ePainBook: Intrathecal Pump Implants - Presented by Arizona Pain Specialists

The purpose of the pump is to interrupt pain signals that travel through the spinal cord. Pain signals which normally travel
to the brain are lessened and pain relief is perceived. Medication is delivered into the intrathecal space surrounding the
spinal cord. The ITP delivers pain medication directly to the pain receptors in the spinal cord and smaller doses of
medication are required to gain relief.

ITP implants are considered when oral pain medications and other methods of pain control have been exhausted or
proven ineffective.

Procedure:

Before an ITP is placed, an intrathecal medication trial is performed. Medication is placed in the spinal fluid. If pain relief
is adequate, an ITP can be permanently placed to control your pain.

Placement of the ITP can be performed in an outpatient setting or in the hospital. The implantation of the device is done
with local anesthesia and sedation (general anesthesia is usually not required). After a sterile scrub, local anesthesia is
used to numb the needle entry location. Once the area is numb, a larger needle and catheter are placed into the
intrathecal space using x-ray guidance.

Once the catheter is in the proper location, the pump is then connected and placed under the skin on the lower part of
your abdomen. The catheter and pump are tunneled under your skin and all wounds are surgically closed.

The pump delivers pain medication (opiates, local anesthetics, and/or muscle relaxants) directly into the intrathecal space
around the spinal cord. The medication reservoir in the pump is refilled periodically (every four to six weeks) by your pain
physician by injecting the medication through your skin into the pump.

The entire procedure typically takes one to two hours and may be performed on an outpatient or in-patient basis.

Benefits:

ITPs can be used to treat a variety of painful conditions. Nociceptive pain, or pain from tissue irritation can usually be
effectively treated with uploads like morphine. Nociceptive pain transmission is interrupted at the spinal cord and pain
relief is experienced.

Neuropathic pain, peripheral or central nervous system pain, tends to be receptive to treatments with local anesthetics
more than opioids. Examples of neuropathic pain syndromes include CRPS (complex regional pain syndrome or reflex
sympathetic dystrophy), cancer pain, phantom limb pain, post herpetic neuralgia (shingles), carpal tunnel syndrome,
failed back surgery syndrome, and peripheral neuropathy (Diabetes Mellitus, vitamin deficiencies).

Spasmodic pain can also be successfully treated by ITPs. This type of pain is effectively treated with anti-spastic muscle-
relaxing medications like Baclofen. Spasticity may be caused by impairment in the brain or spinal cord and is seen in
several conditions, such as stroke, brain injury, spinal cord injury, cerebral palsy, and multiple sclerosis (Rawlins 2004).
Spasticity is an abnormal increase in muscle tone and tightening of the muscles.

Risks:

Intrathecal pump implants are effective and safe devices used for pain management. The complications associated with
implants are mostly pharmacological and transient (Kamran). Some of the common side effects due to the medications
that are dispersed through the pump are:

• Nausea & Vomiting
• Itching
• Weakness
• Facial flushing
• Constipation
• Sleepiness
• Respiratory Depression

More serious complications that can ensue are:

• Hematoma
• Bleeding
• Infection
• Infection/Meningitis
• Catheter malfunction

ITP implants are considered an appropriate treatment for many patients who suffer from chronic difficult to control pain.
As with any medication taken, there are always risks and potential side effects that may occur. All patients receiving a
pump implant should be evaluated by their physician and risks of ITPs should be discussed.

Outcomes:

A large clinical study involving twenty four European centers showed that intrathecal pump implant therapy is clinically
effective, well tolerated and may offer improvements in pain relief and function. Muscle tone, spasm levels, and pain
intensity reductions were observed. Also cognition and motor function showed improvements (Guillaume 2005).

Intrathecal Baclofen therapy is considered safe and so effective that it has evolved into the standard treatment for severe
spasticity (Rawlins 2004). Most patients and caregivers express satisfaction with the therapy and would recommend it to
other patients. Spasm frequency appears to be the single most common variable positively affected by therapy (Vender
2006). Another study showed excellent long term efficacy in the treatment of lower extremity spasticity (Ethans 2007).

Another study observed the effects of intrathecal Morphine when delivered to patients with painful cancer. In this study all
patients and their families reported an improved quality of life with an increased level of activity, and it was deemed
“efficacious and safe” (Gilmer-Hill 1999). Another benefit with ITPs in terminal cancer is that continuous intrathecal
narcotic infusion is a very effective method to control terminal cancer pain and enables treatment in an outpatient setting
(Motsch 1988).

Pain can be a debilitating condition physically, as well as emotionally. ITPs can dramatically help those with painful
conditions that are unrelieved by other therapies. Call Arizona Pain Specialists today and see what they can do to relieve
your pain.

