Thorakale Myelopathie durch Katheterspitzengranulom bei einliegender intrathekaler Schmerzpumpe

Zusammenfassung

Hintergrund

Katheterspitzengranulome stellen eine seltene, jedoch potenziell reversible Komplikation der intrathekaler Opioidtherapie dar und können durch mechanische oder entzündlich-toxische Effekte zu einer Myelopathie führen.

Fallbeschreibung

Ein 70-jähriger Patient mit langjähriger intrathekaler Morphintherapie entwickelte innerhalb von 2 Tagen eine progrediente Reithosenanästhesie, Sensibilitätsstörung ab Höhe Th10 und eine aufsteigende Paraparese (ASIA D). Die MRT zeigte eine thorakale Myelopathie mit fokaler Raumforderung an der Katheterspitze (Th8/9). Unter multimodalem intraoperativem Neuromonitoring wurde der Katheter vollständig über den lumbalen Zugang entfernt. Histologisch fand sich fibrinoleukozytäres Material ohne Hinweis auf Infektion. Postoperativ kam es zu einer raschen, jedoch nicht vollständigen neurologischen Erholung. In der Verlaufskontrolle zeigte sich bildgebend eine deutliche Rückbildung des Myelopathiesignals ohne residuelle Neurokompression.

Schlussfolgerung

Katheterspitzengranulome sollten bei akuter neurologischer Verschlechterung unter intrathekaler Opioidtherapie stets in Betracht gezogen werden. Eine sofortige Explantation des Kathetersystems ist entscheidend, um eine irreversible Schädigung des Rückenmarks zu vermeiden. Bei persistierenden neuropathischen Schmerzen kann eine spätere Rückenmarkstimulation (SCS) als ergänzende Therapieoption in Erwägung gezogen werden.

Abstract

Background

Catheter-tip granulomas represent a rare but potentially reversible complication of long-term intrathecal opioid therapy and may cause spinal cord compression or inflammatory myelopathy.

Case description

A 70-year-old male with a history of intrathecal morphine pump therapy presented with rapidly progressive saddle anesthesia, sensory loss below T10, and ascending paraparesis (ASIA D) over 2 days. MRI revealed a thoracic myelopathy associated with a focal lesion at the catheter tip (T8/9). Under continuous intraoperative neuromonitoring, the catheter was completely removed via the initial lumbar approach. Histology demonstrated fibrinoleukocytic material without infection. The patient experienced rapid but incomplete postoperative neurological improvement, and follow-up MRI confirmed marked regression of the thoracic myelopathy without residual neurocompression.

Conclusion

Catheter-tip granuloma should be considered in patients presenting with new or worsening neurological deficits during intrathecal opioid therapy. Prompt surgical removal of the intrathecal system is crucial to prevent permanent spinal cord injury. In cases of persistent neuropathic pain, spinal cord stimulation may represent a valuable secondary treatment option after resolution of inflammation.

Schlüsselwörter

Katheterspitzengranulom - intrathekale Schmerzpumpe - Myelopathie - Morphin - Rückenmarkstimulation - Neuromonitoring

Keywords

catheter-tip granuloma - intrathecal morphine pump - myelopathy - spinal cord compression - neuromonitoring - spinal cord stimulation

Publication History

Article published online:
27 January 2026

• Literatur

• 1 Deer TR, Pope JE, Hayek SM. et al. The Polyanalgesic Consensus Conference (PACC): Recommendations on Intrathecal Drug Infusion Systems Best Practices and Guidelines. Neuromodulation 2017; 20: 96-132
• 2 Williams J, Louw G, Towlerton G. Intrathecal pump systems for giving opioids in chronic pain: a systematic review. Health Technology Assessment 2001; 32
• 3 Yaksh TL, Rudy TA. Chronic catheterization of the spinal subarachnoid space. Physiol Behav 1976; 17: 1031-1036
• 4 Zimmermann A, Rauck RL. The delayed appearance of neurological signs in intrathecal granuloma warrants imaging surveillance: a case series and review of the literature. Pain Pract 2012; 12 (07) 561-9
• 5 Prager J, Deer TR, Levy R. et al. Best practices for intrathecal drug delivery for pain. Neuromodulation 2014; 17: 354-72
• 6 Murphy PM, Skouvaklis DE, Amadeo RJJ. et al. Intrathecal catheter granuloma associated with isolated baclofen infusion. Anesth Analg 2006; 102: 848-852
• 7 Deer TR, Krames ES, Hassenbusch S. et al. Management of Intrathecal Catheter-Tip Inflammatory Masses: An Updated 2007 Consensus Statement From An Expert Panel. Neuromodulation. 11:77–91 2008;
• 8 Coffey RJ, Burchiel K. Inflammatory mass lesions associated with intrathecal drug infusion catheters: report and observations on 41 patients. Neurosurgery 2002; 50: 78-86
• 9 Leong SK, Laing B, Saines N. Magnetic resonance imaging (MRI) and computed tomography (CT) findings in intrathecal catheter granuloma: Report of two cases. European Journal of Radiology Extra 2010; 74: e17-e21
• 10 Zacest AC, Carlson JD, Nemecek A. et al. Surgical Management of spinal catheter granulomas: operative nuances and review of the surgical literature. Neurosurgery 2009; 65: 1161-1164
• 11 Kumar K, Taylor RS, Jacques L. et al. Spinal cord stimulation versus conventional medical management for neuropathic pain: a multicentre randomized controlled trial. Pain 2007; 132: 179-188
• 12 Bschorer M, Martinez-Moreno M, Tietke M. et al. The Management of Unresectable Intrathecal Catheter-Tip-Associated Granuloma Using Morphine Therapy Cessation and Spinal Cord Stimulation. Cureus 2020;
• 13 Sachdeva R, Dwivedi A, Law M. et al. Regeneration and remyelination promoting effects of spinal cord stimulation following spinal cord injury: A scoping review. Experimental Neurology 2026;