Citation: dupoiron d, deer t.Dura fistula: a rare complication of simultaneous placement of neurostimulation leads and an intrathecal catheter.Neuromodulation.2021.10.1111/ner.13464.Summary: we report here an uncommon complication, secondary to the successive use of neurostimulation and intrathecal analgesia in a patient with progression of cancer-causing severe cancer related pain.The patient presented late in the treatment course with a dural fistula, which negatively impacted his outcome.The potential mechanisms are considered, and treatment options are discussed along with potential options for prevention of this poor outcome in future patients. reported event: at this time, the situation deteriorated rapidly with intractable pain despite an increase in intrathecal dosages to upper limits of acceptable dosing.Evaluation of the idds was implemented with standard x-rays, computed tomography scan with 3d reconstruction that illustrated the catheter position adjacent to the implanted paddle lead, but with no dislodgement, kinking, or breaking of the catheter (figure 1a).In order to understand the dynamic cerebrospinal fluid (csf) flow of the drug, a nuclear imaging study with indium-111 was performed.The imagery displayed the expected indium diffusion inside the csf tracking to the brain (figure 1b) with a denser concentration of spread in the lumbar spine without significant abnormality (figure 1c).To further evaluate the function of the device, a side port myelogram was performed in the operating theater.This imaging revealed a contrast leak from the catheter coursing into the epidural space in an area where csf flow dissipated (figure 2a).The diagnosis of a dura fistula was confirmed and felt to be the etiology.A catheter revision was then performed with removal of the original catheter and replacement below the level of the plate electrode.Fluoroscopy was used to confirm a normal appearing myelogram (figure 2b).The pump was removed, and the catheter connected to a subcutaneous port to allow for more rapid and significant adjustments to the system.For one week, the pain was stabilized, and the neurosurgical team was consulted regarding the dural fistula, but at that time in the context of palliative care no surgical treatment was recommended.One week later, the clinical condition deteriorated rapidly with an uncontrolled level of pain requiring high dose iv opioids and ketamine, which achieved minimal improvement.Fluoroscopic evaluation showed and objective enlargement of the fistula just under the epidural lead further clarifying the clinical situation.As the situation became dire, the patient requested terminal sedation that was then performed following ethical (b)(6)law rules.
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Citation: dupoiron d, deer t.Dura fistula: a rare complication of simultaneous placement of neurostimulation leads and an intrathecal catheter.Neuromodulation.2021.10.1111/ner.13464 b.3.Please note that this date is based off of the date that the article was accepted for publication as the event dates were not provided in the published literature.Section d information references the main component of the system.Other relevant device(s) are: product id: 8781, serial/lot #: (b)(4), ubd: (b)(6) 2021, udi#: (b)(4), implanted: (b)(6) 2019 explanted: product type: catheter.If information is provided in the future, a supplemental report will be issued.
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