As > 95,000 spinal
drug-delivery devices have been implanted since their inception in the 1980s, the recognition of associated adverse effects is essential. Since 1985, numerous reports have described the presence of
catheter-tip
granulomas. In the current case, the authors describe a less frequent complication of epidural
bupivacaine precipitation. Regardless of origin, these unusual lesions have been increasingly recognized as a rare but potentially devastating complication of intrathecal infusions. A 34-year-old woman with an intrathecal
pain-pump delivering
fentanyl,
bupivacaine, and
clonidine for
thoracic outlet syndrome presented with rapidly progressive neurological deficits and increasing neck and upper-extremity
pain. Neuroimaging disclosed a C7-T1 mass that was thought to be a
hematoma that occurred after a recent epidural
steroid injection. On emergency
surgical decompression by
laminectomy, a chalky mass containing viscous fluid was identified surrounding an epidurally located
catheter. Histopathological examination revealed a proteinaceous mass consistent with
drug precipitate enveloped by
fibrosis and mild
inflammation. Postoperatively, the patient recovered with minimal neurological deficit. The presentation and clinical relevance are discussed in conjunction with a review of the pertinent literature.
Catheter-tip masses are a rare complication of implantable
drug-delivery devices occurring in < 3% of all patients with intrathecal
catheters. Regardless of the anatomical site, the most common presenting features are neurological deficits, worsening
pain, and increasing requirements for
pain medication. Expedient diagnosis and management are essential for physicians treating patients with
spinal infusion devices to prevent significant neurological sequelae. Further investigation is warranted regarding the use of
bupivacaine as an adjunct in permanent
spinal infusion systems.