Expandable Sendai-Virus-Reprogrammed Human iPSC-Neuronal Precursors: In Vivo Post-Grafting Safety Characterization in Rats and Adult Pig.

One of the challenges in clinical translation of cell-replacement therapies is the definition of optimal cell generation and storage/recovery protocols which would permit a rapid preparation of cell-treatment products for patient administration. Besides, the availability of injection devices that are simple to use is critical for potential future dissemination of any spinally targeted cell-replacement therapy into general medical practice. Here, we compared the engraftment properties of established human-induced pluripotent stem cells (hiPSCs)-derived neural precursor cell (NPCs) line once cells were harvested fresh from the cell culture or previously frozen and then grafted into striata or spinal cord of the immunodeficient rat. A newly developed human spinal injection device equipped with a spinal cord pulsation-cancelation magnetic needle was also tested for its safety in an adult immunosuppressed pig. Previously frozen NPCs showed similar post-grafting survival and differentiation profile as was seen for freshly harvested cells. Testing of human injection device showed acceptable safety with no detectable surgical procedure or spinal NPCs injection-related side effects.

The Unmet Need for Intrathecal Drug Delivery Pumps for the Treatment of Cancer Pain in England: An Assessment of the Hospital Episode Statistics Database.

OBJECTIVES: Intrathecal drug delivery (ITDD) devices have been shown to be a clinically effective and cost-effective option for the management of cancer pain and recommended for use in England. The aim of this study is to assess the impact of the 2015 NHS England Clinical Commissioning Policy on the uptake of ITDD pumps for the management of cancer pain or if there is an ongoing unmet need for this intervention in England. MATERIALS AND METHODS: Hospital Episode Statistics (HES) were obtained for all patients undergoing ITDD for the management of cancer pain between 2014 and January 2020. In addition, HES were utilized to estimate the number of patients with cancer potentially eligible for ITDD pump during the same period. RESULTS: The number of patients with cancer and those potentially suitable to receive an ITDD for the management of cancer pain have increased year on year since 2014. This increase has not been matched by an uptake in the provision of ITDD. Conservative estimates suggest that at least 8000 people with cancer pain would be eligible for ITDD; 458 patients received an intervention for pain management between April 2018 and March 2019 and only 30 ITDD pumps were implanted in that same period. CONCLUSIONS: We observed a substantial gap between the need and provision of ITDD for patients with refractory cancer pain in England despite the recommendation for the use of ITDD for this patient population. In addition, we present suggestions for improvement of access to and provision of ITDD in England.

[A new design puncture needle and a device of microcatheter protection for lumbar intrathecal catheterization in rats].

Objective: To introduce a new design needle and a device of microcatheter protection for lumbar intrathecal catheterization in rats,and evaluate its feasibility and effectiveness.Methods: Sixty pathogen-free adult male Sprogue-Dawley rats were randomly divided into two groups(n=30 in each group), the control group (group C) and the modification group(group M). The traditional puncture device, 20G needle, was used in the group C without extemal shielding protection. The new design puncture needle and the microinjection cock were used in the group M. All rats were assessed for motor function on postoperative. The motor function was evaluated 1 day afteroperation. Lidocaine was injected in the catheter at 1st,3rd,7th,14th,21st day post-catheterization, methylene blue was injected in intrathecal at 30th day after operation, and the catheter location was observed. The paw withdrawal threshold(PWT) was measured at 1st,3rd,7th,14th,21st,30th day after operation, open-field test was tested at preoperative and one week postoperative for the purpose of evaluating the autonomous behavior of rats. Results: About motor function:level Ⅰ 75.9%,level Ⅱ 20.7%,level Ⅲ 3.4% in group C, and level Ⅰ 96.7%,level Ⅱ 3.3% in group M, Compared with group C,group M had higher percentage of the level Ⅰ in motor function (P＜0.05);Lidocaine test and methylen blue location showed that each one case of catheter was removed on the 14th and 21st day after intubation in group C, and total four cases were removed till the 30th day, while all catheters were in normal location in group M. There was significant difference between two groups in protection of the extemal portion of catheter(P＜0.05); The time of intrathecal injection in group M was only 1 minute, and it spent more than 3 minutes in group C. Compared with group C,the time of intrathecal injection is significantly shorter in group M(P＜0.01);PWT was reduced to the lowest on the third day after catheterization, and there was significant difference compared with preoperative(P＜0.05), PWT recovered on the 7th day and there were no significant difference between two groups; Compared with preoperative, there was no significant difference in the parameters of the group M in the open field test, neither between two groups. Conclusion: The new design puncture needle by its less injury and higher efficiency can be used in intrathecal catheterization. The microinjection cock is reliable and convenient for repeat injection with a perfect protection function of the external portion of catheter, meanwhile it has no impact on rats' autonomous behavior so that it is worthy of further promoting.

