Case scenario: self-extraction of intrathecal pump medication with a concomitant intrathecal granulomatous mass.

I NTRATHECAL drug delivery systems are frequently used to treat chronic pain and spasticity conditions. One of the first clinical uses of an implantable intrathecal opioid delivery device occurred in 1981 for the management of chronic malignant pain, although trials of opioids for intractable cancer pain began with Wang in 1979. Initially utilized as a means of pain amelioration in cancer patients, intrathecal therapy now has indications that have expanded to include nonmalignant chronic pain conditions. Opioids are often utilized as an infusion agent, with the principal advantage of intrathecal delivery near the site of action within the central nervous system, increasing the therapeutic efficacy, and thus reducing the likelihood of side effects associated with other delivery modalities. The implementation of intrathecal drug delivery systems has shown efficacy in many pain states, but complications or adverse effects may arise. Aprili et al., in a recent systematic review and metaanalysis, examined the potential risks of intrathecal catheters in cancer patients and reported rates of 2.3% (95% CI, 0.8– 6.1) and 1.4% (95% CI, 0.5–3.8) for superficial and deep infections, respectively; bleeding was found to be 0.9% (95% CI, 0–2.0) and neurologic injury 0.4% (95% CI, 0–1.0). The most significant adverse event of mortality can be associated with intrathecal opioids, and mortality rates have been reported of 0.088% at 3 days after implantation, 0.39% at 1 month, and 3.89% at 1 yr, a higher mortality rate than after spinal cord stimulation implants or after lumbar discectomy in community hospitals. The purpose of presenting this case is to highlight key points essential for the diagnosis and treatment of intrathecal granulomatous masses and the vigilance required by physicians managing patients with intrathecal drug delivery systems.