Implantation is performed in the operating room under anesthesia. Abdominal placement lateral to the umbilicus and above the beltline is usually chosen for easy accessibility and implant tolerance. The patient is positioned in lateral decubitus to allow for access to the spine, tunneling area, and implant site (Fig. 13.37). A Tuohy needle is used to access the intrathecal space via the L1-L2 interlaminar window under fluoroscopy. After free flow of CSF is verified, the implantable catheter is threaded into the intrathecal space up to the symptomatic level. An incision is opened above and below the Tuohy needle and catheter, and blunt dissection is used to expose the thoracolumbar fascia. A purse-string suture is made around the needle entry point and tied after the Tuohy needle is removed, making sure to maintain free flow of CSF. An anchor is then sutured to the thoracolumbar fascia and a loop of catheter coiled in the recess before attention is turned to creation of a pocket for the pump. The pocket should be approximately 1.5-2 cm in depth, and the use of a template is helpful. A supplied tunneling device is used to connect the pocket to the back incision. Excess catheter may be removed but is generally coiled beneath the pump for consistency of catheter volume. Patients should be admitted for overnight observation.

Complications from the procedure include bleeding, infection, seroma, cerebrospinal fluid leak or hygroma, and post-dural puncture headache. Opiate infusions can cause granuloma formations at the catheter tip next to the spinal cord and should cause hesitation when placement for nonmalignant pain syndromes is considered. The incidence may be as high as 3% (Medtronic 2008). Spinal cord compression and permanent neurologic injury may result. Some institutions perform yearly monitoring with CT and fine-cut magnetic resonance imaging (MRI) studies to evaluate the catheter tip. If a granuloma is found, the intrathecal infusion must be transitioned to saline and replaced by oral opiates, a daunting task. Device problems include catheter occlusion, disconnection, pump failure, and pump battery depletion. Medication side effects such as nausea, vomiting, urinary retention, weakness, and pruritus may occur with escalating doses. Different medications or combinations can be used to minimize escalation of single drug doses and side effects.

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