Comparison of a flexible versus rigid bone cement injection system in unilateral percutaneous vertebroplasty.

BACKGROUND: Percutaneous vertebroplasty (PVP) has been demonstrated to be effective in the treatment of acute osteoporotic vertebral fracture (AOVF). However, bilateral puncture takes more time to accept more X-ray irradiation; some scholars apply unilateral puncture PVP, but the cement cannot be symmetrically distributed in the vertebral body, so we use a flexible cement injector that undergoes PVP through the unilateral pedicle puncture. This research aims to compare the clinical results of PVP for AOVF with unilateral pedicle puncture using a straight bone cement injector and a bendable cement injector, determine the value of a bendable cement injector. METHODS: We undertook a retrospective analysis of patients with thoracic and lumbar compression fracture treated with unilateral pedicle puncture percutaneous vertebroplasty from our institution from June 2013 to July 2015. Operation time, radiation exposure, bone cement injection amount, and the incidence of bone cement leakage were recorded on presentation, the cement leakage was measured by X-ray and computed tomography scan. The patients were followed up postoperatively and were assessed mainly with regard to clinical and radiological outcomes. RESULTS: There was no significant difference in the operation time, radiation exposure time and incidence of bone cement leakage between the two groups. There was significant difference in the amount of bone cement injection and the difference between the two groups. There were no significant differences in VAS and the relative height of the vertebral body and local Cobb angle and QUALEFFO between the two groups at 1 week after PVP, significant difference was observed only 12 months after operation. CONCLUSIONS: Application of flexible cement injector is safe and feasible, compared with the application of straight bone cement injector, without prolonging the operative time, radiation exposure time and the incidence of bone cement leakage; it has the advantages of good long-term effect and low incidence of vertebral fracture recurrence.

Malfunctioning sufentanil intrathecal pain pump: a case report.

BACKGROUND: Sufentanil is a potent opioid uncommonly used to manage pain and is rarely administered via an intrathecal pain pump system. CASE PRESENTATION: This case illustrates the use of intrathecal sufentanil in a 50-year-old Caucasian man for the management of chronic pain; however, the intrathecal drug delivery system experienced a malfunction which led to 1/100th output of the correct dosage. Interesting aspects of this case report include the uncommon choice of sufentanil use for an intrathecal drug delivery system, as well as the unusual pharmacokinetics of this drug. Specifically, this patient did not experience the major withdrawal that would be expected given significant under dosing of opioid, and this may be explained by the lipophilicity and context-sensitive half-times of sufentanil. CONCLUSIONS: Because of the absence of a clinically significant withdrawal in this case report, clinicians must be aware of relevant pharmacokinetic properties and unusual intrathecal drug delivery system technologies that influence a patient's response when device malfunction occurs.

Use of an intravenous port catheter for the delivery of intrathecal morphine in a terminally ill cancer patient with pain.

