Intrathecal Port Research Articles

A new approach for leptomeningeal metastases: chemotherapy administered through lumbar intrathecal port.

Intrathecal chemotherapy is a local therapeutic modality used for treatment of leptomeningeal metastases. However, the techniques currently used, i.e. repeated lumbar puncture and Ommaya reservoir, have certain disadvantages. Lumbar intrathecal port (LIP) placement is a relatively novel technique, which has been used for pain management in cancer patients. To investigate the use of LIP for intrathecal administration of chemotherapeutic agents in patients with leptomeningeal metastases. Retrospective study of 13 patients treated with intrathecal chemotherapy for secondary leptomeningeal involvement of a primary solid tumor were included in this retrospective study. The patients received intrathecal chemotherapy through a LIP. The patients received a total of 123 intrathecal chemotherapy doses. No grade 3-4 toxicity, technical problem or severe complication developed. During a median of 136 days of follow-up (range, 67-376 days), 12 patients died (92.3%). The treatment resulted in symptom improvement in all patients and self-rated overall health and quality of life improved, compared with baseline. The LIP system, which has been used for intrathecal pain management for decades, appears to offer a safe alternative for intrathecal chemotherapy in patients with leptomeningeal metastases. Further studies are warranted to clarify its potential use in this setting.

Intrathecal catheter and port placement for nusinersen infusion in children with spinal muscular atrophy and spinal fusion.

Spinal administration of medications is challenging in patients with complete posterior spinal fusion. We describe percutaneous image-guided intrathecal port placement for administration of the antisense oligonucleotide nusinersen for children and young adults with spinal muscular atrophy. To describe and present our initial experience with a new technique for administering nusinersen in patients with spinal muscular atrophy and posterior spinal fusion. We reviewed medical records of 13 patients who received intrathecal ports using DynaCT, biplane fluoroscopy and iGuide from April 2018 through June 2019, and we describe the clinical course over 1year. Image-guided catheter and port implantation was successful in all cases. Two ports were subsequently removed, one for persistent cerebrospinal fluid leak and one for superficial infection. The other 11 have functioned successfully for a minimum of 23months. We report our experience with image-guided intrathecal port placement in children with complete posterior spine fusion. The implanted port permits dosing in an outpatient setting and avoids the need for multiple future radiologic procedures, and it reduces discomfort, procedural costs and potential risks and sequelae of multiple anesthetics and radiation exposures. Further studies are needed to define the relative risks and benefits of intrathecal ports compared to other approaches such as repeated transforaminal lumbar punctures.

Multicenter Experience with Nusinersen Application via an Intrathecal Port and Catheter System in Spinal Muscular Atrophy.

Nusinersen, an antisense oligonucleotide enhancing the production of the survival motor neuron protein, is approved for the treatment of spinal muscular atrophy (SMA) but requires repetitive lumbar punctures. Application via a subcutaneous port connected to a permanent intrathecal catheter has been proposed as an alternative for patients with severe scoliosis, spinal fusion, or comorbidities, rendering serial interlaminar punctures complicated and risky. Since experience with this technique is sparse and follow-up data are lacking, we assessed feasibility, safety, and tolerability of this approach in eight patients with SMA II/SMA III receiving Nusinersen in a multicenter study. Median age at port implantation was 21 years (range: 10-30 years), and median follow-up time thereafter was 19 months (range: 7-24 months). Leakage of the port catheter occurred in two patients, promptly resolving after resuturing. No further complications such as infection, dislocation, kinking, or obstruction of the port were noted in any of the patients. These findings suggest that application via an intrathecal port and catheter system represents a safe and feasible option for Nusinersen treatment in subjects with SMA. However, to detect rare adverse events longer term follow-up in a larger study cohort is warranted.

ОПЫТ ПРИМЕНЕНИЯ ДЛИТЕЛЬНОЙ ИНТРАТЕКАЛЬНОЙ ОПИОИДНОЙ ТЕРАПИИ В ЛЕЧЕНИИ ФАРМАКОРЕЗИСТЕНТНОГО НЕЙРОПАТИЧЕСКОГО БОЛЕВОГО СИНДРОМА

The article gives information about the way how the problem of pharmacoresistant neuropathic pain is solved. It presents the definitions of pharmacoresistant neuropathic pain, which makes it possible to accurately identify such patients and to plan tactics for their treatment. Intrathecal opioid analgesia has been used in clinic practice since 1979 and has gained a great popularity till now due to its high analgesic potency. The case of treatment of pharmacoresistant neuropathic pain syndrome of central origin in a patient who had spinal injury and stabilizing spinal surgery is presented. Conservative therapy for 3 years was considered to be ineffective and the patient was implanted with an intrathecal port for long-term opioid therapy. The follow-up period was 6 months. The effect of the procedure allowed the patient to abandon the massive drug therapy, as well as significantly improve the quality of life.

