Inadvertent Spinal Shock during an Intrathecal Drug Delivery System Refill – A Case Report and Troubleshooting Algorithm

Intrathecal drug delivery systems (IDDS) are used to treat patients with chronic refractory pain syndromes and spasticity. IDDS offer an effective therapy to control pain while offering the advantage of a decrease in the incidence of side effects from high-dose systemic opioid therapy. Serious outcomes including death or permanent brain damage may occur from medication administration errors, primarily during maintenance of IDDS. The pump refill and reprogramming procedures, although elemental in theory, are not bereft of serious and fatal side effects .The importance of understanding the IDDS and competency in performing pump refills and programming is of critical importance. To reduce the risk of drug-related errors, particular attention should be paid to the proper functioning of pump hardware, drug reservoir volume discrepancies and overdose symptoms reported by patients. Furthermore, the clinician should be prepared for drug errors and follow the risk mitigation flowchart mentioned in the clinician refill reference card provided by the IDDS manufacturer. We present a case report of a 62-year old male with a history of post-laminectomy syndrome, associated with chronic back pain for the last 4 years. The patient developed inadvertent total spinal shock during a refill procedure of the IDDS reservoir. The educational objective of this case report is to highlight troubleshooting options, plus some of the risks and complications that can occur when managing an intrathecal pump delivery system. Clinicians involved in the ongoing care of patients with IDDS should undergo periodic competency validations. Imaging modalities are useful adjuncts for intrathecal pump refills when a patient has a more difficult entry or previous complications at the time of refill. A rapid recognition of evolving complications and implementation of appropriate treatment are the cornerstones of successfully managing complications associated with refilling of IDDS. Key words: Intrathecal drug delivery system, drug refill, total spinal shock, seroma, catheter port study, rotor study