Primary Hydromorphone-Related Intrathecal Catheter Tip Granulomas: Is There a Role for Dose and Concentration?

Veizi, I. Elias; Hayek, Salim M.; Hanes, Michael; Galica, Ryan; Katta, Sivakanth; Yaksh, Tony L.

doi:10.1111/ner.12481

Cited by 24 publications

(14 citation statements)

References 65 publications

(108 reference statements)

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“…This section on IT granuloma highlights somewhat disparate findings: on the one hand, higher dose and concentration of opiates (such as morphine and hydromorphone) increase the risk of granuloma formation, on the other hand, a mast cell degranulation response-a phenomenon seen in allergy/hypersensitivity-is implicated. While not mutually exclusive, the latter phenomenon may support recent descriptions of hydromorphone-related IT catheter tip granulomas at low concentrations (750 mcg/mL) and dose (as low as 160 mcg/day) (83). It remains unclear whether granuloma formation occurs as a generalized reaction that is determined by the local concentration and exposure to the opiate or is related to individual patient predisposition and hypersensitivity to the opioid.…”

Section: Discussionsupporting

confidence: 58%

“…The overall incidence of histologically defined granuloma rises with local concentration, but granulomatous reactions were indeed noted even at the lowest concentrations . This is supported by recent clinical reporting of ICTGs occurring in four patients receiving fairly low doses and concentrations (≤1 mg/mL) of IT hydromorphone .…”

Section: Intrathecal Catheter Tip Granuloma Formation: Risk Mitigationsupporting

confidence: 63%

See 1 more Smart Citation

The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks

Deer¹,

Pope²,

Hayek

et al. 2017

Neuromodulation: Technology at the Neural Interface

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131

144

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Section: Discussionsupporting

confidence: 58%

Section: Intrathecal Catheter Tip Granuloma Formation: Risk Mitigationsupporting

confidence: 63%

The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks

Deer¹,

Pope²,

Hayek

et al. 2017

Neuromodulation: Technology at the Neural Interface

Self Cite

131

144

View full text Add to dashboard Cite

“…Though the vast majority of reported cases have involved morphine, 3 and to a lesser extent hydromorphone, 4 ITGs have also been reported in the context of intrathecal delivery of fentanyl, 3 sufentanil, 5 and tramadol. 6 …”

Section: Introductionmentioning

confidence: 99%

Unique Intradural Inflammatory Mass Containing Precipitated Morphine: Confirmatory Analysis by LESA‐MS and MALDI‐MS

et al. 2018

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Opioids are often used for analgesia via continuous intrathecal delivery by implantable devices. A higher concentration and daily dose of opioid have been postulated as risk factors for intrathecal granuloma formation. We present a 42-year-old female patient with chronic abdominal pain from refractory pancreatitis, with an intrathecal drug delivery device implanted 21 years prior, delivering continuous intrathecal morphine. After many years without concerning physical signs or complaints, with gradual increases in daily morphine dose, she presented with rapidly progressive neurologic deficits, including lower extremity, bladder, and bowel symptoms. These symptoms were determined to be secondary to mass effect and local inflammation related to an intrathecal catheter tip granuloma, detected on magnetic resonance imaging of the spine. The mass was urgently resected. On histopathologic examination, this granuloma was found to be unique, in that in addition to the expected inflammatory components, it appeared to contain precipitated nonpolarizable crystals. These were identified as precipitated morphine using liquid extraction surface analysis-tandem mass spectrometry (LESA-MS/MS) and matrix-assisted laser desorption ionization-Fourier transform ion cyclotron resonance-mass spectrometry imaging (MALDI-FTICR-MSI). In addition to the unique finding of precipitated morphine crystals, the long-term follow-up of both morphine concentration and daily dose increases provides insight into the formation of intrathecal granulomas.

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“…Hardware-related complications are equipment revisions (27%), catheter-related problems such as migration, dislodgement, kinking, obstruction, and occlusion (18%), mechanical failure (5%), and pump removal (5%). An uncommon but potentially serious problem is granuloma formation at the catheter tip, for which vigilance in any patient is recommended [22–24]. …”

Section: Discussionmentioning

confidence: 99%

Intrathecal Analgesic Drug Delivery is Effective for Analgesia in a Patient with Post-Poliomyelitis Syndrome: A Case Report

Tilburg

2016

Am J Case Rep

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Patient: Female, 45Final Diagnosis: Post-poliomyelitis syndromeSymptoms: Chronic painMedication: Fentanyl • Oxycodone • Gabapentin • Naproxen • ParacetamolClinical Procedure: Intrathecal analgesic drug deliverySpecialty: AnesthesiologyObjective:Unusual setting of medical careBackground:Post-poliomyelitis syndrome (PPS) is a progressive neuromuscular syndrome, with chronic pain being one of the most prevalent symptoms. We present a case report on intrathecal analgesic drug delivery to diminish chronic, refractory pain in a patient with PPS.Case Report:In a wheelchair-bound 45-year-old female patient (Caucasian, body mass index [BMI] 20.5) with severe chronic, refractory pain, a Synchromed® II pump (Medtronic, Minneapolis, Minnesota, USA) was implanted after multi-disciplinary consultation and a successful trial period. After 8 months, relocation of the pump due to regional pressure problems with surrounding erythema had to occur. A second pump relocation due to pressure problems and skin erosion was needed 18 months after the first relocation, moving from the abdominal wall to the sheath of the rectus abdominis muscle, resulting in resolution of the problems.Conclusions:In patients with PPS, intrathecal analgesic drug delivery can be an option to treat chronic, refractory pain. Multidisciplinary consultation is necessary to deal with the wide variety of problems in these patients. Skin problems at the site of the pump reservoir can be challenging and time-consuming and, ultimately, can necessitate relocation (or removal) of the device.

show abstract

Primary Hydromorphone-Related Intrathecal Catheter Tip Granulomas: Is There a Role for Dose and Concentration?

Cited by 24 publications

References 65 publications

The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks

The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks

Unique Intradural Inflammatory Mass Containing Precipitated Morphine: Confirmatory Analysis by LESA‐MS and MALDI‐MS

Intrathecal Analgesic Drug Delivery is Effective for Analgesia in a Patient with Post-Poliomyelitis Syndrome: A Case Report

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