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Tim Deer - One of the best experts on this subject based on the ideXlab platform.
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polyanalgesic consensus conference 2012 consensus on diagnosis detection and treatment of Catheter tip granulomas inflammatory masses
Neuromodulation, 2012Co-Authors: Tim Deer, Michael J Cousins, Robert M. Levy, James P Rathmell, Allen W Burton, Joshua P Prager, Eric Buchser, David Caraway, Jose De Andres, Sudhir DiwanAbstract:Introduction: Continuous Intrathecal infusion of drugs to treat chronic pain and spasticity has become a standard part of the algorithm of care. The use of opioids has been associated with noninfectious inflammatory masses at the tip of the Intrathecal Catheter, which can result in neurologic complications. Methods: The Polyanalgesic Consensus Conference is a meeting of a group of well-published and experienced practitioners; the purpose of the meeting is to update the standard of care for Intrathecal therapies to reflect current knowledge gleaned from literature and clinical experience. An exhaustive literature search was performed, and information from this search was provided to panel members. Analysis of the published literature was coupled with the clinical experience of panel participants to form recommendations regarding Intrathecal inflammatory masses or granulomas. Results: The panel has made recommendations for the prevention, diagnosis, and management of Intrathecal granulomas. Conclusion: The use of chronic infusions of Intrathecal opioids is associated with the formation of inflammatory masses at the Intrathecal Catheter tip in a small minority of treated patients. Nonetheless, the appearance of these space-occupying lesions can lead to devastating neurologic sequelae. The prevention, early detection, and successful treatment of intraspinal granulomas are important considerations when offering Intrathecal drug therapy to patients with chronic intractable pain.
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management of Intrathecal Catheter tip inflammatory masses an updated 2007 consensus statement from an expert panel
Neuromodulation, 2008Co-Authors: Tim Deer, Samuel J Hassenbusch, Elliot S. Krames, James C. Eisenach, Allen W Burton, David Caraway, Stuart Dupen, Michael A Erdek, Eric Grigsby, Robert LevyAbstract:Background. Expert panel of physicians and nonphysicians, all expert in Intrathecal (IT) therapies, convened in the years 2000 and 2003 to make recommendations for the rational use of IT analgesics based on the preclinical and clinical literature known up to those times, presentations of the expert panel, discussions on current practice and standards, and the result of surveys of physicians using IT agents. An expert panel of physicians and convened in 2007 to review previous recommendations and to form recommendations for the rational use of IT agents as they pertain to new scientific and clinical information regarding the etiology, prevention and treatment for IT granuloma. Method. A review of preclinical and clinical literature from 2000 to 2006 was undertaken and disseminated to an expert panel of physicians. Focused discussions concerning the rational use of IT agents and its relationship to the etiology of, prevention of, and treatment of IT granuloma were held. Results. This report presents here new knowledge of the etiology of Catheter tip granuloma and guidelines for its prevention and treatment.
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inflammatory mass of an Intrathecal Catheter in patients receiving baclofen as a sole agent a report of two cases and a review of the identification and treatment of the complication
Pain Medicine, 2007Co-Authors: Tim Deer, Louis J Raso, Tina G GartenAbstract:Introduction. Intrathecal inflammatory masses or granuloma have been described extensively in the literature in patients receiving chronic spinal infusions for pain. After an extensive literature review, no reported cases of baclofen causing this disorder when administered as a sole agent were identified. Intrathecal baclofen has been used to treat spasticity secondary to stroke, multiple sclerosis, cerebral palsy, spinal cord injury, and other neurological disease. Cases. Two patients who received Intrathecal infusions of baclofen to treat spasticity developed Catheter failure. Magnetic resonance imaging analysis showed the presence of an inflammatory mass at the tip of each Catheter causing the dysfunction. The Catheters were removed and replaced by a percutaneous technique. Discussion. Inflammatory mass on an Intrathecal Catheter can result in a variety of symptoms. These problems range from the patient being asymptomatic to flaccid paraplegia. Animal studies have shown an association with high concentrations of morphine and hydromorphone theorized to be related to a mast cell degranulation response. Presence of this lesion in these two patients should heighten the suspicion for inflammatory mass in any patient treated for spasticity. The diagnosis of Intrathecal Catheter tip inflammatory mass is made after an initial suspicion of a Catheter occlusion or failure. The gold standard of diagnosis is T2-weighted magnetic resonance imaging. A computerized tomography myelogram is acceptable if a magnetic resonance imaging is not feasible. Conclusion. We report two cases of inflammatory mass in patients receiving baclofen as a sole Intrathecal agent. The authors would recommend vigilance in any patient receiving Intrathecal baclofen. If the suspicion arises of this problem, a magnetic resonance imaging or computerized tomography myelogram should be obtained with a focus on the Catheter tip.