We present a case of a terminally ill cancer patient with metastasis who was suffering from inadequate pain control despite high doses of systemic opioid administration. In addition, her quality of life was significantly impaired due to opioid-induced troublesome side effects. In the situation as above, intrathecal opioid administration has established as a safe and effective therapeutic option with a positive benefit-risk ratio. This case reports a novel technique, where an intravenous port catheter was used to administer intrathecal opioid.

Simple Fluoroscopy-Guided Transforaminal Lumbar Puncture: Safety and Effectiveness of a Coaxial Curved-Needle Technique in Patients with Spinal Muscular Atrophy and Complex Spines.

Patients with spinal muscular atrophy often have complete interlaminar osseous fusion, precluding lumbar puncture via the standard interlaminar approach. Recently, we have developed a new coaxial curved-needle variation of fluoroscopy-guided transforaminal lumbar puncture for intrathecal injections in this patient population. Between October 2017 and November 2018, fifty-nine consecutive transforaminal lumbar punctures using this technique were performed in 12 patients with spinal muscular atrophy for intrathecal nusinersen injection, with a 100% technical success rate and no C1-2 punctures required. One major complication occurred, consisting of a post-dural puncture headache, which required a therapeutic transforaminal epidural blood patch. Two minor complications occurred, both of which involved inadvertent puncture of a dorsal muscular arterial branch, without clinical sequelae. A fluoroscopy-guided curved-needle transforaminal approach is an effective technique for lumbar puncture in difficult cases, such as in this cohort of patients with spinal muscular atrophy and complete interlaminar osseous fusion undergoing intrathecal nusinersen injections.

Characterization of Effect of Repeated Bolus or Continuous Intrathecal Infusion of Morphine on Spinal Mass Formation in the Dog.

BACKGROUND: We determined whether intrathecally delivering the same daily dose of morphine (MS) at a fixed concentration of 25 mg/mL by periodic boluses versus continuous infusion would reduce intrathecal mass (IMs) formation in dogs. METHODS: Adult dogs (hound cross, n = 32) were implanted with intrathecal catheters connected to SynchroMed II infusion pumps. Animals were randomly assigned to receive infusion of 0.48 mL/day of saline or MS dosing (12 mg/day at 25 mg/mL) as boluses: x1 (q24hour), x2 (q12hour), x4 (q6hour), or x8 (q3hour) given at the rate of 1000 µL/hour, or as a continuous infusion (25 mg/mL/20 µL/hour). RESULTS: With IT saline, minimal pathology was noted. In contrast, animals receiving morphine displayed spinally compressing durally derived masses with the maximal cross-sectional area being greatest near the catheter tip. Histopathology showed that IMs consisted of fibroblasts in a collagen (type 1) matrix comprised of newly formed collagen near the catheter and mature collagen on the periphery of the mass. The rank order of median cross-sectional mass area (mm2 ) was: Saline: 0.7 mm2 ; x2: 1.8 mm2 ; x4: 2.7 mm2 ; x1: 2.7 mm2 ; x8: 4.2 mm2 ; Continuous: 8.1 mm2 , with statistical difference from saline being seen with continuous (p < 0.0001) and x8 (p < 0.05). Bench studies with a 2D diffusion chamber confirmed an increase in dye distribution and lower peak concentrations after bolus delivery versus continuous infusion of dye. CONCLUSIONS: Using multiple bolus dosing, IMs were reduced as compared to continuous infusion, suggesting relevance of bolus delivery in yielding reduced intrathecal masses.

Intrathecal therapy for pain in cancer patients.

