Pump Implant

Intrathecal drug delivery, or “Pain Pump” is a method of delivering medication directly to your spinal fluid. The fluid filled space around your spinal cord is called the subarachnoid or intrathecal space. Cerebrospinal fluid (CSF) flows through this area bathing and protecting your brain and spinal cord. An intrathecal drug pump works much more efficiently than oral medication because it delivers medicine directly into the CSF, bypassing the path that oral medication takes through your body.

Dr. Nasser uses a small pump that is surgically placed under the skin of your abdomen and delivers medication through a catheter to the area around your spinal cord. A pain pump is considered the safest way to take pain medication on a long term basis. Because the medication is delivered directly to the spinal fluid, your symptoms can be controlled with a much smaller dose than is needed with oral medication. The goal of a drug pump is to better control your symptoms and to reduce oral medications, therefore reducing their associated side effects, increased flexibility in dosing, fewer office and pharmacy visits.

In Order to Qualify for Surgery:

There are several reasons why Dr. Nasser may recommend a Pain Pump:

• You have had positive response with a trial dose of medication.
• Conservative Therapies have failed.
• You would not benefit from additional surgery.
• You are dependent on pain medication.
• You have no medical condition that would keep you from undergoing implantation.
• You are not allergic to any drugs used in the pump.

Living with a Pain Pump:

You must schedule medication refills on a regular basis with Dr. Nasser. At your refill appointments the effectiveness of your treatment will be assessed and your pump will be adjusted accordingly. The goal is to find the optimal amount of pain control while having minimal side effects.

How Is It Performed?

The pump is a round metal device about the size of a hockey puck that is surgically implanted beneath the skin of your abdomen. A small plastic tube, called a catheter, is surgically place in the intrathecal space of the spine and is connected to the pump. The pump is programmed to slowly release medication over a period of time. It can also be programmed to release different amounts of medication at different times of the day depending on your changing needs. The pump stores the information about your prescription in its memory, and Dr. Nasser can easily review this information with the programmer. When the reservoir is empty, Dr. Nasser refills the pump by inserting a needle through your skin and into the fill port on top of the reservoir. This procedure is completely reversible if you should ever decide to have the pump removed.

There are two parts to the procedure. (1) placement of the catheter in the intrathecal space surrounding
the spinal cord. (2) placement of the pump in the abdomen.

Placement of the Catheter:
A small incision is made in the middle of your back. The body arch (lamina) of the vertebra is exposed. The catheter is placed in the subarachnoid or intrathecal space above the spinal cord and secured in place with sutures.

Tunneling of the Extension:
Once the catheter is in place, and extension catheter is passed under the skin from the spine and around your torso to the abdomen where the pump will be implanted.

Placement of the Pump:
A 4”-6” incision is made in the side of your abdomen. Dr. Nasser creates a pocket for pump between the skin and muscle layer. The extension catheter is attached to the pump. The pump is correctly positioned under the skin and sutured to the thick fascia layer overlying the stomach muscles.

Close the Incisions: The incision in your back and abdomen are closed with sutures or staples and a dressing is applied.

Preparing for Surgery

Follow All Pre-operative Instructions given to you by Dr. Nasser.
You must have someone to drive you home after the surgery.

Realistic Expectations: An important factor in deciding whether to have a Pain Pump procedure is understanding that each person experiences a different level of relief.

Medical Evaluation: Dr. Nasser may ask you to schedule a complete physical examination with your family physician several weeks before the operation. This is needed to make sure you are healthy enough to have the surgery and complete the recovery process. Many patients with chronic medical conditions, like heart disease, may also be evaluated by a specialist, such as a cardiologist, before the surgery.

Test: Several tests, such as blood and urine samples, and an electrocardiogram, may be needed to help Dr. Nasser plan your surgery.

Medications: Tell Dr. Nasser about the medications you are taking. He will tell you which medications you should stop taking and which you should continue to take before surgery.

Test Stimulation: You will be awakened so that you can help the doctor determine how well the stimulation voters your pain pattern. Several stimulation settings will be tried and you will be asked to describe the location of any tingling you feel. These settings will be used to program the pulse generator at the end of surgery. Your feedback is important to ensure the best pain relief.

Tunnel the Wire: Once the leads are in place, sedation is again given. The lead wire is based under the skin from the spine to the buttock, where the generator will be implanted.

Place the Pulse Generator: A small skin incision is made below the waistline. The surgeon creates a pocket for the generator beneath the skin. The lead wire is attached to the pulse generator. The generator is then correctly positioned within the skin pocket.

• Stop all BLOOD THINNERS – ASPRIN or any Anti-Inflammatory Medications (Motrin, Aleve) 7 days prior to surgery as they can cause bleeding during surgery.
• Stop any naturopathic or herbal medication 7 days prior to surgery, these can also cause bleeding.
• Continue with all other medications unless otherwise specified by Dr. Nasser.
• Bring a list of ALL medication with you to give to the Anesthesiologist.
• You are advised to STOP SMOKING or use of Tobacco for one week prior to surgery.
• You must use Hibiclens Soap for 3 days (twice a day) prior to your procedure, paying close attention to the surgery site. This can be purchased at any local pharmacy.
• DO NOT eat or drink anything (even water) after midnight the night before surgery.
• For Diabetic Patients, if you are on insulin; NO insulin the morning of surgery.
• DENTAL EVALUATION. Although the incidence of infection after surgery is very low, an infection can occur if bacteria enter your bloodstream. To reduce the risk of infection, major dental procedures (such as tooth extractions and periodontal work) should be completed before your surgery.
• SOCIAL PLANNING. You may need to make advance arrangements to have someone assist you at home. DO NOT travel for six weeks after surgery.

