Intrathecal Pain Pumps in Adhesive Arachnoiditis
Intrathecal pain pumps should generally be avoided in patients with adhesive arachnoiditis, as arachnoiditis is considered a relative contraindication due to the introduction of foreign material into an already inflamed and adherent subarachnoid space. 1
Key Contraindications
Arachnoiditis represents a relative contraindication because the condition involves chronic inflammation of the leptomeninges and intrathecal neural elements, creating an environment where catheter placement may worsen the inflammatory process or fail to deliver medication effectively due to CSF flow abnormalities 1, 2. The American Society of Clinical Oncology explicitly contraindicates intrathecal pump therapy in patients with active infections, coagulopathy, or very short life expectancy 1.
When Intrathecal Therapy Might Be Considered (Last Resort Only)
If you are considering an intrathecal pump despite arachnoiditis, this should only occur under very specific circumstances:
Prerequisites for Consideration
- Surgical detethering must have been performed first with residual neuropathic pain persisting despite this intervention 1
- Extensive systemic therapy failure must be documented, including oral opioids at escalating doses and appropriate adjuvant medications 3, 1
- Life expectancy must exceed 6 months to justify the invasive nature and cost of pump implantation 3
Mandatory Trial Period
- A trial with temporary epidural or spinal catheter is absolutely required before any permanent pump implantation 3, 1
- Pain reduction must be ≥50% during the trial period to proceed with permanent implantation 3, 1
- Psychological evaluation documenting favorable candidacy is mandatory for non-malignant pain conditions 1
Clinical Evidence Supporting Caution
Research demonstrates that intrathecal pumps can actually cause or worsen arachnoiditis. A case report documented severe adhesive arachnoiditis developing after intrathecal pump placement, requiring laminectomy, detethering, and eventual pump explantation 4. Another case showed spinal adhesive arachnoiditis developing after intrathecal therapy administration 2.
Historical data from 2007 listed arachnoiditis as a potential indication for intrathecal opioids 5, but this predates current understanding and the more recent guideline evidence explicitly categorizing it as a relative contraindication 1.
Critical Pitfalls to Avoid
- Do not place a pump without surgical detethering first if adhesions are present, as catheter placement into adherent tissue will likely fail 1
- Do not skip the mandatory trial period, as local diffusion difficulties in CSF cause uneven morphine distribution, and catheter tip position critically influences clinical effect 5
- Be aware that catheter-related complications occur in approximately 10% of cases (17 of 165 patients in one series), including dislocation, obstruction, and kinking 5
- Recognize that granuloma formation can occur at the catheter tip with highly concentrated intrathecal medications during long-term infusions 3
Alternative Approaches
Given the relative contraindication, consider these alternatives first:
- Spinal cord stimulation (which has been successful after failed intrathecal pump therapy in arachnoiditis patients) 4
- Aggressive systemic pain management with opioid rotation and adjuvant medications 3
- Surgical detethering if not already performed 1, 4
- Neurolytic blocks for localized pain in appropriate candidates 3