Intrathecal Pain Pump Implant: What to Expect

An intrathecal pain pump is a small medical device, that delivers medications directly to the spinal cord, into the intrathecal space. Medications placed here, have a stronger and faster pain relief effect than medications taken in pill form.

A pain management specialist places the pain pump under the skin of your abdomen, right above the belt area. Other people can’t see it, even if you’re wearing a swimsuit. The pump is connected to a small tube (catheter) that drips medications directly around your spinal cord.

The spinal cord is the “mecca” of pain sensations. Just like the brain, the spinal cord is very important in receiving pain signals from the rest of the body. It has many receptors (sensors), that can shut off the pain. Among these are the opioid receptors. Opioids are commonly used in pain pumps, sometimes in combination with other medications. When delivered through a pain pump, opioids have fewer systemic (body-wide) side effects. A pain pump is a great way to control long-lasting pain that has failed to improve with other treatments or with surgery.

Who benefits from having a pump?

Pain pumps, also known as implantable drug delivery systems, are often the last resort treatment for cancer pain and other chronic pain conditions. They are also used to relieve chronic muscle spasms in people with certain neurologic illnesses.

A pump is recommended for people with:

• Cancer – pain starts from cancer spreading to the bones or from nerve damage and scar formation after surgeries that remove tumors.
• Failed back surgery syndrome (FBSS) – long-lasting pain after one or more surgeries that failed to control your back pain or shooting leg pain.
• Complex regional pain syndrome (CRPS) and Causalgia – long-standing burning pain in an arm or leg. If untreated, this condition can spread to the underlying joints or even to the other side of the body. With CRPS, the trigger is not always clear but it may be an injury, such as a fracture. With causalgia, there is a known and direct injury to a nerve.
• Arachnoiditis – a painful inflammation and scarring in the protective layers of the spinal cord or brain.
• Chronic pancreatitis – long-lasting abdomen pain due to the pancreas becoming inflamed or from a blockage of its duct.
• Body-wide muscle spasms – are due to illnesses like multiple sclerosis and cerebral palsy or injuries to the spinal cord and brain.

Advantages of having a pain pump

Receiving medications through a pain pump, instead of taking them in pill form, has several advantages:

1. Only a small amount of medication is needed. Even a small concentration (1/300th of the same medication in pill form) can relieve your pain. Medications taken in pill form, require a much higher dose since they flow through the whole body before reaching the spinal cord. Thus, medications (like opioids) are needed in higher doses when taken as pills, and are likely to cause side effects, tolerance, and addiction.
2. Few side effects. Giving medications, like opioids, through a pain pump gives superior pain relief and reduces side effects (nausea, constipation, drowsiness).
3. Reduced addiction risk to opioids. A pain pump gives pain medications directly to the spinal cord, the place where medications take effect. Therefore, only small doses of opioids are needed and the chance for addiction is considerably lowered. Pumps are an excellent option for people whose pain is severe and who are intolerant to opioid pills.
4. No need to remember when to take your medications. The pump is programmed to release medications slowly and constantly. It can also give extra medication at those times of the day when you expect to have more pain. The pump stores information about your medication dose and prescription in its memory. There’s no need to refill prescriptions every month since your doctor’s office will refill your pump every 3-6 months.

Is a pain pump the right choice for me?

Your doctor may recommend a pain pump if you meet some of these criteria:

• You’ve failed conservative therapies like oral pain medication, physical therapy, and pain-relief injections such as nerve blocks and epidurals.
• You are dependent on pain medication and are starting to have strong side effects or addiction.
• A past surgery did not solve your pain problem and additional surgery is not likely to help.

You are not a candidate for a pain pump if:

• Psychological problems prevent you from understanding how to use the pump (dementia, psychosis).
• There is an infection that can spread to the pump. Examples include widespread body infections and spinal infections, such as meningitis.
• You are allergic to the medications in the pump, for example, Morphine. However, if you are allergic to one medication, your doctor can usually use a different one.
• Cancer has spread to the spine and is blocking the spinal space.

What medicine goes in the pump?

Usually, your pump delivers different types of medications. They can sometimes be used together to enhance each other, in order to give you superior pain relief. Based on your response during a one week trial, your doctor will decide what works best for you.

Medications used in your pump include:

• Opioids – Morphine and Hydromorphone (Dilaudid) are often used.
• Local anesthetics (i.e. Bupivacaine) – This medicine blocks pain signals in the spinal cord. It is often combined with morphine in order to treat neuropathic pain (a type of pain caused by damage to the nervous system).
• Clonidine – This medicine can also lower blood pressure and also relieves pain.
• Baclofen – This is a safe and effective drug that lowers muscle spasms.
• Ziconotide – This is a strong medication, extracted from snails, that blocks pain signals in the spinal cord.

The trial

Pain management doctors specialize in implanting pain pumps. Before implanting a pump, your doctor will first do a trial.

During the trial you will receive a single shot of medication in your back, in the space that surrounds your spinal cord. This is a quick procedure, done in the doctor’s office. It is not very painful – it merely feels like a flu shot. You go home the same day.

The trial allows your doctor to find the best type of drug for your pain. If your pain decreases by at least 50%, the trial is successful and you are then scheduled for a pump implant.

The pump implant

The pump implant procedure usually takes 30 minutes to an hour. You are under general anesthesia, so you are completely comfortable and unaware of the procedure. You go home the same day.

There are three main steps:

1. A catheter (thin tube that delivers medication) is placed in your back (spinal space).
2. The pump (reservoir that holds and delivers medicine) is placed under the skin of your abdomen, below the waistline. This placement is comfortable for you and unlikely to show through your clothes.
3. Medication flow is started once the catheter is connected to the pump.

What to expect after the pump implant

• While recovering from the implant, you can take oral pain medicine as directed by your doctor. Opioids may be used, for a limited time only, until the pump medication starts to work.
• For the next six weeks, you will need to avoid physical effort such as bending, lifting, twisting, or reaching overhead. This prevents the catheter from slipping out of place, while you are healing.
• The degree of pain relief depends on your underlying pain condition and its severity. Most patients feel a reduction in pain and are able to increase their activity level.

What are the risks?

• During pump implant – infection and bleeding, a temporary leak of (CSF) fluid from your spinal space that may result in a headache.
• After implant – catheter blockage, pump malfunction leading to medication withdrawal, a failure to relieve pain, patient misuse.
• Drug side effects – difficulty breathing with opioid overdose, muscle spasm, difficulty with urination, constipation, nausea, dizziness, swelling.

What to expect once you have a pump

• Your doctor will work closely with you to get the medication dose just right.
• You will learn how to use the optional remote control, that allows you to get extra pain relief medicine, as needed.
• There are follow-up visits every 3-5 months, so your doctor’s office can refill your pump medications.
• Magnetic resonance imaging (MRI) scans are allowed, while you have a pump.
• A majority of patients prefer to have a pump for the rest of their life. However, a pump can be removed if your painful condition improves to the point you no longer need treatment.