Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia 22908, USA.
J Neurosurg Spine. 2010 Jan;12(1):66-71. doi: 10.3171/2009.7.SPINE08888.
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.
自 20 世纪 80 年代以来，已有超过 95000 个脊髓药物输送装置被植入，因此认识相关的不良反应至关重要。自 1985 年以来，已有许多报道描述了导管尖端肉芽肿的存在。在当前病例中，作者描述了硬膜外布比卡因沉淀较少见的并发症。无论其来源如何，这些不常见的病变已被越来越多地认为是鞘内输注的一种罕见但潜在破坏性的并发症。一名 34 岁女性因胸出口综合征而接受芬太尼、布比卡因和可乐定的鞘内疼痛泵治疗，出现进行性神经功能缺损和颈部及上肢疼痛加剧。神经影像学显示 C7-T1 肿块，被认为是最近硬膜外类固醇注射后发生的血肿。在紧急行椎板切除术减压后，发现一个粉笔状的肿块，其中含有粘性液体，环绕着硬膜外定位的导管。组织病理学检查显示了一种蛋白性肿块，与包裹在纤维化和轻度炎症中的药物沉淀一致。术后，患者的神经功能缺损最小。本文结合相关文献复习，讨论了其临床表现和临床意义。导管尖端肿块是植入式药物输送装置的罕见并发症，在所有鞘内导管患者中<3%发生。无论解剖部位如何，最常见的表现是神经功能缺损、疼痛加剧和对疼痛药物的需求增加。对于治疗脊髓输注装置患者的医生来说，及时诊断和治疗至关重要，以防止发生严重的神经后遗症。需要进一步研究布比卡因在永久性脊髓输注系统中的辅助作用。
