The Management of Unresectable Intrathecal Catheter-Tip-Associated Granuloma Using Morphine Therapy Cessation and Spinal Cord Stimulation

Catheter-tip-associated granulomas (CTG) are a rare but serious complication of intrathecal analgesic delivery pumps (IADP), which interfere with pain modulation and can cause irreversible neurologic deficits. The treatment of symptomatic CTG generally involves surgical resection and catheter removal. We present a case of an unresectable CTG, which we managed using progressive lowering of the intrathecal morphine sulfate (ITMS) dosage as well as spinal cord stimulation (SCS). A 55-year-old female with failed back surgery syndrome (FBSS) presented with new-onset left-sided lumbar radiculopathy after five years of moderately successful ITMS therapy. An MRI study suggested an unknown mass associated with the tip of the catheter. The tumor's adherence to nerve roots of the conus terminalis prevented a complete resection and only allowed for a biopsy. After the SCS implantation, we progressively lowered the ITMS dose. In a follow-up consultation, the patient reported the regression of the radiculopathy as well as satisfactory pain levels without oral opiates. In this case of CTG, cessation of intrathecal morphine prevented the further growth of the granuloma. SCS effectively addressed both the chronic lumbar back pain as well as the new-onset radicular pain caused by the CTG.