PURPOSE OF REVIEW: Intrathecal drug delivery systems (IDDS) for cancer pain remain little employed despite a high level of efficiency even though the technique is widely recommended. This review aims to summarize recent advances in IDDS for cancer patients. RECENT FINDINGS: The respective roles of catheter positioning, volume and flow rate in diffusion of intrathecal treatments, as well as the individual roles of blood pressure, heart rate, and amplitude of the respiratory movements in cerebrospinal fluid (CSF) treatment dispersion, are now well established. Models are available using MRI data. Morphine has long been the gold standard in first line treatment, but recent publications conclude that ziconotide has largely proven its efficiency and that adverse effects are controllable. Four recent publications have evaluated cohorts of cancer patients treated by IDDS in 315 patients. All found a great efficiency of intrathecal treatment for cancer pain. Technical innovations include new catheters and anchorage devices for easier placement and a lower rate of complication. Three-dimensional (3D) CT scan appears to be a noninvasive technique for the diagnosis of catheter complications. Ultrasound should be used to locate pump septum for refill. SUMMARY: All recent recommendations highlight the efficiency of IDDS and propose to use it sooner.

Multicentre clinical simulation evaluation of the ISO 80369-6 neuraxial non-Luer connector.

To avoid potentially fatal wrong-route neuraxial drug errors, international standard ISO 80369-6 specifying a non-Luer neuraxial connector design was published in 2016. We describe usability studies used in development of the design. Thirty-eight doctors and 17 nurses performed simulated procedures on manikins, using devices fitted with Luer connectors or draft ISO 80369-6 'non-Luer' connectors. The procedures included spinal anaesthesia; intrathecal chemotherapy; lumbar puncture, cerebrospinal fluid collection and pressure measurement; epidural catheter placement with bolus injection and critical care use. Participants attempted cross connection between neuraxial connectors and a range of other medical device connectors, including those from the ISO 80369 small-bore connector series. Video recording analysis was used for all assessments. Participants subjectively assessed performance of the draft non-Luer connector, including suitability for routine clinical use. Participants performed 198 procedures. The connector achieved easy, leak-free connections. The willingness of participants to use the non-Luer connectors were: spinal anaesthesia 100%; intrathecal chemotherapy 88%; lumbar puncture, cerebrospinal fluid collection and pressure measurement 93%; epidural catheter placement with bolus injection 78%; critical care use 100%. Concerns raised were generally device related, rather than connector related. Most cross-connection attempts failed, even using above clinical forces and, when successful, were judged of low clinical risk potential; the exception was a malaligned connection between the non-Luer slip and female Luer connectors. This led to revision of the dimensional tolerances of the non-Luer connector to reduce this risk, before publication of the final specification in 2016. We conclude that the ISO 80369-6 neuraxial non-Luer connector is suitable for clinical use.

Visualization of intrathecal delivery by PET-imaging.

BACKGROUND: Intrathecal (IT) delivery is useful in both basic research and clinical treatments. Here we aim to test a new minimally invasive distribution route to the subarachnoid space (SAS) and the flow of IT administrations. We placed a radioligand into SAS during positron emission tomography (PET) scanning as a proof of concept. NEW METHOD: We injected a 11C-labeled PET-tracer using a surgically placed catheter in the cisterna magna of anesthetized female pigs. The pigs were scanned for 1.5-2 hours in a PET/CT-scanner. The pressure from continuous infusion of artificial CSF (aCSF) promoted distribution of the tracer. The procedure was done under continuous intracranial pressure (ICP) monitoring. The catheter was made accessible both by externalization through the skin and through a subcutaneously placed sterile titanium port connected to the catheter. After image reconstruction, we used PMOD software to assess the tracer distribution throughout SAS. Internalisation of the catheter to a port enables survival studies. Previous studies performing ventriculography have placed a catheter trough brain cortex and parenchyma; such procedures may affect any behavioural or neurological evaluation, and have an increased risk of bleeding per- and post-operatively (Kaiser & Frühauf, 2007). RESULTS: The PET-CT visualized tracer was evenly distributed in the SAS. Furthermore, the ICP measurement made it possible to adjust infusion speed within acceptable pressure levels. CONCLUSION: This new method can be useful for testing distribution of PET-tracers, antibiotics, chemotherapeutics and a wide range of other pharmaceuticals targeting the CNS and spinal cord in large animal models, and potentially later in human.

