Re: in DC

[Guest guest]

,

While I don't know about a PCA pump for you, you might inquire about

an implant. They can put a pump in that can continously deliever

morphine and you have to do nothing except get the pump in....see

this site: Hope this helps.

Peggy/MI

http://www.mayfieldclinic.com/PE-PUMP.htm

Overview

Intrathecal drug delivery, or " pain pump, " is a method of giving

medication directly to your spinal cord. The system uses a small pump

that is surgically placed under the skin of your abdomen and delivers

medication (morphine or baclofen) through a catheter directly to the

area around your spinal cord. Similar to an epidural that women may

have during childbirth, this pain management option may be used if

all other traditional methods have failed to relieve your long-term

symptoms. Because the medication is delivered directly to the spinal

cord, your symptoms can be controlled with a much smaller dose than

is needed with oral medication.

This pump can help lessen chronic pain caused by:

Failed back surgery syndrome: failure of one or more surgeries to

control persistent leg pain (sciatica), but not technical failure of

the original procedure.

Cancer pain: constant pain caused by tumors compressing the spinal

nerves, or scarring from previous radiation therapy.

Reflex sympathetic dystrophy: a progressive disease of the nervous

system in which patients feel constant chronic burning pain

Causalgia: a burning pain caused by peripherial nerve injury.

Arachnoiditis: painful inflammation and scarring of the meninges

(protective layers) of the spinal nerves.

Chronic pancreatitis: chronic abdominal pain caused by inflammation

or blockage of the pancreatic duct.

This pump can help lessen spasticity (muscle rigidity and spasms that

make movement of the arms and legs difficult) caused by:

Cerebral palsy: a nervous system disorder that impairs control of

body movement

Multiple sclerosis: a disorder of the brain and spinal cord caused by

damage to the outer layer (myelin) of nerve cells

Stroke: damage to the brain from lack of oxygen; due to an

interruption of the blood supply

Brain injury

Spinal cord injury

What is an intrathecal drug pump?

The fluid filled space around your spinal cord is called the

subarachnoid or intrathecal space. Cerebrospinal fluid (CSF) flows

through this area, bathing and protecting your brain and spinal cord.

Intrathecal drug delivery works much more efficiently than oral

medication because it delivers medicine directly into the CSF,

bypassing the path that oral medication takes through your body. In

fact, you generally need about 1/300 the amount of medication

(morphine or baclofen) than when taking it orally. This therapy is

completely reversible if you should ever decide to have the pump

removed.

The pump system

The pump is a round metal device about the size of a hockey puck that

is surgically implanted just beneath the skin of your abdomen. A

catheter, or small plastic tube attached to the pump is also

surgically placed and delivers pain medication directly into the

intrathecal space (Fig. 1).

A space inside the pump called the reservoir holds the medication.

When the reservoir is empty, the doctor or nurse refills the pump by

inserting a needle through your skin and into the fill port on top of

the reservoir.

Your doctor uses an external computer-like device to program the pump

to slowly release the medication over a period of time. The pump also

can be programmed to release different amounts of medication at

different times of the day, depending on your changing needs. The

pump stores the information about your prescription in its memory,

and your doctor can easily review this information with the

programmer.

Am I a candidate?

You may be a candidate for intrathecal drug delivery if you meet the

following criteria:

Conservative therapies have failed

You would not benefit from additional surgery

You are dependent on pain medication

You do not have psychological problems

You have no medical conditions that would keep you from undergoing

implantation

You are not allergic to any of the drugs used in the pump

You have had positive response with a trial dose of medication

Who performs the procedure?

Neurosurgeons and doctors who specialize in pain management and spine

disorders implant pain pumps.

The procedure is performed in two stages: Stage 1 is a trial and

Stage 2 is implantation of the permanent device.

Stage 1. Trial

Before you can have surgery, you must undergo a " trial run " to see if

the device decreases your level of pain. Depending on your particular

condition, one of the following screening tests will be necessary.

Single injection: you will receive one injection of intrathecal

medicine (morphine or baclofen) via a lumbar puncture.

Multiple injections: you are given multiple injections over a series

of days by either a lumbar puncture or catheter.

Continuous trial: a catheter is placed in the correct area of your

spine and connected to an external pump. The dose is increased every

2 hours until you notice pain relief.

Stage 2. Permanent implantation

During the trial, your doctor gathered information about the best

location for the catheter and the type of drug that works best for

you.

What happens before surgery?

You may be scheduled for presurgical tests (e.g., blood test,

electrocardiogram, chest X-ray) several days before surgery. In the

doctors office you will fill out paperwork and sign consent forms.

Patients are admitted to the hospital the morning of the procedure.

No food or drink is permitted past midnight the night before surgery.

An intravenous (IV) line is started in your arm. An anesthesiologist

will explain the effects of anesthesia and its risks.

What happens during surgery?

There are two parts to the procedure: 1) placement of the catheter in

the intrathecal space of the spinal cord, and 2) placement of the

pump/reservoir in the abdomen. There are five main steps of the

procedure. The operation generally takes 3 to 4 hours.

Step 1. Prepare the patient

You are placed on the operative table and given anesthesia. Once

asleep, your body is rolled onto its side. Next, the areas of your

back and stomach are shaved and prepped where the catheter and the

pump are to be placed.

Step 2. Placement of the leads

A small skin incision is made in the middle of your back. The bony

arch (lamina) of the vertebra is exposed. The catheter is placed in

the subarachnoid, or intrathecal space, above the spinal cord and

secured in place with sutures (Fig. 2).

Step 3. Tunneling of the extension

Once the catheter is in place, an extension catheter is passed under

the skin from the spine, around your torso to the abdomen where the

pump will be implanted.