Journal Articles:

Intrathecal Baclofen Therapy and Multiple Sclerosis: Outcomes and Patient Satisfaction
John R. Vender, M.D.; Mary Hughes, M.D.; Betsy D. Hughes, B.S.; Sydney Hester, M.D.; Stephen Holsenback, B.S.;
Brenda Rosson, R.N. Neurosurg Focus. 2006;21(2) 2006 American Association of Neurological Surgeons

Complications of Intrathecal Drug Delivery Systems Saadat Kamran MD, Ballard D. Wright MD Department of Neurology,
Anesthesiology University of Kentucky and The Pain Treatment Center Lexington, KY

Intrathecal baclofen therapy: indications, pharmacology, surgical implant, and efficacy. Ethans K. Acta Neurochir Suppl.
2007;97(Pt 1):155-62 PMID: 17691371

A clinical study of intrathecal baclofen using a programmable pump for intractable spasticity. Guillaume D, Van
Havenbergh A, Vloeberghs M, Vidal J, Roeste G. Arch Phys Med Rehabil. 2005 Nov;86(11):2165-71

Intrathecal morphine delivered via subcutaneous pump for intractable pain in pancreatic cancer. Gilmer-Hill HS, Boggan
JE, Smith KA, Frey CF, Wagner FC Jr, Hein LJ. Surg Neurol. 1999 Jan;51(1):6-11.

Continuous intrathecal opiate therapy with a portable drug pump in cancer pain. Motsch J, Bleser W, Ismaily AJ, Distler L.
Anasth Intensivther Notfallmed. 1988 Oct;23(5):271-5.

Intrathecal baclofen therapy over 10 years. Rawlins PK. J Neurosci Nurs. 2004 Dec;36(6):322-7.

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Intrathecal Pumps (ITPs)
by Nicole Berardoni M.D, Paul Lynch M.D, and Tory McJunkin M.D

Intrathecal Pumps (ITPs) are devices used in the treatment of
many chronic pain states. The pumps have shown effective in
treating cancer pain, severe back pain, neuropathic pain, and
muscle spasticity. ITPs are an automated piece of equipment that
are programmed to deliver medication into the spinal fluid through
a small catheter. This exciting pain relief technique has been
shown to be both safe and effective

Book I - Pain Syndromes

Chapter 1     Low Back Pain
Chapter 2     Neck Pain
Chapter 3     Cancer Pain
Chapter 4     Headaches
Chapter 5     Spinal Stenosis
Chapter 6     Sciatica
Chapter 7     Arthritis
Chapter 8     Fibromyalgia
Chapter 9     Motor Vehicle Injuries
Chapter 10   Complex Regional Pain
Syndrome
Chapter 11   Vertebral Body
Fractures
Chapter 12   Hip and Leg Pain
Chapter 13   Diabetic Peripheral
Neuropathy

Book II - Interventional Procedures

Chapter 14   Epidural Steroid
Injection
Chapter 15   Facet Injections/Medial
Branch Blocks
Chapter 16   Radiofrequency Ablation
Chapter 17   Spinal Cord Stimulator
Implants
Chapter 18   IntraDiscal
Electrothermal Therapy (IDET)
Chapter 19
Vertebroplasty/Kyphoplasty
Chapter 20   Discography
Chapter 21   Percutaneous
Discectomy
Chapter 22   Occipital Nerve Block
Chapter 23   Sympathetic Block
Chapter 24   Stellate Ganglion Block
Chapter 25   Intrathecal Pump
Implants
Chapter 26   Caudal Steroid Injection
Chapter 27   Adhesiolysis
Chapter 28   Cervical Steroid
Injection
Chapter 29   Sacroiliac Joint
Injections
Chapter 30   Celiac Plexus Block
Chapter 31   Head and Neck
Procedures
Chapter 32   Joint Injections
Chapter 33   Continuous Catheter
Nerve Blocks
Chapter 34   Peripheral Nerve
Stimulation/Field Stimulation
Chapter 35   Disc Denervation

Book III   Other Treatments

Chapter 36   Medication Management
Chapter 37   Acupuncture
Chapter 38   Prolotherapy
Chapter 39   Botox
Chapter 40   Massage
Chapter 41   Alternative and
Complementary Medicines
Chapter 42   Exercise and Nutrition
Counseling
Chapter 43   Prayer
Chapter 44   Cognitive Behavioral
Therapy
Chapter 45   Group Therapy
Chapter 46   Biofeedback
Chapter 47   Chiropractic
Manipulations
Chapter 48   Vitamin Supplements
Chapter 49   Customized
Pharmaceutical Formulations
Chapter 50   Hormone Therapy

Frequently Asked Questions