Pain pump, Intrathecal drug pump
A pain pump, also known as intrathecal drug pump is a method of administering medication directly to the spinal cord to provide relief from chronic pain.
Taking oral pain medications may not provide quick and effective pain relief, particularly with chronic pain but by using an intrathecal pain pump, pain medications are delivered directly to the spinal cord for quick and effective pain relief.
Intrathecal pain pump involves surgically placing a small pain pump under the skin of your abdomen, just above the belt area. The pump is hidden so that it can’t be seen by other people. The pump is connected to a small tube known as catheter. The catheter is placed in the intrathecal space of the spine. Through the catheter, medications are delivered directly to the area around your spinal cord.
Because medications are delivered directly to the pain area, the medications have a stronger and faster pain relief effect than medications taken orally. Also, your symptoms can be controlled with a much smaller dose than when you take oral medications, thus reducing the side effects of oral medication.
Opioids are medications commonly used in intrathecal pain pumps. Opioids may sometimes be used in combination with other medications. Opioids have fewer systemic side effects when delivered through a pain pump than when taken orally.
A pain pump is a great way to provide quick and effective pain relief and also control chronic pain that has failed to improve with other conservative treatments or with surgery.
Intrathecal pain pumps: Indications and Patient selection
The intrathecal pain pump is programmed to slowly release medication to the spinal cord over a period of time. Depending on your changing needs, it can also be programmed to release different amounts of medication at different times of the day. The pump stores the information about your prescription in its memory so that your doctor can easily review this information.
When the pump is empty, your doctor or a nurse can refill it by inserting a needle through your skin and into the fill port through which the medication is delivered into the pump.
The therapy is completely reversible. The pump can be removed if you ever decide to have it removed.
Patient’s selection for intrathecal pain pump
You may be a candidate for intrathecal pain pump if you meet the following criteria:
- You have chronic pain that conservative treatments and therapies have failed to improve
- You depend on oral pain medications
- You are not a candidate for additional surgery
- You don’t have psychological problems
- You don’t have medical conditions that would prevent you from undergoing implantation
- You are not allergic to any of the medications used in the intrathecal pain pump
- You have had positive response with a trial therapy
Intrathecal pain pump is recommended for patients with:
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Cancer
Chronic pain that starts from cancer and spreads to the bones
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Post-surgical pain
Pain from nerve damage and scar formation after surgeries.
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Failed back surgery syndrome
Chronic pain after one or more surgeries that couldn’t improve your back pain.
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Complex regional pain syndrome
Chronic burning pain in an arm or leg that spread to the underlying joints or even to the other side of your body.
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Causalgia
A long-lasting burning pain caused by damage or injury to the peripheral nerve.
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Arachnoiditis
This is a painful inflammation and scarring in the protective layers of the spinal nerves
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Chronic pancreatitis
Chronic abdominal pain that is as a result of the pancreas becoming inflamed or from a blockage of the pancreatic duct.
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Body-wide muscle spasms
Illnesses such as multiple sclerosis and cerebral palsy or injuries to the spinal cord and brain can result in body-wide muscle spasms.
Types of pain pumps
There are two main types of pain pumps, which are;
1. Non-programmable/Fixed-rate pain pumps or mechanical pumps
This type of pain pump delivers a continuous amount of medication at a consistent flow rate. It is completely mechanical and works using a gas chamber. It doesn’t require a battery or electrical current to operate.
2. Programmable/Variable-rate pain pumps or battery-operated pumps
This type of pain pump is programmed so that the amount and timing of medication delivery can be adjusted to suit your needs. It can be adjusted as your medication schedule changes. It uses battery to operate. The battery needs to be replaced when it runs out.
Pain pumps pros and cons
Pain pumps have both advantages and disadvantages. Before you decide to have a pain pump, ensure that you are fully informed about the pros and cons of undergoing the procedure.
Pros or advantages of pain pumps
1. Only a small amount of medication is needed
Medications taken orally require a much higher dose because they go through the digestive system before reaching the spinal cord. Since some of the medications will be lost as they travel through the digestive system, a higher dose is required. But with pain pumps, even a small concentration of medication can relieve pain.
2. Medications work faster
Pain pump delivers medication directly to the pain area. Unlike oral medications that will need to travel through the digestive system before getting to the pain area, pain pumps work very fast. You will begin to feel pain relief almost immediately after the medication is delivered.
3. It is more effective
Pain pump provides better results than oral medications. While oral medications may sometimes not provide chronic pain relief, pain pumps most often provide pain relief. People with chronic pain that have not found relief from taking oral medications may be advised to have pain pumps.
4. Few side effects
Medications like opioids are needed in higher doses when taken orally and are likely to cause side effects such as nausea, tolerance, physical dependence, addiction, and so on. Also, opioids taken orally are usually used for a longer period of time, thereby increasing the chances of side effects. Medications delivered directly to the spinal cord with pain pump cause fewer side effects as smaller amount of medication is needed. Medication is usually delivered within a short time.
5. You don’t need to keep track of when to take your medications.
When your doctor prescribes oral opioids for you, dosage will be written along with it. You need to follow the dosage accordingly. But with pain pump, it is programmed to release medications slowly and constantly. The flow of medications may also be increased at the times of the day when you expect to have more pain. All these are done automatically because the pump stores information about your medication dosage and prescription in its memory.
Cons or disadvantages of pain pumps
1. Reactions to medications
Reactions to medications are the most common complication with pain pumps. Some people may have negative reactions when medications are delivered.
2. Problems with the catheter used
Due to the fact that the catheter from the pump enters the spinal canal, there are risks of spinal fluid leakages, infections, and bleeding. The area where the pump is placed, usually in the abdomen, can become very swollen, infected or painful.
