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CT scan of lumbosacral spine sagittal view showing entry of 2 catheters at L2/3 level. Lumbar subcutaneous pseudomeningocele extending from L1 to L3 level.
Source publication
Catheter related complications are not uncommon with permanently implanted intrathecal drug delivery systems. Pericatheter leak of cerebrospinal fluid usually responds to conservative treatment. We report a case of tension pseudomeningocele due to retained lumbar intrathecal catheter. It is essential to be aware of this rare complication and we rec...
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Citations
... However, complications following IDDS catheters removal are scarce in the literature. Most reports describe complications related to retained catheters, catheter migration, or CSF leak after IDDS explant (13)(14)(15)(16). ...
... Nevertheless, a literature search will uncover multiple case reports suggesting that this is not without risk. Vodapally et al. (13) described a case of pseudomeningocele after a catheter broke in its spinal end distal to the anchor. Intracranial migration of retained lumbar catheters from IDDS causing subarachnoid hemorrhage (SAH) or severe symptoms have also been published (14,15). ...
Introduction
Implanted intrathecal drug delivery systems (IDDS) are increasingly used in the treatment of spasticity and in patients with refractory pain. Literature discussing complications associated with intrathecal pump placement is widely available. However, reports of complications following the removal of chronically placed catheters are scarce. We reviewed our series of patients who had surgery to remove the intrathecal catheter.
Methods
Retrospective review was performed for all patients who underwent surgery to remove a catheter linked to an IDDS between 2010 and 2016. Patients older than 18 years were included in final analysis. Demographic (including age at removal, sex, BMI, and comorbidities) and etiologic characteristics (indications of IDDS implant and explant, interval between implant and explant, and concomitant surgery) were analyzed. Simple logistic regression was performed to seek any potential predictor of complications.
Results
Fifty‐nine patients underwent removal of their intrathecal catheter after variable periods (mean interval of 189 months). On eight occasions, patients developed complications after catheter removal (mean interval between implant and explant was 76 months for these cases). Retained catheter was the cause of complications in half of these occasions. Persistent cerebrospinal fluid leak was the next most common complication, with requirement of an external ventricular drain and lumbar drain to facilitate wound healing on two separate occasions.
Conclusion
Removal of an intrathecal catheter from IDDS systems may cause complications that in some cases require additional surgery.
... [3,16] In the presence of intracranial hypotension or symptomatic pseudomeningocele that are persistent despite conservative management, resection of the retained catheter with concomitant CSF leak repair is warranted. [31] Thin slice CT-scan of the spine allows localization of the retained fragment and helps to ascertain if there is an epidural component that can be retrieved. As in our case, the presence of pseudomeningocele can be determined by CT-scan and active CSF leakage or fistula can be visualized with CT myelogram. ...
Background
Shearing of an intrathecal catheter during implantation of a drug delivery system is an underreported complication that can be challenging to manage.
Case Description
A 53-year-old man with refractory cancer pain had an intrathecal pump system implanted. The procedure was complicated with catheter shear and retention in the intrathecal space. A second catheter was successfully placed but formation of a painful pseudomeningocele and ineffective pain relief complicated the outcome. A minimally invasive approach through a tubular retractor was employed to access the spinal canal via a laminotomy, the sheared catheter was removed and the dural defect repaired. Complete resolution of the pseudomeningocele and efficient pain control were observed at follow-up.
Conclusion
Minimally invasive approach to the spine is demonstrated as a safe and effective alternative in this case of retained catheter induced cerebrospinal fluid (CSF) leak.
... There is no consensus about the treatment of retained fragments. Both conservative [52,53] (Fig. 11) and surgical treatment [52,54] are performed. Nevertheless, serious complications like subarachnoid haemorrhage [39,55,56] and migration into the ventricle [56] are reported. ...
Objectives:
Intrathecal drug administration using an implanted pump system is well established in intractable spasticity and pain. However, despite continuous advancements in manufacturing technology, adverse events related to the pump and catheter still occur. Most of them, such as migration, damage, disconnection and occlusion, are related to the spinal catheter. The aim of this overview is to update radiologists on how plain radiography of the implanted delivery system for intrathecal drug administration should be interpreted and to increase awareness for the need of urgent and timely multidisciplinary troubleshooting.
Methods:
Plain radiographic images of patients treated with intrathecal drug administration using an implantable drug delivery system were analysed in a multidisciplinary setting at our (university) referral centre for complications in intrathecal drug administration.
Results:
Examples of catheter-related adverse events are described and a proposal is made for stepwise interpretation of standard plain radiographic images.
Conclusions:
Plain radiological images are the mainstay for the diagnosis of catheter-related adverse events in intrathecal drug delivery. Radiologists play an important role in an early diagnosis. An awareness of abnormal radiological findings seems important to avoid a life-threatening withdrawal syndrome.
Teaching points:
• Untimely cessation of intrathecal drug delivery can lead to a life-threatening withdrawal syndrome. • Initially mild symptoms can lead to an exacerbation of a withdrawal syndrome. • Most intrathecal catheter-related problems are visible on plain radiography. • Common causes of catheter problems are migration, lacerations, occlusion and disconnection. • Knowledge on implanted intrathecal catheters is crucial for interpretation of plain radiography.