Refill Procedures of Intrathecal Drug Delivery Systems With a Recessed Fill Port on the Pump Surface: A Prospective Comparison Study of Ultrasound-Guided vs. Blind Refill Technique.

OBJECTIVES: Structural differences of implantable drug delivery systems (IDDSs) might have an impact on the efficiency of needle access to the reservoir fill port (RFP). The aim of this study was to assess the efficiency of RFP needle access with an ultrasound (US)-guided vs. a blind refill technique in IDDSs with a Recessed RFP (Recessed-RFP-IDDS). MATERIALS AND METHODS: The primary outcome was the number of attempts needed to enter the RFP with a needle comparing the US-guided technique vs. the blind refill technique. The time to enter the RFP with the needle was a secondary outcome. We compared the amount of attempts between both techniques with the non-parametric Wilcoxon rank sum test. RESULTS: Fourteen adult patients underwent a total of 75 refills of their Recessed-RFP-IDDS during a period of 24 months. The median number of attempts to enter the RFP did not differ significantly between the US-guided technique and the blind refill technique (2.0 (IQR: 1-5) vs. 1.5 (IQR: 1-5.0), p = 0.572). The median time to enter the RFP with the needle did not differ significantly between both techniques (35.0 sec (IQR: 26.0-58.0) vs. 41.0 sec (IQR: 25.5-46.8), p = 0.878). CONCLUSION: The results of this study suggest that there is no difference in the RFP needle access efficiency between the US-guided and the blind refill technique in superficially located Recessed-RFP-IDDSs, if performed by experienced practitioners. However, the study did not address efficiency of the RFP needle access in IDDSs with aberrancy in pump location or refills performed by inexperienced staff.

Method and Apparatus for the Automated Delivery of Continuous Neural Stem Cell Trails Into the Spinal Cord of Small and Large Animals.

BACKGROUND: Immature neurons can extend processes after transplantation in adult animals. Neuronal relays can form between injected neural stem cells (NSCs) and surviving neurons, possibly improving recovery after spinal cord injury (SCI). Cell delivery methods of single or multiple bolus injections of concentrated cell suspensions thus far tested in preclinical and clinical experiments are suboptimal for new tract formation. Nonuniform injectate dispersal is often seen due to gravitational cell settling and clumping. Multiple injections have additive risks of hemorrhage, parenchymal damage, and cellular reflux and require additional surgical exposure. The deposition of multiply delivered cells boluses may be uneven and discontinuous. OBJECTIVE: To develop an injection apparatus and methodology to deliver continuous cellular trails bridging spinal cord lesions. METHODS: We improved the uniformity of cellular trails by formulating NSCs in hyaluronic acid. The TrailmakerTM stereotaxic injection device was automatized to extend a shape memory needle from a single-entry point in the spinal cord longitudinal axis to "pioneer" a new trail space and then retract while depositing an hyaluronic acid-NSC suspension. We conducted testing in a collagen spinal models, and animal testing using human NSCs (hNSCs) in rats and minipigs. RESULTS: Continuous surviving trails of hNSCs within rat and minipig naive spinal cords were 12 and 40 mm in length. hNSC trails were delivered across semi-acute contusion injuries in rats. Transplanted hNSCs survived and were able to differentiate into neural lineage cells and astrocytes. CONCLUSION: The TrailmakerTM creates longitudinal cellular trails spanning multiple levels from a single-entry point. This may enhance the ability of therapeutics to promote functional relays after SCI.

The use ultrasound guided for refilling intrathecal baclofene pump in complicated clinical cases: A practical approach.

