Authors: Vakhtang Shoshiashvili, Inga Shoshiashvili, Tamari Rukhadze.
Approximately 5-15% of cancer patients experience severe pain (6-10 based on VAS) that is resistant to traditional analgesic therapies. For this patient selective interventional analgesic treatment, options must be considered. The Polyanalgesic Consensus Conference panel of experts made the recommendations on use of intrathecal analgesics based on preclinical trials and clinical experiences. On the other hand, intrathecal drug delivery by the implantable pump or subcutaneous port-catheter can be complicated with PDPH. In these cases, EBP is needed if conservative treatment failed.
We are presenting a case report of PDPH after intrathecal catheter-subcutaneous access port insertion. The patient was a 45 years old male with melanoma, unknown primary site. As a result of metastatic spread in ribs, both lungs and thoracic vertebrae patient experienced respiratory insufficiency during exercise and severe pain in chest and chest cavity. For pain treatment patient needed in high dose opioids constantly and for optimization intrathecal catheter-subcutaneous port had been inserted on the L3-4 level. The morphine dose titrated and 4 mg/24 h intrathecal injection was sufficient for pain relief without respiratory depression. On the second day after portcatheter implantation patient felt severe frontal headache. PDPH diagnosed but conservative treatment with bed rest, fluids and caffeine intake was not helpful.
Epidural blood patch performed on the level below the catheter insertion. PDPH relieved temporarily and repeated EBP was needed for successful pain treatment. After this there were no problems of intrathecal port-catheter functioning and specific pain treatment.
We are concluding that intrathecal catheter – subcutaneous access port system is a useful method for terminally ill cancer patient pain treatment with special needs. Like other intrathecal interventions, it can be complicated with PDPH. For treatment of this complication, EBP is helpful if conservative treatment failed.
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