After Surgery

Patients go home the same day of surgery.

Your Recovery at Home: The success of your surgery will depend largely on how well you follow Dr. Nasser’s instructions at home during the first few weeks after surgery.

Incision site is to be cleaned by sponge bathing only – twice a day with hibiclens soap until you are seen by Dr. Nasser. Some loss of appetite is common after surgery. It is important to have a balanced diet (often with an iron supplement) to promote proper tissue healing and restore muscle strength. Drink plenty of Water!

Pain: After your surgery, you will most likely feel some pain Dr. Nasser will provide medication to make you feel as comfortable as possible. It is normal to have swelling and warmth of the affected area. However, if there is excessive swelling, redness, or drainage from the incision site call Dr. Nasser immediately.

Spinal Headaches are caused by leakage of cerebrospinal fluid around the catheter. Lie flat and drink plenty of caffeinated non-carbonated fluids (tea or coffee) do not drink caffeine after 2 pm.

Wound Care: Do Not use any ointments or creams on the incision unless instructed to by Dr. Nasser. It is normal to have blood under the dressing. If there is excessive ooze the dressing can be changed by a healthcare professional. You may have stitches or staples running along your wound or a sterile mesh on the skin. The stitches or staples or mesh will be removed at your follow-up appointment.

Activity and Exercise: void these activities until your first Post Op Visit:

• NO swimming
• NO golf
• NO tennis
• NO running
• No bending
• No twisting
• No yard-work
• No lifting
• No crawling
• No stooping
• No housework
• Do Not sleep on your stomach
• No crouching
• No sexual activity
• Do Not raise your arms above your head
• DO NOT Travel for 6 weeks after surgery

Time off Work depends on your work requirements. Office workers usually require 2-4 weeks off and manual laborers 6-12 weeks off.

Wear your abdominal binder at ALL TIMES (including while sleeping). Your binder may only be removed for hygiene purposes.

Do Not shower for 2 days after your surgery. You may sponge bathe only with no direct water on the incision.

On the 3rd. day after your surgery – you may shower with a bandage directly over the wound. No direct water on the incision site.

Do Not remove your bandage for 2 days after surgery.

On the 3rd. day after surgery, your bandage is to be removed and changed daily with a dry dressing only.

For 6 weeks after surgery limit all strenuous activity. No lifting anything over 10 pound. Avoid bending at the spine, especially twisting.

No swimming, golf, tennis, running or sexual activity.

NO Driving until approved by Dr. Nasser after your first post operative appointment.

Pump Refill:
You must schedule medication refills on a regular basis with Dr. Nasser. At your refill appointment, the effectiveness of your treatment will be assessed and your pump will be adjusted accordingly. The goal is to find the optimal amount of pain control while having minimal side effects.

Possible Complications of Surgery

Infection:
Your body needs time to heal, so be patient. Do not rush the recovery process. It is important to follow Dr. Nasser’s instructions carefully and make sure you are not pushing yourself too fast or too soon. Infection may occur in the wound or deep around the pump. Minor superficial wound infections are generally treated with wound cleansing and antibiotics. Major or deep infections may require more surgery and removal of the implant. Any infection in your body can spread to your implant.

Preventing Infection:
Keeping your wound clean with antibacterial soap and water is crucial in preventing infection. A common cause of infection following surgery is from bacteria that enter the bloodstream during dental procedures, urinary tract infections, or skin infections. Dr. Sherfey will discuss with you whether taking preventive antibiotics before dental procedures is needed in your situation.

Warning signs of infection:
Notify Dr. Nasser immediately if you develop any of the following:

• Drainage from the wound
• Persistent fever (higher than 101°F orally)
• Shaking chills
• Increasing redness, tenderness, or swelling of the wound

During the procedure you will receive antibiotics to prevent injection.

Pain:
A small number of patients continue to have pain after surgery. However, this complication is rare, however, and the vast majority of patients experience excellent pain relief following surgery.

Neurovascular Injury:
While rare, injury to the nerves or blood vessels can occur during surgery. There is a risk paralysis, death and bleeding.

The nature, purpose and risks of the operation and the complications which may arise during or result from the operation have been explained to me, including the possibility of having pain, limited motion, weakness or paralysis, blood clots, headaches, nerve injury, scar, non-union, mal-union, risk of anesthesia, need for additional surgery, painful hardware, reflex sympathetic dystrophy, bleeding, need for transfusion, pulmonary embolus, infection, acute or chronic reaction to implant, drug reaction, cardiac arrest, organ injury, amputation, para or quadriplegic, stroke, and even death; and such understand that my condition may actually become worse as a result of the operation because of any one or more of the conditions above mentioned. I have been advised that because of the risks and the uncertain outcome, Dr. Nasser will undertake the operation only at my specific request and direction and with the understanding that the operation does entail risks.