DP40: INTRATHECAL THERAPY FOR SYMPTOM MANAGEMENT IN A PATIENT WITH SUSPECTED DEJERINE-ROUSSY SYNDROME: A CASE REPORT
Sapan Patel, DO; William R Grubb, MD, DDS
Rutgers-Robert Wood Johnson University Hospital
Introduction: Intrathecal pumps deliver medication directly into the cerebrospinal fluid (CSF) surrounding the spinal cord, offering continuous pain relief for conditions such as cancer pain, complex regional pain syndrome (CRPS), and severe neuropathic pain. More rarely, they manage hypertension indirectly by mitigating sympathetic overactivity in spinal cord injury (SCI) or autonomic dysreflexia. This case report details the management of a patient with paroxysmal hypertensive disorder and unexplained abdominal pain, following multiple negative specialist evaluations, and examines the role of intrathecal pumps in multidisciplinary treatment of suspected Dejerine-Roussy Syndrome.
Case Presentation: A 64-year-old male presented to the Emergency Department (ED) every six weeks with severe epigastric pain and marked hypertension. Over several years, he underwent an uneventful cholecystectomy and negative findings from esophagogastroduodenoscopy (EGD), colonoscopy, magnetic resonance cholangiopancreatography (MRCP), magnetic resonance angiography (MRA), bone marrow biopsy with genetic screenings, and positron emission tomography (PET) scan, all failing to identify the etiology of his paroxysmal hypertension and abdominal pain. After years of specialist consultations without a diagnosis, he was referred to pain management. Initial treatments with a splanchnic nerve injection and spinal cord stimulator provided minimal relief, with resolution of his pain and hypertensive episodes achieved only after intrathecal pump insertion (Figure 1).
Under general anesthesia, a Medtronic SynchroMed III Model 8667-20 intrathecal pump with Catheter Model 8781 was implanted using fluoroscopic guidance, with the catheter advanced to the T7 vertebral interspace (Figure 2). The pump was filled with 20 ml of hydromorphone 20 mg and bupivacaine 40 mg. Infusion parameters included a continuous rate of 0.0749 mg/day hydromorphone and 0.1498 mg/day bupivacaine, with patient-controlled boluses of 0.005 mg hydromorphone and 0.01 mg bupivacaine over 1 minute, up to six times daily, with a 4-hour lockout interval. One week post-implant, the patient reported a 75% reduction in pain, requiring approximately four boluses per day. Notably, both abdominal pain and hypertensive episodes had resolved. In the ensuing months, the patient continued to experience significant symptom relief and fewer hospital admissions.
Discussion/ Conclusion: Intrathecal pumps offer an effective and advanced solution for managing chronic abdominal pain when conventional treatments prove inadequate. Managing chronic abdominal pain is particularly challenging when the etiology remains elusive despite thorough specialist evaluations and resists standard therapies, including medications, nerve blocks, and physical therapy. Clinical studies demonstrate that intrathecal therapy provides sustained pain relief and functional improvement. Patients receiving intrathecal drug delivery report lower pain scores, enhanced quality of life compared to conventional regimens, and reduced hospital admissions. Notably, these systems can also alleviate symptoms of unclear origin, such as hypertensive episodes, as illustrated in the patient discussed with suspected Dejerine-Roussy Syndrome. In conclusion, intrathecal pumps represent a powerful option for managing chronic abdominal pain and treating cardiovascular and nervous system disorders.
Figure 1: CT scan image showing the placement of an intrathecal pump, with the catheter positioned at the T7 vertebral level for targeted delivery of medication.
Figure 2: Medtronic SynchroMed III Model 8667-20 intrathecal pump