In the perioperative period, bleeding with the subsequent development of a pocket hematoma is perhaps the most troublesome and preventable problem. Meticulous attention to hemostasis during pump pocket formation will avoid this problem. An additional aid in prevention is the placement of an abdominal binder, such as a 6 in. Ace wrap, around the abdomen and lightly compressing the fresh pump pocket for 24 to 48 hours. This compression dressing helps to avoid the accumulation of blood or fluid in the pocket.
The possibility of epidural and intrathecal hemorrhage is frequently mentioned, with the obvious risk of neurological injury. This complication, unfortunately, tends to occur at the time of catheter implant. Pre-operatively, care should be taken to discontinue nonsteroidal anti-inflammatory drugs and reverse any anticoagulation. Signs of a developing hematoma are usually a sudden increase in focal back pain associated with tenderness, progressing numbness and/or weakness in the lower extremities, and loss of bowel or bladder control (in the form of retention/constipation or incontinence). This clinical presentation warrants immediate imaging with MRI or CT/myelogram and emergent neurosurgical intervention if there is neurological deterioration.
With implantable devices, one of the most feared complications is wound infection. The use of prophylactic antibiotics has been controversial, but a consensus seems to have developed around the practice of using some preoperative antibiosis. One method is to use a cephalosporin intravenously an hour prior to surgery without subsequent antibiosis. Some clinics use daily prophylaxis while an externalized screening electrode trial is under way. Intraoperatively, antibiotic irrigation may be used. Attention on the part of surgical personnel to handle all sterile parts with care, avoiding unnecessary contact with any, even prepped, skin may reduce contamination.
While not all wound infections require removal of the device, general experience with foreign bodies implanted in the body (e.g., CSF shunts, spinal instrumentation, prosthetic devices) indicates that all but superficial infections will require system removal. Implantable pumps contain an internal filter that guards against direct contamination resulting in meningitis. However, with infection tracking along the in-trathecal catheter, either an epidural abscess or meningitis may result.
Neurological injury is a definite possibility whenever the CSF space is entered. Needle placement, even when guided fluoroscopically, is essentially blind with respect to intraspinal neural structures. Potential injury to the nerve roots can to some extent be mitigated by performing the catheter placement under local anesthesia. The patient under local anesthesia will, in the case of nerve root injury, report a radiating electric shock-like or burning sensation in the distribution of the involved nerve root. The needle should be immediately withdrawn and placement at a different level considered. With catheter placement, the spinal cord becomes at risk. Catheters that are spring wound or have internal stiffening wires must not be forced through the spinal canal because the tip could become buried in an intramedullary position. Often penetration of the spinal cord results in the production of dysesthesias and a burning or stinging pain below a nondermatomal lesion; this may not result in noticeable neurological signs immediately. Intramedullary infusion of drug may result in the progressive signs of a spinal cord lesion and should be immediately evaluated as such with MRI scanning or CT/myelography and appropriately dealt with by the neurosurgeon.
Cerebrospinal fluid leaks are a natural consequence of placing catheters in the subarachnoid space. The opening created in the dura mater by the introducing needle will be larger than the entering catheter, creating a predisposition to some potential leakage. The dura mater has a moderate amount of elasticity, and this property probably accounts for why the incidence of leaks is not higher. If the particular technique used seems to result in a relatively high incidence of spinal headache or CSF collection under the skin, a blood patch injecting 10 to 20 mL of autologous venous blood one level above the catheter entry point or at the entry point under fluoroscopic control may prevent CSF leakage.
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