Transcript Spasticity Update

Intrathecal Therapy Systems:
Troubleshooting / Explantation / Infection
Michael Saulino, MD PhD
MossRehab
Assistant Professor
Thomas Jefferson University
Adjuvant Assistant Professor
Temple University
CME Disclosures 1
• Speaker’s bureau for Jazz Pharmaceuticals
• Speaker’s bureau and clinical investigator for
Medtronic, Inc
• Speaker’s bureau for Ipsen
• Consultant for SPR therapeutics and
Myoscience
CME Disclosures 2
• Will discuss off label and investigational
indications for medications and devices
• All activities are reviewed by Albert Einstein
Healthcare Network’s conflict of interest
committee
• Honoraria are paid directly to PMR department
Current status of intrathecal
delivery systems
3 systems have US FDA approval
3 medications have US FDA approval
Baclofen
Synchromed 2 Adults + peds
Medstream
Prometra
Morphine
Ziconotide
Adults
Adults
Adults
Adults
Presentation will focus on Synchromed
Intrathecal Delivery Issues
• Pump
Potential problems: pocket fill, battery failure, empty
reservoir, programming errors, motor stall
• Catheter
Potential problems: kinks, holes, blockages
Pump Issues
• Check for alarms / electronic logs
• Verify residual volume during  compare to
expected volume
• Use localization techniques if unsure of reservoir
port access
• Verify drug (s), concentration, daily/ hourly
dosing, alarm volume/date
• Bridge bolus during concentration change
Radiograph appearance
Ultrasound appearance
Motor Stall
• Automatic stall with MRI and nearly universal restart
after MRI
• Can also be caused by gear shaft wear
• Higher incidence with unapporved medications (7.0
% vs. 2.4 %) – hydrophilic drugs such as fentanyl and
bupivacaine may have higher
• More common with older pumps
• Electronic log of any motor stall
Potential Catheter Disruptions
Copyright Ellen Barker Michael Saulino
10
Catheter Micro-fractures
Investigation Techniques
for Catheter Problems
Plain radiography
Catheter dye study
CT myelogram
Nuclear medicine cisternogram
Magnetic resonance imaging
Plain radiography
• AP/lateral thoracic and lumbar spine, flat plate
of abdomen and spot film over pump site
• Always check your own films
• Advantages: can be done remotely without
technical expertise
• Disadvantages: will probably only pick up
gross breaks and tears, projection difficulties
Catheter dye study
• Access catheter access port, aspirate catheter
contents/CSF, discard fluid, inject myelogram
dye with real-time fluoroscopy, reprogram
pump to refill catheter
• DO NOT INJECT DYE IF YOU CANNOT
ASPIRATE CATHETER CONTENTS
Catheter dye study
• Advantages:
– ? improved sensitivity compared to plain films
• Disadvantages:
– technical expertise
– can’t inject if you cannot aspirate
– will probably miss small tears
CT myelogram
after side port injection
• Remove 2-3 mls of fluid
• Inject 2-3 mls of isotonic contrast
• Patient is then immediately spiral scanned
from 2 vertebral segments above the tip
of the catheter, down through the pump in
the abdomen.
CT myelogram dye study
• Advantages:
– Improved sensitivity compared to plain
films and fluoroscopy
– “Free” CT of abdomen, thorax, lumbar and
thoracic spine
• Disadvantages:
– Technical expertise
– Coordination with radiology
– Cannot undertake if fluid cannot be
aspirated from side port
Normal study
Contrast loculated in the spinal canal
Contrast ventral to CSF suggesting
subdural migration
Contrast extravasating into the subcutaneous
tissues suggesting catheter breakage
Contrast
filing
of an
intrathecal
granuloma
Nuclear medicine cisternogram
• Obtain flow rate and catheter volume
• Inject 0.5 mCi of In-111 DTPA into pump
reservoir
• Collect serial images
(typically 24, 48 and 72 hrs)
Nuclear medicine cisternogram
Advantages
• Can perform study if you cannot aspirate from
side port
• Observe the native flow rate
Disadvantages
• Coordination with nuclear medicine
• Several days to obtain result
• Poor anatomic localization
Normal
nuclear
medicine
study
Catheter occlusion
with
focal collection
Pump
to
catheter
occlusion
MRI
Advantages
• Can perform study if you cannot
aspirate from side port
• Anatomic detail
Disadvantages
• Poor visualization of catheter
Granuloma
Dura
Catheter
Arachnoid Layer
Infection issues
• “Ounce of prevention is worth a pound of cure”
• No contraindication for cancer, HIV or AIDS
(one of the best studied populations for this therapy)
• No true consensus on chronic infections
– MRSA carriers - ? surveillance nasal swab
– Neurogenic bladder - ? surveillance culture
• Complicated cases may require collaborative decision
making with infectious disease
Infection issues
• Differential diagnosis: superficial cellulitis,
seroma, hematoma, menigitis
• Labs: CBC with diff, ESR, CRP
• Radiologic: CT, Ultrasound
• Exposed metal or catheter is colonized – will
need to explant
Infection issues
• Can consider immediate explant and re-implant
at another site
• Wean intrathecal agents as much as possible
• Supplement (oral/IV) to prevent withdrawal
• Can consider intrathecal antimicrobial therapy
• Complicated cases may require collaborative
decision making with infectious disease
Thank
you