... Several reports have described the mechanical complications of ITDDS (4, 6-10). Although catheter-related problems are infrequent (11-18), catheter complications such as kinks, breaks, or disconnections are common causes of reoperation (2, 19) or pump failure (13). The recent increase in the use of intrathecal pump implantation may lead to an increased incidence of such complications; therefore, guidelines are needed to prevent or resolve these complications. ...
The intrathecal drug delivery system (ITDDS), an effective treatment tool for intractable spasticity and pain, is associated with various complications but breakage of the catheter is rare. We report the case of a 50-yr-old man with ITDDS, in whom an intrathecal catheter was severed, resulting in a 28.6-cm-long intrathecal fragment. The catheter completely retracted into the intrathecal space from the anchor site. The catheter was severed during spine flexion, and the total distal fragment was repositioned in the intrathecal space. Although the outcome of ITDDS was associated with the length or diameter of the broken catheter, no neurologic complications occurred in our patient. Thus, we inserted another catheter instead of removing the old one. Thereafter, the patient has been regularly followed up, and no neurologic complications have developed during the 28 months.
As the use of intrathecal therapy has become more common in our armamentarium for the treatment of chronic pain, the indications for implantation have expanded to include new conditions and patient populations; however, the literature regarding these developing indications is sparse, consisting primarily of case reports and case series. As such, robust, long-term data are lacking. In this chapter, we review the management of intrathecal drug therapy in specific patient populations that require further attention. This includes patients with atypical pain syndromes, children, immunocompromised patients, and patients on blood thinning agents. In addition, we discuss treatment options for individuals with other implantable devices. Finally, we examine the treatment algorithm in the setting of cerebrospinal fluid leaks. Of note, while there are currently only three intrathecal agents approved for use by the Food and Drug Administration, morphine (an opioid), ziconotide (a non-opioid calcium channel antagonist), and baclofen (a GABAB receptor agonist), this chapter also reports on the use of investigational intrathecal therapies that are considered off-label.
Background and importance:
Lumbar drain placement is a common neurosurgical procedure, with several surgical and medical indications extending even beyond the specialty. One complication of placement is a fractured catheter fragment. In some circumstances, catheter retrieval is necessary which is classically performed through an open approach. Here, we present the only reported case of a retained lumbar drain catheter which was retrieved using a transforaminal endoscopic approach to the lumbar spine.
Clinical presentation:
This is a 39 year-old woman who underwent an elective craniotomy with planned perioperative lumbar drain placement for cerebrospinal fluid diversion using a 14-gauge Tuohy needle. Placement was noted to be technically challenging, and during the final attempt on removal of the system, it was noted that the distal end of the catheter had been sheared and retained in the thecal sac. Postoperatively a computed tomography scan of the lumbar spine was obtained showing the catheter fragment which entered the thecal sac dorsally at the L3-4 level but penetrated the ventral dura traveling in the epidural space caudally and terminating in the left lateral recess of L4-5. Given its presumed epidural location near the left L4-5 lateral recess and foramen, the decision was made to attempt a left transforaminal endoscopic approach for catheter retrieval before resorting to a standard open surgery.
Conclusion:
As minimally invasive spine techniques for spine surgery continue to evolve, we have highlighted the versatility of the endoscope in spine surgery as it was implemented in our case, allowing for reduced perioperative morbidity associated with retained spinal catheter retrieval.
Lumbar pseudomeningoceles are uncommon complication of lumbar disc surgeries. This pathology is an extradural encapsulated cerebrospinal fluid collection that develops as a consequence of an incidental durotomy or unrepairable dural tear. Iatrogenic lumbar pseudomeningocele has received scant attention and review of the literature reveals only a single case report or small series of two to four cases. With careful review of the literature since the first description of the problem in 1946 by Hynman and Gerber, we found 58 more cases Herein, we wish to describe three new symptomatic cases with a review of relevant literature. Diagnosis in all these cases was by magnetic resonance imaging. All of the patients underwent surgery with primary closure of the dural defect with a good postoperative result.
Berichte über Komplikationen bei peripheren Nervenblockaden (PNB) beinhalten im Wesentlichen Intoxikationen durch Lokalanästhetika, Verletzungen von Nerven, Gefäßen und anderen umgebenden Strukturen sowie infektiologische Ereignisse. Der vorliegende Fallbericht weist auf eine Komplikation hin, über die bisher wenige Erkenntnisse vorliegen. Es handelt sich um die Durchtrennung eines Schmerzkatheters, bei der ein Teil des Katheters im Patienten verblieb. Die Ursachen und das praktische Vorgehen in dieser Situation werden diskutiert.
Intrathecal spinal catheters (lumbar drains) are indicated for several medical and surgical conditions. In neurosurgical procedures, they are used to reduce intracranial and intrathecal pressures by diverting CSF. They have also been placed for therapeutic access to administer drugs, and more recently, vascular surgeons have used them to improve spinal cord perfusion during the treatment of thoracic aortic aneurysms. Insertion of these lumbar drains is not without attendant complications. One complication is the shearing of the distal end of the catheter with a resultant retained fragment. The authors report the case of a 65-year-old man who presented with a subarachnoid hemorrhage due to the migration of a retained lumbar drain that sheared off during its removal. To the best of the authors' knowledge, this is the first case of rostral migration of a retained intrathecal catheter causing subarachnoid hemorrhage. The authors review the literature on retained intrathecal spinal catheters, and their findings support either early removal of easily accessible catheters or close monitoring with serial imaging.