3. Potential mechanical failures and complications
The catheter can kink, obstruct, dislodge, and disconnect from the pump. The pump can fail from battery failure or depletion, pump inversion, pump erosion or other technical issues.
4. Risk of certain medical issues
Pain pumps could cause spinal damage, development of a granuloma at the end of the catheter.
Pain pump surgery and recovery time
Before a permanent pain pump is implanted, you must first undergo a trial test so that your doctor can know if the therapy will be effective or reduce your pain.
Depending on your particular condition, one of the following trial tests may be conducted:
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Single injection
You will be given one injection of intrathecal medicine through a lumbar puncture.
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Multiple injections
You will be given multiple injections in few days by either a lumbar puncture or catheter.
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Continuous trial
A catheter will be placed in an area of your spine and connected to an external pump.
During the trial test, your doctor will gather information and ascertain your improvement levels. The best location for the catheter and the type and amount of medications that work best for you will also be ascertained.
If the trial test provides significant pain relief, you will be scheduled for permanent surgery.
During the surgery
There are two parts to the surgery. The first is the placement of the catheter in the intrathecal space that surrounds the spinal cord, and the second is the placement of the pump in the abdomen.
Procedure steps
Step 1: Prepare the patient
You will be taken to an operative room and placed on the operative table. You will be given anesthesia to make you fall asleep throughout the procedure. The areas of your back and stomach where the catheter and pump will be implanted are shaved and prepped.
Step 2: Placement of the catheter
Your surgeon will make a small incision in the middle of your back to expose the bony arch of the vertebra. The catheter will be placed in the subarachnoid, or intrathecal space, above the spinal cord. The catheter will be secured in place with sutures.
Step 3: Tunneling of the extension
Once the catheter is in place, an extension catheter will be passed under the skin from the spine. The extension catheter passes through your torso to the abdomen where the pump will be implanted.
Step 4: Placement of the pump
Your surgeon will make an incision in the side of your abdomen just below your waistline. A pocket for the pump will be created between the skin and muscle layers. The extension catheter will then be attached to the pump. The pump will be correctly positioned under the skin and secured in place with sutures.
Step 5: Closure of the incisions
The incisions made in your back and abdomen will be closed with sutures or staples. After the incisions are closed, the areas will be properly dressed to heal.
The whole procedure usually takes 3 to 4 hours.
Recovery time
After the surgery, your doctor may prescribe oral pain medicine to help with pain. Opioids may be used for a short time until the pump medication starts to work.
You will need to avoid physical activities such as bending, lifting heavy objects, twisting, or reaching overhead for the next 6 weeks. This prevents the catheter from slipping out of place until you heal. There are also certain specific directions that your doctor will give you to follow. Ensure you keep to those directives.
It usually takes 6–8 weeks for patients to fully recover after undergoing pain pump surgery.
Pain pump may not provide total pain relief but it can help reduce chronic pain so that you can go about your daily activities.
FAQs
What kind of medicine is in a pain pump?
There are usually different types of medications in pain pumps. Medications can sometimes be combined to provide superior pain relief. Medications that your surgeon will use usually depend on what works best during your trial test.
Medications used in pain pump include:
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Opioids
Opioids such as Morphine and Hydromorphone are often used.
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Local anesthetics
Local anesthetics such as Bupivacaine is often combined with morphine in order to treat neuropathic pain.
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Clonidine
Clonidine can lower blood pressure and also relieve pain.
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Baclofen
Baclofen is a safe and effective drug that can be used.
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Ziconotide
This is a strong medication that blocks pain signals in the spinal cord.
Do pain pumps really work?
Yes. Intrathecal pain pump works more efficiently than oral medication. This is because medications are delivered directly into the pain area for quicker and better pain relief.
How long does pain pump last?
You will continue to experience pain relief as long as the medications are delivered to the pain area. The medication in the pump or reservoir needs to be refilled every 6 weeks to 6 months. The frequency of refills depends on the amount of medications in the pump and the amount of medication you receive daily.
What are the side effects of a pain pump?
Side effects of pain pump include:
- Infection
- Bleeding
- The catheter could move out of place, get blocked, or malfunction
- The pump could stop working
- Accumulation of fluid can occur around the pump, resulting in headache
- Failure to relieve pain
Side effects from the drugs overdose may include:
- Nausea
- Vomiting
- Respiratory depression
- Twitching
- Muscle spasm
- Urinary retention
- Constipation
- Dizziness
- Anxiety
- Depression
- Edema
Can I drive with a pain pump?
Do not drive until your follow-up appointment or until you recover. During your recovery, you may ride in a car for short distances of 45 minutes or less. After recovery, you may be able to drive your car.
How does a pain pump make you feel?
A pain pump can help reduce your chronic pain and make you feel better. If you have very severe excruciating pain that has been ongoing even after taking series of oral pain medications or therapies, a pain pump may be your last resort in finding relief.
How much does a pain pump cost?
The total cost of pain pump procedure includes facility cost, anesthesia cost, surgeon fee, cost of medications used, and cost of pump refills. The total cost is the sum total of all these different specific costs and it varies.
What is a pain pump trial?
Before a permanent pain pump is implanted, you must first undergo a trial test so that your doctor can know if the therapy will be effective or reduce your pain.
Depending on your particular condition, one of the following trial tests may be conducted:
-
Single injection
You will be given one injection of intrathecal medicine through a lumbar puncture.
-
Multiple injections
You will be given multiple injections in few days by either a lumbar puncture or catheter.
-
Continuous trial
A catheter will be placed in an area of your spine and connected to an external pump.
During the trial test, your doctor will gather information and ascertain your improvement levels. The best location for the catheter, the type, and amount of medications that work best for you will also be ascertained.
If the trial test provides significant pain relief, permanent pain pump surgery will be conducted.
