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Published on: February 23, 2015
Paraplegia secondary to progressive necrotic myelopathy in a patient with an implanted morphine pump
1Department of Neurology/Division of Physical Medicine and Rehabilitation, Medical University of South Carolina, Charleston, SC, USA.
Abstract:
We present an individual with chronic low back pain who was treated with an implanted morphine pump, which provided very good pain relief for 16 mos. However, the patient developed acute paraplegia secondary to progressive necrotic myelopathy, a rare form of transverse myelitis. The cause of this patient's neurologic deficit was unclear. Three months after the onset of paralysis, a trial of discontinuation of the intrathecal morphine was performed to exclude the morphine as a reversible cause of paralysis. Within 24 hrs after his pump was depleted, his pain became significantly worse. He was maintained on oral opioids for 6 mos, and his pain was only partly controlled, with a daily average visual analog scale score of 7/10. There was no improvement in his neurologic status after stopping the intrathecal morphine therapy, and several consecutive magnetic resonance images of the spine demonstrated radiologic progression of spinal cord involvement. The patient developed classic opioid side effects of excessive somnolence and constipation. Intrathecal morphine therapy was re-instituted, and the patient reported a significant decrease of his pain, an improvement in quality of life, and no complications related to pump functioning.
Insights
Intrathecal morphine effectively managed chronic low back pain but was followed by paraplegia. Discontinuation did not improve paralysis, and re-initiation relieved pain without complications.
Area of Science:
- Neurology
- Pain Management
- Spinal Cord Medicine
Background:
- Chronic low back pain (CLBP) significantly impacts quality of life.
- Implanted drug delivery systems, like intrathecal morphine pumps, offer an option for refractory CLBP.
- Rare complications associated with intrathecal therapies require careful evaluation.
Observation:
- A patient with CLBP experienced effective pain relief with an implanted morphine pump for 16 months.
- The patient subsequently developed acute paraplegia attributed to progressive necrotic myelopathy.
- Neurologic deficit progression was observed despite discontinuation of intrathecal morphine.
Findings:
- Discontinuation of intrathecal morphine led to significant pain exacerbation, with oral opioids providing only partial relief.
- No neurologic improvement occurred after stopping intrathecal morphine; spinal MRI showed worsening myelopathy.
- Re-initiation of intrathecal morphine therapy resulted in substantial pain reduction and improved quality of life without adverse events.
Implications:
- This case highlights the complexity of diagnosing neurologic deficits in patients with chronic pain and implanted devices.
- It underscores the importance of considering myelopathy as a potential cause of paraplegia, distinct from direct drug toxicity.
- The findings support the continued use of intrathecal morphine for refractory pain when benefits outweigh risks, even in the presence of unrelated neurologic complications.
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