Surgical Complications

Infection risks are probably the most feared complication with the use of intraspinal opioids. Infection can occur at the pump insertion site, along the catheter track, and within the intrathecal space. The hardware must be placed under sterile technique according to manufacturer recommendations with the use of perioperative antibiotics and intraoperative antibiotic irrigation. After the initial pump filling before implantation, the first puncture to refill the pump should not be earlier than 10 days after implantation. While bacteri-ostatic filters are present in the pump and the catheter tubing, great care should be taken by trained practitioners to not introduce bacteria during subsequent refills. Meningitis, although rare, should be suspected in the presence of fever, headache, stiff neck, rigors, and photophobia. If an infection develops, normal skin flora, such as Staphylococcus aureus and S. epider-midis, are the most common offenders.

Excessive bleeding is another surgical complication. The procedure does not involve highly vascular areas, but the blind nature of the tunneling rod and catheter placement may prove problematic. Postsurgical formation of a small epidural hematoma can create a medium for bacterial growth; a large clot can compress the spinal cord or cauda equina. As mentioned above, if patients have bleeding disorders or are anticoagulated, these represent an absolute contraindication to pump placement.

Tissue damage resulting in neurological sequelae such as radiculitis, myelitis, paralysis, and incontinence may also occur [16]. Intrathecal granuloma formation at the catheter tip can present as intractable pain or weakness and have devastating effects [21]. Cerebrospinal fluid leakage and the formation of CSF hygromas is also possible.

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