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Anesth Analg 2007;104:209
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000247680.39823.5a

LETTER TO THE EDITOR

Editor-in-Chief Steven L. Shafer

Intrathecal Catheter Granuloma with Baclofen Infusion

Samer N. Narouze, MD, MSc, and Nagy A. Mekhail, MD, PhD

Department of Pain Management, Cleveland Clinic Foundation, Cleveland, Ohio, narouzs{at}ccf.org

To the Editor:

Murphy et al. (1) reported a case regarding the development of an intrathecal catheter tip mass after intrathecal baclofen infusion. Others have suggested that granulomas do not occur with isolated intrathecal baclofen infusion (2). Before concluding that intrathecal baclofen infusion may lead to the development of such granulomas, we need to address a few questions.

First, the authors reported that the magnetic resonance image (MRI) showed the catheter tip was "occluded" by a fibrous mass consistent with catheter tip-associated granuloma. However, when they interrogated the drug delivery system, it did not reveal any evidence of failure to aspirate or deliver the drug. One would expect a disparity between the volumes of expected drug as calculated versus the volume actually found in the reservoir (3).

Second, they performed a catheter myelogram, which excluded catheter migration or leakage. However, they did not comment about encountering increased pressure during injection or increased resistance while aspirating, as one would expect from a catheter that is occluded by a mass.

Third, the MRI picture shown in Figure 1 in the report is not convincing. We think it may merely represent a localized inflammatory response resulting from the trauma of repeated catheter implantation, rather than representing a drug-related, catheter-tip granuloma.

Fourth, the dose of baclofen was modest, and the duration of the treatment was not long enough to be associated with granuloma formation. Spinal cord injury patients, in contrast to multiple sclerosis patients, require baclofen dose escalation with time. The dose increase in this case was not excessive.

REFERENCES

  1. Murphy PM, Skouvaklis DE, Amadeo RJJ, et al. Intrathecal catheter granuloma associated with isolated baclofen infusion. Anesth Analg 2006;102:848–52.[Abstract/Free Full Text]
  2. Hassenbusch S, Burchiel K, Coffey RJ, et al. Management of intrathecal catheter tip inflammatory masses: a consensus statement. Pain Med 2002;3:313–23.[ISI][Medline]
  3. Aldrete JA. Intrathecal opioid infusion (letter). Anesthesiology 2004;101:256.[ISI][Medline]



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M. J. Cousins and P. M. Murphy
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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press