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management of Intrathecal Catheter tip inflammatory masses a consensus statement
Pain Medicine, 2002Co-Authors: Samuel J Hassenbusch, Kim J. Burchiel, Michael J Cousins, Tim Deer, Kenneth A Follett, James N Rogers, Marc B. Hahn, Elliot S. Krames, Robert J Coffey, Oren SagherAbstract:California; n Alabama Pain Center, Huntsville, Alabama Objectives. In a companion article, we synthesized current clinical and preclinical data to formulate hypotheses about the etiology of drug administration Catheter-tip inflammatory masses. In this article, we communicate our recommendations for the detection, treatment, mitigation, and prevention of such masses. Methods. We reviewed published and unpublished case reports and our own experiences to find methods to diagnose and treat Catheter-tip inflammatory masses in a manner that minimized adverse neurological sequelae. We also formulated hypotheses about theoretical ways to mitigate, and possibly, prevent the formation of such masses. Results. Human cases have occurred only in patients with chronic pain who received Intrathecal opioid drugs, alone or mixed with other drugs, or in patients who received agents that were not labeled for long-term Intrathecal use. Most patients had noncancer pain owing to their large representation among the population with implanted pumps. Such patients also had a longer life expectancy and exposure to Intrathecal drugs, and they received higher daily doses than patients with cancer pain. Clues to diagnosis included the loss of analgesic drug effects accompanied by new, gradually progressive neurological symptoms and signs. When a mass was diagnosed before it filled the spinal canal or before it caused severe neurological symptoms, open surgery to remove the mass often was not required. Anecdotal reports and the authors’ experiences suggest that cessation of drug administration through the affected Catheter was followed by shrinkage or disappearance of the mass over a period of 2-5 months. Conclusions. Attentive follow-up and maintenance of an index of suspicion should permit timely diagnosis, minimally invasive treatment, and avoidance of neurological injury from Catheter-tip inflammatory masses. Whenever it is feasible, positioning the Catheter in the lumbar thecal sac and/or keeping the daily Intrathecal opioid dose as low as possible for as long possible may mitigate the seriousness, and perhaps, reduce the incidence of such inflammatory masses.
Oren Sagher - One of the best experts on this subject based on the ideXlab platform.
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management of Intrathecal Catheter tip inflammatory masses a consensus statement
Pain Medicine, 2002Co-Authors: Samuel J Hassenbusch, Kim J. Burchiel, Michael J Cousins, Tim Deer, Kenneth A Follett, James N Rogers, Marc B. Hahn, Elliot S. Krames, Robert J Coffey, Oren SagherAbstract:California; n Alabama Pain Center, Huntsville, Alabama Objectives. In a companion article, we synthesized current clinical and preclinical data to formulate hypotheses about the etiology of drug administration Catheter-tip inflammatory masses. In this article, we communicate our recommendations for the detection, treatment, mitigation, and prevention of such masses. Methods. We reviewed published and unpublished case reports and our own experiences to find methods to diagnose and treat Catheter-tip inflammatory masses in a manner that minimized adverse neurological sequelae. We also formulated hypotheses about theoretical ways to mitigate, and possibly, prevent the formation of such masses. Results. Human cases have occurred only in patients with chronic pain who received Intrathecal opioid drugs, alone or mixed with other drugs, or in patients who received agents that were not labeled for long-term Intrathecal use. Most patients had noncancer pain owing to their large representation among the population with implanted pumps. Such patients also had a longer life expectancy and exposure to Intrathecal drugs, and they received higher daily doses than patients with cancer pain. Clues to diagnosis included the loss of analgesic drug effects accompanied by new, gradually progressive neurological symptoms and signs. When a mass was diagnosed before it filled the spinal canal or before it caused severe neurological symptoms, open surgery to remove the mass often was not required. Anecdotal reports and the authors’ experiences suggest that cessation of drug administration through the affected Catheter was followed by shrinkage or disappearance of the mass over a period of 2-5 months. Conclusions. Attentive follow-up and maintenance of an index of suspicion should permit timely diagnosis, minimally invasive treatment, and avoidance of neurological injury from Catheter-tip inflammatory masses. Whenever it is feasible, positioning the Catheter in the lumbar thecal sac and/or keeping the daily Intrathecal opioid dose as low as possible for as long possible may mitigate the seriousness, and perhaps, reduce the incidence of such inflammatory masses.
