Presented at the 2013 AAPM Annual Meeting « Back

Intrathecal Bupivacaine-Induced Chemical Arachnoiditis

Monika Y. Patel, MD, monikay.patel@gmail.com¹, Larry C. Driver, MD², Matthew Davis, MD³, (1) University of Texas and Baylor College of Medicine, Houston, Texas, (2) University of Texas-MD Anderson Cancer Center, Houston, Texas, (3) TIRR, University of Texas, Houston, Texas

Introduction: In more recent years, intrathecal bupivacaine hydrochloride has been used via intrathecal delivery alone or in combination with opioids for improved chronic pain management1. The purpose of this article is to present a rare case of presumed intrathecal bupivacaine induced chemical arachnoiditis. Case: A 60-year-old male with past medical history of chronic lumbar back pain presented with acute onset of bilateral lower extremity weakness and recurrent falls three weeks after bupivacaine was added to his intrathecal morphine pump. CSF analysis at that time showed persistent decreased glucose (31 mg/dl), increased protein (876 mg/dl), and increased WBC 262 (lymphocytes 89%). However, infectious, malignant and auto-immune work-up was negative. Spine MRI revealed dorsal tethering at T8-T9, diffuse linear leptomeningeal enhancement from T5-T12, conus medullaris and cauda equina consistent with arachnoiditis. Cessation of the intrathecal bupivacaine and prednisone did show functional return. However, when the intrathecal pump was restarted residual bupivacaine in the intrathecal catheter caused symptoms to relapse and led to long-term incomplete paraplegia. Results: Bupivacaine induced chemical meningitis reports have similar CSF findings3. Neurohistological studies performed showed inflammation of the leptomeninges after continuous intrathecal bupivacaine infusion1,2. Conclusions: Although rare, bupivacaine induced chemical arachnoiditis may occur with intrathecal bupivacaine. Further studies of long-term use of intrathecal bupivacaine are needed to characterize the adverse effects, toxicity, neurohistology, CSF analysis, and compatibility with other agents. References: 1) Hildebrand KR, Elsberry DD, Deer TR. Stability, Compatibility, and Safety of Intrathecal Bupivacaine Administered Chronically via an Implantable Delivery System. The Clinical Journal of Pain. 2001; 17: 239–244. 2) Deer TR, Serafini M, Buchser E, Ferrante FM, Hassenbusch SJ. Intrathecal Bupivacaine for Chronic Pain: A Review of Current Knowledge. International Neuromodulation Society, Neuromodulation. 2002; 5(4): 196–207. 3) Tateno F, Sakakibara R, Kishi M, Ogawa E. Bupivacaine-induced chemical meningitis. Journal of Neurology. 2010;257(8):1327-9. 4) Anderson VC, Burchiel KJ. A Prospective Study of Long-term Intrathecal Morphine in the Management of Chronic Nonmalignant Pain. Neurosurgery 1999; 44(2): 289-300. 5) Esses SI, Morley TP. Review Article: Spinal Arachnoiditis. The Canadian Journal of Neurological Sciences. 1983; 10: 2-10. 6) Mironer YE, Haasis JC, Chapple I, Brown C, Satterthwaite JR. Efficacy and Safety of Intrathecal Opioid/Bupivacaine Mixture in Chronic Nonmalignant Pain: A Double Blind, Randomized, Crossover, Multicenter Study by the National Forum of Independent Pain 7) Kato J, Konishi J, Yoshida H, Furuya T, Kashiwai A, Yokotsuka S, Gokan D, Ogawa S. Cauda equina syndrome following combined spinal and epidural anesthesia: a case report. Canadian Journal of Anaesthesia. 2011; 58(7):638-41. 8) Peláez R, Mira MD, Ferrer AM, Mendiola MA, Aguilar JL. [Transient neurological syndrome after spinal hyperbaric bupivacaine: a new case]. [Article in Spanish]. Rev Esp Anestesiol Reanim. 2006; 53(6):373-7. 9) López-Soriano F, Lajarín B, Verdú JM, Rivas F, López-Robles J. [Cauda equina hemisyndrome after intradural anesthesia with bupivacaine for hip surgery]. [Article in Spanish]. Rev Esp Anestesiol Reanim. 2002;49(9):494-6.

Funding: None