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.

Patients with a History of Spine Surgery or Spinal Injury may have a Higher Chance of Intrathecal Catheter Granuloma Formation

“…The continuous contact with the neural tissue may have caused an extraordinary local concentration of morphine, and this may have predisposed our patient to the development of the ICTG. Another report has shown that an ICTG can be formed at the sacral level . Therefore, other factors that may contribute to ICTG formation should also be sought.…”

“…We also reviewed the bibliographies of the studies identified by the electronic database search and retrieved other relevant studies. There were 27 relevant original case series and case reports identified . Two case reports of ICTG developed in patient receiving non‐opioid medications were excluded from analysis because development of ICTG in these patients remains very rare .…”

“…Another report has shown that an ICTG can be formed at the sacral level. 22 Therefore, other factors that may contribute to ICTG formation should also be sought.…”

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

“…In humans, ICTGs have occurred with IT infusions of morphine (74,79,86,(91)(92)(93)(94)(95)(96)(97)(98)(99)(100)(101)(102)(103)(104)(105)(106)(107)(108)(109) or hydromorphone (86,110). In contrast, though less widely employed for IT infusions and with one exception (111), no granulomas have been reported in patients receiving IT admixtures with fentanyl as the IT opioid.…”

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

“…Furthermore, none of the 18 patients receiving bupivacaine in combination with fentanyl, in this study, developed granuloma. Indeed, ICTGs have been reported to occur with intrathecal infusions of morphine (6)(7)(8)(10)(11)(12)(13)(14)(15)18,19,22,(25)(26)(27)(31)(32)(33)(52)(53)(54)(55)(56)(57), or hydromorphone (13,23,58,59). However, the vast majority of reported hydromorphone-related ICTG cases had also been exposed to morphine prior to receiving hydromorphone, and therefore, it was not clear whether the ICTG was purely a phenomenon related to intrathecal hydromorphone infusions (13,17,18,23,33,59).…”