Muscular spasticity due to neurological disorders is a heavy cause of severe pain and disability for many patients, compromising the independence and quality life. Baclofene is a good tool to guarantee patients independence and pain control. Anyway in chronic therapy oral treatment become unsatisfactory. In all these cases, intrathecal baclofen therapy (ITB), after sub fascial implantation of intrathecal pumps is used as an important long term treatment to reduce spasticity. After pump implantation the drug reservoir must be refilled periodically in order to maintain the reduction of spasticity and avoid the symptoms and signs of withdrawal. ITB refilling, which involves the insertion of a needle through the skin until the access port of the pump, is often hard, mainly due to the layer of abdominal fat, spasticity, suboptimal pump positioning, pump rotation or inversion, and scar formation over the implantation site. To avoid the difficulties of ITB refilling radiography or other invasive supportive examinations are sometimes needed. We reported here our experience and we suggest a simple method to use the ultrasound in refilling with particular attention to some cases with complications after implantation with a difficult approach in refilling. We used the ultrasound examination to identify the access port of her pump so as to avoid multiple needle punctures and infections and radiation exposition. Ultrasound-guided technique may facilitate ITB refill in technically challenging cases. With ultrasound ITB was easily detectable and was quite simple to identify the exact point of needle injection. In the last years different new applications for ultrasounds are emerging. In our opinion the use of Doppler ultrasounds in the study of muscles and nerves represent an emerging tool for the physician's neurological rehabilitation.

Retrospective Analysis of Intrathecal Drug Delivery: Outcomes, Efficacy, and Risk for Cancer-Related Pain at a High Volume Academic Medical Center.

OBJECTIVES: Cancer pain is common and difficult to treat, as conservative medical management fails in approximately 20% of patients for reasons such as intolerable side-effects or failure to control pain. Intrathecal drug delivery systems (IDDS), while underutilized, can be effective tools to treat intractable cancer pain. This study aims to determine the degree of pain relief, efficacy, and safety of patients who underwent IDDS implantation at a multidisciplinary pain clinic. MATERIALS AND METHODS: A retrospective review was conducted of patients with an intrathecal pain pump implanted for malignant pain. Charts were reviewed for demographics, cancer type, pain scores before and after implantation, and intrathecal drugs utilized. A Wilcoxon Signed-Rank test was conducted on the paired differences of pain scores before and after implant. A regression analysis was conducted using a linear model to assess effects of demographic variables on change in pain scores. RESULTS: 160 patients were included in analysis. The median pain score was 7.1 at time of implantation and 5.0 at one-month postimplantation. For patients with both baseline and one-month pain scores available, the median decrease in pain was 2.5 (p < 0.0001). Pain scores three-month postimplantation did not significantly differ from one-month postimplantation. Median longevity was 65 days. Five patients had pumps explanted due to infection with a median time to pump extraction of 28 days. CONCLUSIONS: IDDS has the potential to improve cancer pain in a variety of patients and should be strongly considered as an option for those with cancer pain intractable to conservative medical management.

X-ray Imaging Analysis of Intrathecal Baclofen Pumps for Pediatric Emergency Medicine.

Intrathecal baclofen therapy has become increasingly popular because of its effectiveness in treating spasticity in pediatric patients. The device implanted into each patient is structurally similar. However, x-ray imaging can give the appearance of missing or extraneous objects on or near the intrathecal baclofen device. The composition of the material used in making the catheters is transparent on x-ray images. In addition, the connection port between the pump and catheter may resemble the shape of a needle. This has led to confusion among emergency room personnel, and unnecessary panic for other people involved. It is important that medical professionals understand many of the new designs of the pump-connector system to avoid further complications.

Intrathecal Therapeutics: Device Design, Access Methods, and Complication Mitigation.