Pain Management With Intrathecal Clonidine In Colon Cancer Patient With Opioid Hyperalgesia: Case Presentation

Hyperalgesia is normally an increase in the response to a painful stimulant. Opioid-induced hyperalgesia (OIH) is a situation frequently encountered in algology clinics. Its treatment is complicated and problematic and often requires alternative methods. A 40-year-old male patient 45 kg weighing had been diagnosed with stage IV colon cancer 2.5 years ago. He had used non-steroid antiinflammatory drugs, opioid analgesics and steroid preparations casually for his increased pain without any monitoring for one year. He was admitted five times for pain control. In the last visit, he complained of severe abdominal, pubic and rectal pain (visual analogue scale [VAS] 8), which was unresponsive to epidural analgesic, and later presented to the algology clinic; he was sleep-deprived, restless and in a panic state. Intrathecal morphine (1 mg) was applied considering his opioid tolerance. Because of increased pain (VAS 8-9) one hour after surgery for abscess in the liver and peritonea, the patient was given intravenous dexketoprofen trometamol and diazem considering his OIH. Then, bolus dexmedetomidine (1 µg/kg) followed by dexmedetomidine infusion (0.2 µg/kg/h) was started. Three days later, diagnostic intrathecal clonidine (30 µg) was applied, and the patient's complaints regressed. With the patient reporting relaxed pain (VAS 1-2) after 30 minutes, an intrathecal port was placed. Both cancer pain and OIH were controlled with clonidine 90 µg/day. He was more relaxed, and his pain was tolerable until his death. Intrathecal clonidine administration may be an effective method for the treatment of OIH.

Coagulase-Negative Staphylococcal Meningitis in Adults: Clinical Characteristics and Therapeutic Outcomes

We wanted to analyze the clinical characteristics and therapeutic outcomes of adult meningitis caused by coagulase-negative staphylococci (CoNS). Over a period of 5 years (January 1999 to December 2003), 127 cases were identified as having adult culture-proven bacterial meningitis caused by a single pathogen. Of them, 14 cases with CoNS meningitis were enrolled, and their clinical characteristics and therapeutic outcomes were analyzed. The 14 cases (median age 37.5; range 24-77 years old) included nine men and five women. With polynerase chain reaction sequencing of bacterial 16S r-RNA, 10 of the 14 CoNS strains were identified as Staphylococcus epidermidis infection, and the other four belonged to Staphylococcus haemolyticus. All 14 cases were in a postneurosurgical state with insertion of a ventriculoperitoneal shunt, external ventricular device or intrathecal port A as their underlying conditions, and 12 of the 14 patients contracted the infection nosocomially. Fever (86%), leukocytosis (79%), hydrocephalus (50%), consciousness disturbance (36%), and seizure (7%) were the major clinical manifestations. All the involved CoNS strains showed resistance to oxacillin but retained their susceptibility to vancomycin and linezolid. All 14 CoNS strains had positive mecA gene detection. With the removal of neurosurgical devices and intravenous vancomycin therapy, 86% (12/14) of the patients survived. CoNS meningitis accounted for 11% (14/127) of our adult bacterial meningitis. All adult CoNS meningitis patients had a disrupted barrier of the central nervous system as the underlying condition. S. epidermidis was the most common CoNS subtype involved. All involved CoNS strains were oxacillin resistant. The therapeutic result showed that adult CoNS meningitis had a mortality rate of 14% (2/14).

Difficult management of pain following sacrococcygeal chordoma: 13 months of subarachnoid infusion

We report on a patient suffering severe pain following a long-standing sacral chordoma in whom management of therapy and pain was extremely difficult. Because orally administered morphine was observed to be ineffective in the early stages of treatment, we tried to achieve pain relief by using epidural morphine. This was also unsatisfactory. Intrathecal infusion of morphine and bupivacaine through a catheter inserted at the L2-L3 level was also found to be ineffective; only a segment block was observed. A structural anomaly of the spine was suspected and confirmed by myelography, showing metastasis at L3. Pain relief improved when an infusion of morphine + bupivacaine was employed through a catheter placed at the L4-L5 level below the blockage. A major problem which continued throughout the course of the disease was the daily occurrence of episodes of unbearable sharp pain that required addition of midazolam to the local anesthetic/opioid subarachnoid infusion. The patient received this mixture through an intrathecal port during the last 13 months of life, a gradually increasing dose being necessary. Periods of analgesia were followed by occasional crises of intense sharp pain suggesting incomplete relief. No serious complications or meningitis occurred. This case emphasizes the difficulty in managing pain in this type of cancer.