1. Technical Nuances of Surgical Implantation of Intrathecal Pain Pumps Susan Garruto MSN,CRNP,RNFA Thomas Jefferson University Hospital

2. Disclosure I have no affiliations to disclose

3. Objectives Identify patients who would benefit from intrathecal drug delivery Describe the technique used for catheter/pump implantation Explain the troubleshooting aspects of catheter/pump implantation

4. Applications for Intrathecal Pain Pumps Spasticity (baclofen) Multiple sclerosis Traumatic brain injury Cerebral Palsy Cord injury Paraparasis Stroke Chronic pain (morphine, prialt) Nociceptive pain

5. Upper Spasticity Patterns

6. Lower Spasticity Patterns

7. Spasticity Trial Single bolus injection (50 mcg) Check effect over 8 hours >8 hour- start with ½ dose <8 hour- start with 2X dose No effect- increase bolus for trial Baclofen (Lioresal)- concentration for direct delivery is much more effective than oral baclofen.

8. Pain Pump Trial Morphine Single bolus- will indicate adverse effects Indwelling catheter to increase morphine dose to gain starting point for dosage in permanent pump.

9. Patient selection Diagnostic Work Up MRI CT Plain X-rays Labs, INR, PTT

10. Pre-op Pump size: 40 cc vs. 20 cc Drug of choice: Lioresal, other Chlorahexadine shower & wipes Revision- always have representative interrogate before surgery.

11. Pre-op Confirm pump size/ drug amount Confirm plan for admission-including rehabilitation unit Often involves caregiver Introduce representative

12. Intra-op Operating Room Pre-operative antibiotics Patient positioned in full lateral decubitus- may have to be creative! Gel pressure points Prep and drape back and abdomen simultaneously.

15. Intra-op Operating Room Local anesthesia Minimal incision- don’t let the incision sacrifice accuracy or angle of reach. Need room to secure catheter. Para-spinal lumbar puncture (L2-3-4) to prevent shearing of the catheter Brisk flow of CSF C-arm fluoroscopy to check catheter placement

16. Implantation Catheter is placed intrathecally (usually L3 or L4) and tunneled subcutaneously to the pump. Tip placement at the T10- T11 level Acute hospital length of stay is 3-5 days

17. Posterior lumbar Anchoring the catheter 2 pursestring sutures- with Touhy needle in place 2 butterfly anchors- anchor butterfly to catheter, anchor butterfly to fascia Need to have fascial tissue, not fat Protect catheter at all times (new catheter is not as delicate) Allow for strain relief loop

18. Abdomen Placement in RLQ or LLQ-patient preference Below the waistline 2.5 cm beneath the skin Sub-fascial –extremely thin patients Trim catheter- hand off excess to be measured Check for CSF flow after tunneling 2 sutures to anchor pump Catheter lies posterior to the pump Access pump to confirm CSF flow before closing incision. Copious antibiotic irrigation, anterior & posterior

19. Intra-op Operating Room Interrogate system before closure Meticulous closure Antibiotic ointment Tegaderm dressing Abdominal binder to prevent migration of generator Flat for 12 hours

20. Post-op Pain medications Antibiotics for 24 hours Bathing instructions Wound care instructions Watch for complications- lack of drug delivery, infection

21. Thomas Jefferson University Philadelphia, PA – USA

22. Short video