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spinal cord compression by Catheter granulomas in high dose Intrathecal morphine therapy case report
Neurosurgery, 1998Co-Authors: Kyle L Cabbell, James A Taren, Oren SagherAbstract:OBJECTIVE AND IMPORTANCE: The use of chronic Intrathecal morphine for the treatment of intractable, nonmalignant pain is becoming more prevalent. A rare but devastating complication of this therapy is the development of spinal cord compression secondary to the formation of Intrathecal granulomas. CLINICAL PRESENTATION: We report three cases of Intrathecal granuloma formation in the thoracic subarachnoid space, associated with Intrathecal morphine pumps. These three patients were receiving high doses of morphine to control their pain (25 mg/d, 28 mg/d, and 45 mg/d, respectively) when they presented with signs and symptoms of thoracic spinal cord compression. Myelography and postmyelographic computed tomography of the spine revealed masses causing spinal cord compression. INTERVENTION: Two patients underwent thoracic laminectomies for resection of these masses, and the other patient had the Intrathecal Catheter removed. A pathological examination revealed sterile granulomas in the resected masses. CONCLUSION: Intrathecal granulomas are likely to occur with increasing frequency as the use of chronic Intrathecal morphine delivery increases in patients with nonmalignant pain. The cause of Intrathecal granulomas is unknown, although it is likely that morphine plays a major role in their formation. We think that those patients receiving high doses of morphine are at greater risk for developing this complication.
Marion L. Walker - One of the best experts on this subject based on the ideXlab platform.
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posterior cervical approach for Intrathecal baclofen pump insertion in children with previous spinal fusions technical note
Journal of Neurosurgery, 2005Co-Authors: Marion L. WalkerAbstract:P Intrathecal baclofen pumps for the management of severe spasticity are being used more often in children with cerebral palsy. The Intrathecal Catheter is traditionally introduced dorsally in the lumbar region. In some children with previous thoracolumbar fusions for scoliosis, the fusion mass obviates the introduction of the Intrathecal Catheter. The authors describe their experience with a posterior cervical approach for Intrathecal baclofen pump insertion in three patients with spastic quadriplegic cerebral palsy who had previously undergone thoracolumbar fusions for scoliosis. Insertion was successful in all three patients; no complications of Catheter disconnection, Catheter dislodgment, or cerebrospinal fluid leakage occurred. Follow-up review ranged from 10 to 28 months postoperatively (mean 17 months). The posterior cervical approach for Intrathecal baclofen pump insertion is a safe and effective alternative for patients who have previously undergone thoracolumbar spine fusions and in whom the tr...
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posterior cervical approach for Intrathecal baclofen pump insertion in children with previous spinal fusions technical note
Journal of Neurosurgery, 2005Co-Authors: James K Liu, Marion L. WalkerAbstract:Intrathecal baclofen pumps for the management of severe spasticity are being used more often in children with cerebral palsy. The Intrathecal Catheter is traditionally introduced dorsally in the lumbar region. In some children with previous thoracolumbar fusions for scoliosis, the fusion mass obviates the introduction of the Intrathecal Catheter. The authors describe their experience with a posterior cervical approach for Intrathecal baclofen pump insertion in three patients with spastic quadriplegic cerebral palsy who had previously undergone thoracolumbar fusions for scoliosis. Insertion was successful in all three patients; no complications of Catheter disconnection, Catheter dislodgment, or cerebrospinal fluid leakage occurred. Follow-up review ranged from 10 to 28 months postoperatively (mean 17 months). The posterior cervical approach for Intrathecal baclofen pump insertion is a safe and effective alternative for patients who have previously undergone thoracolumbar spine fusions and in whom the traditional lumbar approach is not feasible.
Naoki Yoshimura - One of the best experts on this subject based on the ideXlab platform.
