pain management: pain pumps

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  • 1. A Patients Guide to Pain Management: Pain Pumps Spine University 228 West Main, Suite C Missoula, MT 59802 Phone: info@spineuniversity.com Compliments of: Spine University

2. DISCLAIMER: The information in this booklet is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases,physical conditions, ailments or treatments. The information should NOT be used in place of a visit with your health care provider, nor should you disregardA Patient's Guide to Pain Management: Pain Pumpsthe advice of your health care provider because of any information you read in this booklet.Spine UniversitySpine University228 West Main, Suite CMissoula, MT 59802Phone:info@spineuniversity.comhttp://www.spineuniversity.com All materials within these pages are the sole property of Medical Multimedia Group, LLC and are used herein by permission. eOrthopod is a registered trademark of Medical Multimedia Group, LLC.2Compliments of: Spine University 3. A Patient's Guide to Pain Management: Pain Pumps Introduction thin, delicate membrane called the pia mater. Pain pump delivery of opiate drugs isThe second membrane layer surrounding the a rather new option available to persons spinal cord is called the arachnoid mater. with cancer and non-cancer pain. It is alsoThe outermost covering of the spinal cord is called an intraspinal (within the spine) called the dura mater and is somewhat tough. intrathecal (within the spinal canal) pump.The fluid filled space between your spinal It was first used in 1979 after the discoverycord and the arachnoid mater is called the of opiate receptors in the spinal cord. Thesubarachnoid or intrathecal space. This is use of an implant device to deliver medi-where the pain pump delivers medication. It cations directly in the area of the spinal is then mixed with the cerebral spinal fluid. cord was first used in 1981 for cancer pain. Since then, the pain pump has been used for chronic non-cancer pain such as failed low back surgery syndrome and spasticity from neurological conditions like multiple sclerosis, spinal cord injury, and cerebral palsy. This guide will help you understand what parts of the spine are involved what is the surgeon trying to achieve what the pain pump looks like how a pain pump is implanted what the risks and benefits areCerebral spinal fluid is a clear liquid that Anatomybathes and cushions the spinal cord and brain.If the cerebral spinal fluid leaks out of this What parts of the spine are involved?space, it can cause a headache of variable The spinal cord is a nerve tube that is housed severity. within the bony spine. It is covered by a 3 Compliments of: Spine University 4. A Patient's Guide to Pain Management: Pain PumpsRationaleTalk to your surgeon about all medicationsyou are taking before the procedure is sched- What does my surgeon hope to achieve?uled. The pain pump was first used in 1979 afterFollow your surgeon's pre-op instructions, the discovery of opiate receptors in the spinalthey may include the following cord. Opiate receptors are the connections on the nerve cells where medications such as Do not eat or drink for at least six hours morphine actually connect to the cell. These before the procedure. You will be able to take receptors are necessary for the medication toyour usual medication with a small amount of create the signals to the cell to reduce pain. water. If you have diabetes, do not take your Prior to 1979, no one believed that pain medi- insulin or diabetic pills until after the proce- cations worked on the nerves of the spinal dure. cord. We now know that much of the pain You will need a driver to return home. control achieved by medications such as morphine occurs in the spinal cord nerves. It Do not take any aspirin or aspirin- makes sense that we should try to deliver thecontaining medication at least eleven days medications directly to the receptors so the before the procedure. They may prolong medication(s) has the greatest effect. bleeding. Wear loose fitting clothing that is easy totake off and put on. Take a shower the morning of the proce-dure, using a bactericidal soap to reducechances of infection. Do not wear jewelry.Surgical ProcedureWhat happens during the operation? The other great benefit of the pain pump isBefore we discuss the surgery, lets look at the that less medication is required to get thepain pump itself. same effect. When you take pain pills, the medication must travel through your blood- stream in the same concentration throughout your body. This causes side effects when the medication affects different organs systems, such as the bowels, kidneys, and liver. By placing the medication directly into the spinal canal, there is less medication in the blood- stream. Less medication in the bloodstream means fewer unwanted side effects. Preparation How should I prepare for surgery?f4 Compliments of: Spine University 5. A Patient's Guide to Pain Management: Pain PumpsPain Pump You are presently taking oral pain medica-tion and are having significant side effects The pain pump is a round metal device that your surgeon places just under the skin of You benefited from a trial of epidural anes- your abdomen. It is about the size of a hockey thesia puck. Inside the device there is a space calledOnce it is decided that you are a candidate for a reservoir. This holds the medication(s).an intrathecal pump, you will have a trial with Attached to the pump is a catheter or smallmedication delivery to the intrathecal space. plastic tube. The catheter is surgically placedUsually this involves placing a catheter near the spinal cord in the intrathecal space.