Step 4. Placement of the pump

A 4-6 inch skin incision is made in the side of your abdomen below

the waistline. The surgeon creates a pocket for the pump between the

skin and muscle layers. The extension catheter is attached to the

pump. Next, the pump is correctly positioned under the skin and

sutured to the thick fascial layer overlying the stomach muscles.

Step 5. Test stimulate

You will be awakened so that the permanent generator and the

placement of the leads can be tested. You must be able to tell the

surgeon if the tingling sensation is the same as during the trial

stimulation.

Step 6. Close the incisions

The incisions in your back and abdomen are closed with sutures or

staples and a dressing is applied.

What happens after surgery?

You will wake up in the postoperative recovery area, called the PACU.

Your blood pressure, heart rate, and respiration will be monitored,

and your pain will be addressed. Most patients are discharged home

the same day. You will be given written instructions to follow when

you go home.

Discharge instructions

Discomfort

1. Right after surgery, pain is managed with narcotic medications.

Because narcotic pain pills are addictive, they are used for a

limited period (2 to 4 weeks). Also, their regular use may cause

constipation, so drink lots of water and eat high fiber foods.

Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) may be bought

without a prescription. Thereafter, pain is managed with

acetaminophen (e.g., Tylenol).

2. Ask your surgeon before taking nonsteroidal anti-inflammatory

drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin;

naproxen sodium, Aleve). NSAIDs may cause bleeding and interfere with

bone healing.

3. Spinal headaches are caused by leakage of cerebrospinal fluid

around the catheter or lead site. Lie flat and drink plenty of

caffeinated non-carbonated fluids (e.g., tea, coffee).

Restrictions

4. Avoid these activities for 6 to 8 weeks to prevent movement of the

catheter/leads:

-do not bend, twist, stretch, or lift objects over 5 pounds

-do not raise arms above your head

-do not sleep on your stomach

-do not climb too many stairs or sit for long periods of time

5. Do not drive for 2 to 4 weeks after surgery or until discussed

with your surgeon.

6. Housework and yard-work are not permitted until the first follow-

up office visit. This includes gardening, mowing, vacuuming, ironing,

and loading/unloading the dishwasher, washer, or dryer.

7. Postpone sexual activity until your follow-up appointment unless

your surgeon specifies otherwise.

Activity

8. Gradually return to your normal activities. Walking is encouraged;

start with a short distance during the 1st two weeks and then

gradually increase to 1 to 2 miles daily. A physical therapy program

may be recommended.

Bathing/Incision Care

9. You may shower as directed by your surgeon. Do not take a tub bath

or submerge yourself in water for 4 weeks. Pat your incision dry with

a soft towel to avoid irritation.

10. Inspect the incision line twice daily.

11. Fluid may accumulate under the skin around the catheter/leads or

the device creating a visible swelling. Call the doctor if this

occurs. Seromas usually disappear by themselves but may require a

drain.

12. Steri-strips may cover the incision. After showering, gently pat

dry the steri-strips. Gently remove steri-strips after one week.

Sutures or staples that remain in place when you go home will need to

be removed. Ask your surgeon or contact the office to find out when.

13. Wear loose clothing over the incision site to maintain comfort

and prevent skin irritation.

When to Call Your Doctor

14. If your temperature exceeds 101 degrees F or if the incision

begins to separate or show signs of infection, such as redness,

swelling, pain, or drainage.

15. If your headache persists after 48 hours.

16. If you have sudden severe back pain, sudden onset of leg weakness

and spasm, loss of bladder and/or bowel function - this is an

emergency - go to a hospital and call your surgeon.

Refilling the pump

You must schedule medication refills on a regular basis with the

surgeon's office or a pain management specialist. At your refill

appointment, the effectiveness of your treatment will be assessed and

your pump will be adjusted accordingly. The goal is to find the

optimal amount of pain or spasticity control while having minimal

side effects. You should tell your doctor if you experience unusual

symptoms, drug overdose, or feel that your dosage is ineffective. You

may need to take supplemental oral medicine if you have periods of

stronger pain.

What are the results?

Most patients have a 50% reduction in pain as well as overall

improvement in functional abilities. Oral medications are reduced

because the medicine is delivered directly to the spinal cord and

much smaller dosages are needed. Remember this is not a cure for your

disease. Activities that affected your condition prior to the

implantation of this device will continue to do so.

What are the risks?

Side effects for intrathecal pain pumps are minimal, although they do

exist. As with all surgeries, complications may include infection and

bleeding. The catheter could move or become blocked, or the pump

could stop working (rare). Accumulation of fluid (cerebrospinal fluid

leak) can occur around the pump causing a clear watery discharge from

your incisions or a headache. These usually disappear on their own

but may require a drain.

Side effects from the drugs (overdose or underdose) may include

respiratory depression, twitching, muscle spasm, urinary retention,

constipation, nausea, vomiting, dizziness, anxiety, depression,

edema.

Depending on how much medication the pump delivers, the battery will

eventually need to be replaced every 5 to 7 years.

Living with an intrathecal pump

Just like a cardiac pacemaker, other devices such as cellular phones,

pagers, micro-waves, security doors, and anti theft sensors will not

affect your pump. Be sure to carry your Implanted Device

Identification card when flying, since the device is detected at

airport security gates.

If you hear the pump making beeping sounds, call the doctor's office

immediately. This may indicate that the pump needs refilled, battery

needs replaced, or other maintenance.

Withdrawal symptoms from the medication you are receiving may cause

you some discomfort or in extreme cases may require emergency

treatment. Inform family members and friends about what to do in an

emergency; always carry your Emergency Information and Procedure

cards with you at all times.

Reasons for removal of the device include infection, failure to

relieve pain, and patient misuse.