ziconotide and Low-Back-Pain

Intrathecal ziconotide is used for the treatment of chronic pain and is delivered by an implanted drug delivery device. Anesthesiologists should be familiar with the perioperative management of the pump as well as the potential adverse events related to continued ziconotide infusion during general anesthesia. A case is presented demonstrating the perioperative management of an intrathecal drug delivery device infusing ziconotide in a patient presenting for radical cystectomy with pelvic lymphadenectomy and ileal conduit diversion.

Topics: Aged; Analgesics, Non-Narcotic; Anesthesia, General; Carcinoma, Transitional Cell; Chronic Pain; Cystectomy; Deprescriptions; Humans; Infusion Pumps, Implantable; Infusions, Spinal; Intraoperative Complications; Low Back Pain; Lymph Node Excision; Male; omega-Conotoxins; Pelvis; Perioperative Care; Urinary Bladder Neoplasms; Urinary Diversion; Vasoplegia

The formation of catheter tip granulomas is an increasingly observed serious complication of intrathecally administered medication. This complication, which is frequently associated with neurological disturbances, has previously been attributed to high dosages and high concentrations of intrathecal morphine. Much less commonly, intrathecal hydromorphone and intrathecal baclofen have also been associated with intrathecal granuloma formation. In the current case, we report a patient who developed her fi rst catheter tip granuloma after 20 months of intrathecal morphine. After surgical granuloma removal and installation of a new catheter, the patient received intrathecal ziconitide for an interim period of six months. Because of a progressive inefficacy, ziconitide was replaced by hydromorphone. One month later, only nine months after the fi rst operative granuloma removal, a new catheter tip granuloma required a further surgical intervention. This case report highlights the potential of intrathecal morphine and hydromorphone to form consecutive inflammatory granulomas within the same patient. To the best of our knowledge, this is the fi rst report of a patient developing two consecutive catheter tip granulomas within nine months.

Topics: Analgesics, Non-Narcotic; Analgesics, Opioid; Catheterization; Female; Granuloma; Humans; Hydromorphone; Injections, Spinal; Laminectomy; Low Back Pain; Magnetic Resonance Imaging; Middle Aged; Morphine; omega-Conotoxins; Orthopedic Procedures; Postoperative Complications; Recurrence; Spinal Diseases