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Spinal Cord Compression Due to a Catheter Tip Granuloma of an Intrathecal Morphine Pump

Gaurav JainNashaat N Rizk

Neurology and Neuroscience Research. 2018;1(1):5
DOI: 10.24983/scitemed.nnr.2018.00066
Article Type: Image

Abstract

Keywords

    A 59-year-old woman had an intrathecal morphine pump therapy for the last 20 years, due to chronic lumbar back pain and L4,5 post-laminectomy syndrome, and was presented with 6 days onset of lower thoracic back pain accompanied with feelings of heaviness and tingling below mid-thigh level bilaterally. There was no change in the drug concentration (20 mg/ml) within the last four years. She denied having fever, headache, confusion, saddle anesthesia, bladder or bowel incontinence and history of cancer. Upon examination she had decreased pin-point sensation, and absent vibration sense below mid-thigh level bilaterally with intact motor exam.

    The gadolinium enhanced magnetic resonance imaging (MRI) of thoracic spine showed an intraspinal extramedullary ring enhancing lesion at T10 level abutting the spinal cord posterior-laterally on the right side (Figures 1-6). MRI of the head, and the cervical and lumbar spines were unremarkable. Cerebrospinal fluid analysis was normal and cultures were negative for infection. She was diagnosed with catheter tip granuloma [1,2] and the intrathecal morphine was stopped. Pump was operated with normal saline, and serial thoracic MRI was obtained every week until symptoms were resolved after 2 weeks; and granuloma was resolved after 3 weeks.
     

    Figure 1. Gadolinium contrast enhanced mid-line sagittal view of thoracic spine MRI. intraspinal extramedullary ring enhancing lesion at T10 level abutting the spinal cord posterior-laterally on the right side. It measured 14.8 mm superior to inferior and 7.7 mm anterior to posterior abutting the spinal cord posterior-laterally on the right side with no signs of inflammation. MRI, magnetic resonance imaging.

     

    Figure 2. STIR thoracic MRI mid-line sagittal view with no signs of inflamation. MRI, magnetic resonance imaging; STIR, short inversion time inversion recovery.

     

    Figure 3. T1-weighted thoracic MRI mid-line sagittal view. MRI, magnetic resonance imaging.

     

    Figure 4. T2-weighted thoracic MRI mid-line sagittal view. MRI, magnetic resonance imaging.

     

    Figure 5. Gadolinium contrast enhanced transverse view of thoracic spine MRI at upper T10 level. MRI, magnetic resonance imaging.

     

    Figure 6. T2-weighted transverse view of thoracic spine MRI at upper T10 level. MRI, magnetic resonance imaging.

    References

    1. Coffey R, Burchiel K. Inflammatory mass lesions associated with intrathecal drug infusion catheters: report and observations on 41 patients. Neurosurgery 2002;50:78-86; discussion 86-87. PMID: 11844237
    2. Deer TR. A prospective analysis of intrathecal granuloma in chronic pain ppatients: a review of the literature and report of a surveillance study. Pain Physician 2004;7:225-228. PMID: 16868596

    Editorial Information

    Publication History

    Received date: July 26, 2017
    Accepted date: October 27, 2017
    Published date: June 20, 2018

    Funding:

    None

    Conflict of Interest:

    None

    Copyright

    © 2018 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC-BY).

    Gaurav Jain, MD

    Division of Pain Medicine, Department of Anesthesiology, Berkshire Medical Center, Pittsfield, MA, USA

    Nashaat N Rizk, MD

    Department of Anesthesiology, West Virginia University, Morgantown, WV, USA

    Correspondence: Gaurav Jain, MD

    Division of Pain Medicine, Department of Anesthesiology, Berkshire Medical Center, Pittsfield, MA, USA
    Figure 1.JPG
    Figure 1. Gadolinium contrast enhanced mid-line sagittal view of thoracic spine MRI. intraspinal extramedullary ring enhancing lesion at T10 level abutting the spinal cord posterior-laterally on the right side. It measured 14.8 mm superior to inferior and 7.7 mm anterior to posterior abutting the spinal cord posterior-laterally on the right side with no signs of inflammation. MRI, magnetic resonance imaging.
    Figure 2.JPG
    Figure 2. STIR thoracic MRI mid-line sagittal view with no signs of inflamation. MRI, magnetic resonance imaging; STIR, short inversion time inversion recovery.
    Figure 3.JPG
    Figure 3. T1-weighted thoracic MRI mid-line sagittal view. MRI, magnetic resonance imaging.
    Figure 4.JPG
    Figure 4. T2-weighted thoracic MRI mid-line sagittal view. MRI, magnetic resonance imaging.
    Figure 5.JPG
    Figure 5. Gadolinium contrast enhanced transverse view of thoracic spine MRI at upper T10 level. MRI, magnetic resonance imaging.
    Figure 6.JPG
    Figure 6. T2-weighted transverse view of thoracic spine MRI at upper T10 level. MRI, magnetic resonance imaging.

    Reviewer 1 Comments

    1. The rate of symptom progression was described qualitatively in patients who developed neurological deficits in the literature. For instance, a case with a 4-day evolution of symptoms was reported previously. Hence, it would be informative to know the duration of symptoms before diagnosis. 
       ResponseThe duration was 6 days. This information has been added to the manuscript.
       
    2. Patients with catheter tip granulomas may be exposed to different drugs (i.e. morphine or hydromorphone, either alone or as a drug admixture), dosages, or drug concentrations before diagnosis. It is useful to know about the intrathecal drugs that were administered at the time a mass was diagnosed.
       ResponseThe patient was only on morphine at 20 mg/ml without any changes in the last 4 years. This information has been added to the manuscript.
       
    3. Delayed diagnosis and treatment has been found to be associated with residual neurological disabilities. However, it is unclear that whether neurological outcome correlates with the type of treatment for patients with catheter tip granulomas. Removal or revision of the drug administration system is one of the therapeutic options. Case records suggest that patients with a mass that did not fill the spinal canal or cause neurological impairment may be treated by stopping or emptying the drug infusion pump or by refilling it with preservative-free normal saline to run at a minimal infusion rate (approximately 0.1 ml/d). Nevertheless, in the literature, most of the cases underwent surgery to relieve spinal cord or cauda equina compression. Was there any contraindication of surgical intervention for the patient?  
       ResponseThe neurosurgery team preferred observation over surgical option, since the patient did not have any motor deficit or cauda equina syndrome.

    4. Contamination of intrathecal drugs or diluent solutions with bacterial endotoxins or pyrogens is another potential microbiological hypothesis. Did the patient undergo her CSF analysed using the Bacterial Endotoxins Test or the Limulus amoebocyte lysate test for endotoxins? Did she experience meningitis symptoms, or CSF pleocytosis consistent with an endotoxic or pyrogenic reaction?
       ResponseAs the cerebrospinal fluid analysis was normal and cultures were negative for infection, no further investigation was pursued on CSF.

    Reviewer 2 Comments

    1. This is a very interesting case, however, the authors need to explain what this case adds to the existing literature on the subject.
       ResponseThis case is submitted as a brief report in the Images in Neurology section. Authors hope to refresh this clinical entity to the readers with impactful images. This case responded to the conservative treatment which could be an option in mild presentation, rather than surgery.

    Jain G, Rizk NN. Spinal cord compression due to a catheter tip granuloma of an intrathecal morphine pump. Neurol Neurosci Res. 2018;1(1):5. https://doi.org/10.24983/scitemed.nnr.2018.00066

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