Air Embolus to Arachnoid Cyst as a
Rare Delayed Complication of
Intrathecal Medication Delivery
A Case Report
Daniela Atencio, B.S.*
John Gachiani, M.D.*
Erich O. Richter, MD.*
*Department of Neurosurgery, LSU Health Sciences Center, New Orleans, LA
Introduction
• IT therapy is a common treatment for
intractable chronic pain.
• Several complications have been described
from long term use of IT medication,
especially IT opioids.
“Assessing Syndromes of Catheter Malfunction With
SynchroMed Infusion Systems: The Value of Spiral
Computed Tomography With Contrast Injection”
Turner, Michael S. PMR Journal. 2010.
Patient History
• 56 year-old woman with history of chronic
back pain following trauma.
• Intrathecal morphine delivery device
implanted in 2000.
Patient History
• Several years later she presented with
symptoms of loss of drug effect.
• Catheter revision, repositioning the
Catheter tip at a T9-T10 level.
• Following epidural injection and
myelogram, she presented with acute,
severe neurologic decline.
Neurological Examination
Right Side Muscle Strength
Left Side Muscle Strength
Hip
Flexion/Extension
Knee
Flexion/Extension
Plantar Flexion
0/5
Hip Flexion/Extension 0/5
0/5
Knee
Flexion/Extension
0/5
Plantar Flexion
2/5
Dorsiflexion
3/5
Dorsiflexion
3/5
EHL and FHL
3/5
EHL and FHL
4/5
2/5
Reflexes:
Upper Extremities= 1
Lower Extremities= Absent.
*Incomplete sensory loss with
a thoracic level
Discussion
• The arachnoid cyst was near the previous catheter tip
position (prior to revision), we inferred that the cyst
was an undiagnosed CSF loculation from the time of
the previous revision.
• Pneumorrhachis, air trapped within the spinal canal is
a rare condition that is usually asymptomatic. [2, 3]
• In this case the air was constrained by arachnoid
adhesions and appears to have exerted a mass effect
with severe neurological deficits .
• Although CSF loculation has been described as a
complication of long term use of IT medication, severe
compressive complications from such loculations has
not been previously reported.
References
1.
2.
3.
4.
5.
Bagnall, David. The Use of Spinal Cord Stimulation and Intrathecal Drug Delivery
in the Treatment of Low Back-Related Pain. Phys Med Rehabil Clin N Am. Vol 21,
issue 4. Nov 2010, 851-858.
Chaicana Kaisorn L., Pradilla Gustavo, Witham Timothy F., Gokaslan Ziya L., Bydon
Ali. The Clinical Significance of Pneumorachis: A Case Report and Review of
Literature. The Journal of Trauma Injury, infection and Critical Care. Vol 68,
Number 3, March 2010.
Oertel, Markus F., Korinth, Marcus C., Reinges, Marcus H.T., Krings, Timo.,
Terbeck, Sandra., Gilsbach, Joachim M. Pathogenesis, Diagnosis and Management
of Pneumorrhachis. Eur Spine J. 2006. 15. (Suppl. 5):S636-S646.
Phillips, Jinnah A., Escott, Edward J., Moossy, John J., Kellermier, Harry C. Imaging
Appearance of Intrathecal Catheter Tip Granulomas: Report of Three Cases and
Review of the Literature. Am. J. Roentgenol. 2007 189: W375-381
Turner, Michael S. Assessing Syndromes of Catheter Malfunction With
SynchroMed Infusion Systems: The Value of Spiral Computed Tomography With
Contrast Injection. PMR Journal; 2010. Vol. 2, Issue 8 , 757-766.