Intrathecal catheter tip granuloma

FACTS

  • an uncommon complication of intrathecal therapy with high dose morphine / dilaudid (esp. 20-25 mg/mL and above)
  • pathophysiology: high local opioid concentrations activate mast cells → pro-inflammatory cytokines → granulomatous inflammatory mass
  • Non-opioid intrathecal drugs (e.g., baclofen, ziconotide, clonidine) rarely contribute to granulomas. Fentanyl also diffuses much more quickly so less likely to trigger this reaction.

    HPI

    universal ROS
    • worsening pain despite escalating doses
    • neuro deficits

    PHYSICAL EXAM

    universal spine exam
    • evaluate wound

    IMAGING

    MRI with and without contrast will show the enhancing granuloma best.
    A/P
    • mild symptoms: cessation of therapy
    • severe symptoms: immediate removal