SURGICAL MANAGEMENT OF SPINAL CATHETER GRANULOMAS: OPERATIVE NUANCES AND REVIEW OF THE SURGICAL LITERATURE

OBJECTIVESpinal catheter granulomas are a rare and, most likely, underreported complication of intrathecal opioid therapy. Such granulomas can be associated with devastating neurological sequelae if not treated in a timely fashion. Most neurosurgeons, however, are unlikely to have had experience in the surgical management of this condition. CLINICAL PRESENTATIONThe authors present 3 surgical cases of patients with spinal catheter granulomas with neurological deficits. One patient's intraoperative video illustrates the challenges of diagnosis, radiological assessment, and surgery for spinal catheter granulomas. INTERVENTIONAll 3 patients had implanted opioid pumps for management of chronic spinal pain secondary to fracture, tethered cord, and back pain. Increasing back pain and a progressive myelopathy was observed in all patients. A clear radiological diagnosis was made more difficult because of instrumentation artifact in 1 case and claustrophobia in another. Computed tomographic myelography was necessary in 1 case. The surgical findings were: 1 extradural catheter with granuloma and 2 intradural catheters encased with granuloma and adherent to the cord. The extradural catheter was trimmed of granuloma and replaced intradurally in 1 case. The patients with intradural catheter granulomas required judicious dissection of the granulomas from the dorsum of the cord, duroplasty, and catheter section. Critical intraoperative stages were recorded and are presented in digital movie format. Two patients had neurological improvement after surgery; however, 1 patient remained paraplegic. The 2 patients with catheter section required opioid withdrawal treatment. CONCLUSIONThe operative management of spinal intrathecal granulomas associated with opioid infusion pumps can be challenging and depends on a high degree of clinical suspicion, imaging results, and operative findings.