(small plastic tubing) into the intrathecal The tubing is what delivers the medicationspace. It is then connected to an external stored in the pump to the spine.pump. The trial lasts for two to three days. The pump is programmed to dispense the Sometimes a trial will consist of just a single medication at a certain rate throughout theor multiple injection of medication placed in day. The pump stores the information. It can the intrathecal space by a lumbar puncture. be adjusted when needed. When the pumpA 50 percent or greater improvement in pain needs to be refilled with medication, a doctor(or spasticity) and function would suggest or nurse inserts a needle into the top of thethat the implanted device is reasonable to pump through your skin. The medication isconsider. The doctor then knows best where then refilled through the needle.to place the tip of the catheter and what Chronic non-cancer pain can be complicated medication(s) is effective. by physical, psychological, and behavioralIf during this trial period the medication is factors. Candidates for intrathecal pumpnot tolerated or does not provide relief, the undergo evaluation for untreated addiction,implantable device is not considered. The psychological problems, and evaluation forimplanted pump is not necessarily permanent medical contraindications such as risk foras it can be removed at any time. infection.The Procedure Criteria used to determine whether or not you are a good candidate for placement of aWhat happens during the procedure? pain pump include but are not limited to theAnesthesiologists, neurosurgeons, and other followingdoctors who specialize in spine disorders You have tried multiple conservative thera-implant the pump. Surgery is performed as an pies such as physical therapy, chiropractic, outpatient. It is a two-part process and usually massage, relaxation, acupuncture and spinaltakes three to four hours. You will have anes- injections and they have failed to provide thesia during the procedure. Most patients significant benefitare discharged to home the same day as theprocedure. You are not a candidate for surgeryThe catheter or small plastic tubing is inserted You do not have psychological or addictioninto the intrathecal space through a small problemsincision near the spine and secured there. You have no medical conditions that wouldCareful placement of the catheter is important be considered a complication as the medication is only beneficial if placedin the area surrounding the spinal cord, 5 Compliments of: Spine University 6. A Patient's Guide to Pain Management: Pain Pumpsthe intrathecal space. Once the catheter is in There is a significant amount of research and place, an extension catheter is threaded under clinical experience using these medications. the skin around to your abdomen where theOther medications that can be administered pump will be implanted.by the pain pump include bupivacaine and Next your surgeon makes a four to six inch clonidine. Sometimes one of these medica- incision in the side of your abdomen, belowtions is used in combination with an opiate. the waistline. The pump is then insertedBaclofen is another medication this is safe to between the skin and muscle layers. Theuse in the intrathecal space and is helpful for catheter is then attached to the pump.the management of spasticity. Spasticity is Medication is then allowed to flow from thethe abnormal contraction of a muscle making device through the tubing.it somewhat rigid. This causes the muscle tohave difficulty relaxing. This also interfereswith normal movement. As a result, spasticitycan be painful.Other medications that have been studied foruse in a pain pump include fentanyl, metha-done, and ziconotide.Oral medications are more likely to cause sideeffects than intrathecal medications. Usuallythe amount of medication required is signifi-cantly less when delivered directly to thespinal cord. A reduction in side effects suchas sedation, nausea, and constipation shouldbe expected. However, limb numbness, Positioning of the catheter is checked withswelling of the lower legs, orthostatic hypo- fluoroscopy Fluoroscopy is an imaging tech- fluoroscopy.tension (sudden drop in blood pressure), and nique using a continuous X-ray beam that isdifficult