A Systematic Review of Effectiveness and Complications

“…14,21,23,24,31,35,36,79 There were case reports of traumatic syrinx owing to penetration of the spinal cord by the intrathecal 29 There was a report of withdrawal symptoms due to catheter disconnection from the pump. 28…”

A review of intrathecal morphine therapy related granulomas

“…Such a case has been reported that required emergent sacral laminectomy with partial resection of an intradural extra‐axial mass. Unfortunately, this patient had no restoration of neurologic function (Fernandez et al, 2003).…”