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suppression of detrusor sphincter dyssynergia by immunoneutralization of nerve growth factor in lumbosacral spinal cord in spinal cord injured rats
The Journal of Urology, 2004Co-Authors: Satoshi Seki, Katsumi Sasaki, Yasuhiko Igawa, Osamu Nishizawa, Michael B Chancellor, William C De Groat, Naoki YoshimuraAbstract:ABSTRACTPurpose: We investigated the effects of Intrathecal application of nerve growth factor (NGF) antibodies (NGF-Abs) and desensitization of C-fiber afferent pathways by capsaicin treatment on detrusor-sphincter dyssynergia (DSD) after spinal cord injury (SCI).Materials and Methods: In adult female rats SCI was induced by complete transection of the spinal cord at Th8 to 9. Ten days after spinalization vehicle or NGF-Ab (10 μg daily) was continuously administered at the level of the L6-S1 spinal cord through an implanted Intrathecal Catheter connected to an osmotic pump for 2 weeks. Another group of spinalized rats was treated with capsaicin (125 mg/kg subcutaneously) 3 weeks after spinalization and 5 days before experiments. Simultaneous recordings of intravesical pressure and urethral perfusion pressure were then performed. NGF levels in the L6 spinal cord were measured in vehicle or NGF-Ab treated spinalized rats using enzyme-linked immunosorbent assay.Results: DSD was observed in all vehicle treat...
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immunoneutralization of nerve growth factor in lumbosacral spinal cord reduces bladder hyperreflexia in spinal cord injured rats
The Journal of Urology, 2002Co-Authors: Satoshi Seki, Katsumi Sasaki, Matthew O Fraser, Yasuhiko Igawa, Osamu Nishizawa, Michael B Chancellor, William C De Groat, Naoki YoshimuraAbstract:ABSTRACTPurpose: We investigated the effects of Intrathecal application of nerve growth factor (NGF) antibodies (Ab) on bladder hyperreflexia in chronic spinalized rats.Materials and Methods: In adult female rats an Intrathecal Catheter was implanted at the level of the L6 to S1 spinal cord, followed by complete transection of the Th8 to 9 spinal cord. At 10 days after spinalization the Intrathecal Catheter was connected to an osmotic pump for continuous delivery of vehicle or NGF Ab (10 μg. daily) for 2 weeks. Awake cystometry was then performed. NGF levels in the L5 to S1 dorsal root ganglia, L6 spinal cord and bladder were also measured using enzyme-linked immunosorbent assay.Results: The number of uninhibited bladder contractions per voiding cycle, maximal pressure of uninhibited bladder contraction and maximal voiding pressure were significantly decreased in NGF Ab treated versus vehicle treated spinalized rats. Intercontraction interval, baseline intravesical pressure, pressure threshold for voiding...
William D. Freeman - One of the best experts on this subject based on the ideXlab platform.
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development of a lumbar drain simulator for instructional technique and skill assessment
Neurocritical Care, 2020Co-Authors: William Clifton, Aaron Damon, William D. FreemanAbstract:Medical simulation for the teaching of procedural skills to health-care providers is an effective method of instruction to improve safety, quality, and procedural efficiency. There are several commercially available simulators for lumbar puncture training; however, there is currently no model available for lumbar drain Intrathecal Catheter placement. A modular lumbar drain simulator was assembled with the use of a spine model, ballstical gel, and Penrose drain tubing to recreate the procedural steps and tactile feedback of a live lumbar drain insertion. The assembled simulator demonstrated the ability to provide users with manual feeback of a “pop” sensation when Intrathecal puncture was achieved with a 14 gauge Touhy needle, as well as spontaneous CSF flow. A silastic Catheter was able to be inserted into the simulated subarachnoid space in the same manner as a live procedure. A high-fidelity lumbar drain simulator can be constructed in a cost-effective manner. We have detailed the materials and assembly of our successful design in order to provide a novel educational tool for procedural instruction and practice.
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Development of a Lumbar Drain Simulator for Instructional Technique and Skill Assessment
Neurocritical Care, 2019Co-Authors: William E. Clifton, Aaron C. Damon, William D. FreemanAbstract:Background Medical simulation for the teaching of procedural skills to health-care providers is an effective method of instruction to improve safety, quality, and procedural efficiency. There are several commercially available simulators for lumbar puncture training; however, there is currently no model available for lumbar drain Intrathecal Catheter placement. Methods A modular lumbar drain simulator was assembled with the use of a spine model, ballstical gel, and Penrose drain tubing to recreate the procedural steps and tactile feedback of a live lumbar drain insertion. Results The assembled simulator demonstrated the ability to provide users with manual feeback of a “pop” sensation when Intrathecal puncture was achieved with a 14 gauge Touhy needle, as well as spontaneous CSF flow. A silastic Catheter was able to be inserted into the simulated subarachnoid space in the same manner as a live procedure. Conclusions A high-fidelity lumbar drain simulator can be constructed in a cost-effective manner. We have detailed the materials and assembly of our successful design in order to provide a novel educational tool for procedural instruction and practice.