INTRODUCTION: The intrathecal space remains underutilized for diagnostic testing, invasive monitoring or as a pipeline for the delivery of neurological therapeutic agents and devices. The latter including drug infusions, implants for electrical modulation, and a means for maintaining the physiologic pressure column. The reasons for this are many but include unfamiliarity with the central nervous system and the historical risks that continue to overshadow the low complication rates in modern clinical series. MATERIALS AND METHODS: Our intent in this review is to explore the access devices currently on the market, assess the risk associated with breaching the intrathecal space, and propose a research model for bringing to patients the next generation of intrathecal hardware. For this purpose, we reviewed both historical and contemporary literature that pertains to the access devices and catheters intended for both temporary and permanent implantation and the complications thereof. RESULTS: There are few devices that are currently marketed in the United States or Europe for intrathecal use. Most hew to a relatively fixed design pattern predicated on the dimensions and properties of the thecal sac. All are typically composed of soft silicone, and employ a Tuohy needle for access despite design limitations. In general, these catheters are engineered for durability, ease of use, and regional deployment. Devices on the market with steerability or targeted intrathecal fixation are not yet available. Complications, once a legitimate concern, are now quite rare when recommended techniques are followed. CONCLUSIONS: Over the next decade, advances in intrathecal catheter design, access techniques, imaging, and greater understanding of the spinal cord neurophysiology will usher in an era where the intrathecal space is recognized as a highly valued diagnostic and therapeutic target. We anticipate that this will occur in several concurrent phases, each with the potential to accelerate the growth of the others.

SpinoBot: An MRI-Guided Needle Positioning System for Spinal Cellular Therapeutics.

The neurodegenerative disease amyotrophic lateral sclerosis (ALS) results in the death of motor neurons in voluntary muscles. There are no cures for ALS and few available treatments. In studies with small animal models, injection of cellular therapeutics into the anterior horn of the spinal cord has been shown to inhibit the progression of ALS. It was hypothesized that spinal injection could be made faster and less invasive with the aid of a robot. The robotic system presented-SpinoBot-uses MRI guidance to position a needle for percutaneous injection into the spinal cord. With four degrees of freedom (DOF) provided by two translation stages and two rotational axes, SpinoBot proved capable of advanced targeting with a mean error of 1.12 mm and standard deviation of 0.97 mm in bench tests, and a mean error of 2.2 mm and standard deviation of 0.85 mm in swine cadaver tests. SpinoBot has shown less than 3% signal-to-noise ratio reduction in 3T MR imaging quality, demonstrating its compliance to the MRI environment. With the aid of SpinoBot, the length of the percutaneous injection procedure is reduced to less than 60 min with 10 min for each additional insertion. Although SpinoBot is designed for ALS treatment, it could potentially be used for other procedures that require precise access to the spine.

Ease of Fill Port Access During the Ultrasound-Guided vs. the Blind Refill Technique of Intrathecal Drug Delivery Systems With a Raised Septum, a Prospective Comparison Study.

OBJECTIVES: The localization of the reservoir fill port of Intrathecal Drug Delivery Devices (IDDS) can be difficult. The purpose of this study was to assess the ease of fill port access during the ultrasound-guided refill technique compared to the blind refill technique in IDDSs with a raised septum on the pump surface. MATERIALS AND METHODS: Written informed consent was obtained from 19 adult patients undergoing regular refills of their Raised Septum IDDSs (RS-IDDSs). The primary outcome of this single center prospective comparison study was the number of attempts to enter the reservoir fill port with the needle comparing the ultrasound-guided technique vs. the blind technique. The number of skin punctures per refill procedure and time to enter the reservoir fill port was secondary outcomes. For between group comparisons the Friedman test for repeated measures on ranks was used. RESULTS: One hundred and eleven refill procedures were assessed in 19 patients over a period of 24 months. The median number of attempts to enter the reservoir fill port with the needle differed significantly between the ultrasound-guided technique and the blind technique (4 [IQR: 1-6] vs. 1 [IQR: 1-3], p = 0.018), in favor of the blind technique. The median time to enter the reservoir fill port differed significantly between the ultrasound-guided technique and the blind technique (58 sec [IQR: 38-94] vs. 22 sec [IQR: 16-40], p < 0.001). CONCLUSIONS: The results of this study suggest that for a RS-IDDS the blind refill technique needs significantly less attempts to enter the reservoir fill port than the US-guided refill technique.